Pennsylvania Patient Safety Advisory Increasing Influenza and Pneumonia Vaccination Rates in Long-Term Care ABSTRACT are immunized each year against influenza and 42% Influenza and pneumonia remain significant causes to 49% are immunized for pneumococcal disease.5 of mortality from vaccine-preventable diseases, with Morbidity is compounded by underlying health prob- 90% of these deaths occurring in adults age 65 or lems,6 and pneumonia and influenza together remain older, including those residing in long-term care (LTC) one of the six principal causes of death in people age facilities. Improving the delivery of currently available 65 or older, according to a 2005 NCHS report.7 The vaccines decreases the exacerbation of underlying CDC Advisory Committee for Immunization Prac- disease and should be a priority to prevent hospital- tices (ACIP) report on prevention of pneumococcal izations and deaths in this population. The Advisory disease2 states that the highest case fatality rates for Committee for Immunization Practices provides annual pneumococcal bacteremia occur among the elderly, age-defined recommendations for adult immuniza- and Muder reports that the mortality associated with tion for influenza and pneumococcal pneumonia, yet bacteremic pneumonia in nursing home residents a recent National Center for Health Statistics report may be as high as 50%.8 shows that, on average, only 42% to 66% of LTC residents received these vaccinations. Healthcare National Nursing Home Quality Measures and Metrics’ workers self-report a low 45% acceptance of influenza state performance ratings reveal that the immunization immunizations, and unvaccinated healthcare workers rates of Pennsylvania long-stay residents—the number risk spreading influenza to the vulnerable institution- of residents who were assessed and given influenza alized elderly. Barriers to success can be overcome vaccination in the 2007 season—were 3.1% lower by the application of systems interventions, such as than the nationwide average of 85.9%. Pneumococ- standing orders, approved since 2003 by the Penn- cal polysaccharide vaccine (PPV) administration rates sylvania Department of Health and the Centers for also fell 3.2% below the national average of 83.6%. In Medicare & Medicaid Services, as well as provider a national comparison, Pennsylvania nursing homes reminders and a standardized process and outcome ranked 38th for residents given influenza vaccination measure protocol. This article explores risk reduction and 26th for residents administered PPV.9 methods to enable LTC facilities to assess current pro- Treating influenza and pneumonia, rather than striv- gram strengths and weaknesses, to increase vaccine ing to prevent the infections through vaccination, can availability and acceptance, to overcome decisional have variable outcomes and contribute to morbidity, conflict, and to select new strategies to improve the mortality, and the growing concern of antimicrobial effectiveness of vaccination programs. (Pa Patient resistance due to inappropriate antibiotic use.10 Saf Advis 2009 Dec;6[4]:132-7.) In October 2005, the Centers for Medicare & Medic- aid Services (CMS) introduced two major updates to make immunization an organizational priority. CMS Introduction requires long-term care (LTC) facilities to ensure that Vaccination remains the best approach to protect residents are immunized annually against influenza the elderly with chronic health conditions who are and are offered at least one dose of PPV when there is considered at high risk for exposure to influenza,1 no history of immunization. Facilities are required to invasive pneumococcal disease,2 and complications. educate residents or their legal representatives about However, current vaccination rates of elderly individu- the benefits and risks of vaccination, and facilities als lag behind the Centers for Disease Control and must provide residents with influenza vaccine and Prevention (CDC) Healthy People 2010 goals of 90% PPV unless medically contraindicated or refused.11 for institutionalized adults with high-risk conditions The LTC state operations manual guidance for survey- that may contribute to unnecessary outbreaks of insti- ors12 outlines requirements for annual influenza and tutional influenza and pneumococcal pneumonia.3 lifetime pneumococcal immunizations. Section W, added to the minimum data set (MDS 2.0), specifi- Background cally inquires about the influenza vaccine and PPV Influenza virus and pneumoccal pneumonia continue status of each resident.13 to be leading causes of vaccine-preventable diseases in Risk Reduction Strategic Planning the United States, with influenza epidemics causing an average of 36,000 deaths and 200,000 hospi- Despite the 2005 CMS requirement to offer these talizations per year. Ninety percent of these deaths vaccines to all LTC residents, annual immunization attributed to influenza occur in adults older than programs often fall short of providing comprehensive 65 years.4 The National Center for Health Statistics policies and procedures to ensure that recommended (NCHS) 2004 data summary reports that only 59% to vaccines are delivered to all eligible residents and 66% of institutionalized adults in the United States employees.10 Page 132 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Vol. 6, No. 4—December 2009 Pennsylvania Patient Safety Advisory Program Assessment controlled trials on patient decision-making interven- Initial steps toward creating a system to get everyone tions published between 1983 and 2006. These studies vaccinated include assessing the facility’s baseline concluded that uncertainty regarding healthcare deci- vaccination rates and establishing a leadership facil- sions can be resolved by identification of individual ity workgroup with the involvement of the facility support and clinical counseling needs, by presentation medical director. Team member roles can be defined of clear and compelling evidence about vaccination as assignment of resources, development of policy risks and benefits by a strong clinical champion, and statements, and auditing of resident medical records through the use of decision aids such as persuasive for the most recent vaccination information. Defined testimonials, posters, brochures, videos, and vaccina- roles also serve to structure implementation processes tion events for families and residents.17,18 and influence peers by sharing positive experiences. CDC produces vaccine information statements A random survey of nursing directors from 291 Penn- (VISs)—or information sheets—that explain both the sylvania nursing homes conducted between April and benefits and the risks of vaccine administration. June 1999 listed the following factors associated with Federal law requires that the facility provide VISs to higher vaccination levels:14 residents or their legal representatives before influenza vaccinations are given. VISs are available online for ■ Strong belief in the importance and effectiveness PPV and influenza vaccine at http://www.cdc.gov/ of the vaccine vaccines/pubs/vis/default.htm. Furthermore, CDC ■ Development of institutional policies related to provides a decision-making algorithm with recommen- assessment, consent, and orders dations for PPV, revaccination, and uncertain vaccine status for individuals age 65 or older. (See Figure.) ■ Identification of a staff vaccine advocate ■ Concentration on effective practices rather than An important process in the transition of care on basic information about the vaccine between hospitals and LTC facilities is documenta- tion of a resident’s vaccination history in the medical ■ Use of a resident management system, prompting staff record and on the transfer form. Improvement in this to assess vaccination status and order vaccinations process will clearly enhance identification of the resi- ■ Knowledge of financial reimbursements dent’s vaccination needs and prevent revaccination. Vaccine Safety and Effectiveness Practice-Proven Strategies Increase Vaccine An observational study of more than 140,000 older Availability and Acceptance adults occurring over the 1998 to 1999 and 1999 Many residents remain unvaccinated because of to 2000 influenza seasons highlights the effects of missed opportunities. Every healthcare encounter is an influenza vaccine in reducing the exacerbation of opportunity to offer vaccines to eligible residents and comorbidities, demonstrating an almost twofold new admissions.15 Historically, ACIP recommended reduction in hospitalization and death rates due to that influenza vaccine should be offered beyond the underlying comorbidity.19 Although comorbidities traditional fall immunization season (October into are associated with age-related decline in response to January and beyond). Adherence to traditional timing vaccines, these residents have the most to gain from is no longer recommended, and the vaccine should be given as soon as available until the end of the influ- Figure. Algorithm for Pneumococcal Polysaccharide enza season (April/May), depending on activity. Vaccination of People 65 years That this recommendation clearly differs from prac- tice is made evident by a 2000 national survey of No or Has the person been unsure 1,606 physician practices regarding influenza vaccine vaccinated previously? Vaccination indicated in which Davis et al. report that 43% of respondents stopped vaccinating in December and only 27% vac- Yes Yes cinated into February.16 Medicare began coverage for pneumococcal vaccine in 1981 and for influenza Was the person aged No immunizations in 1993 with no coinsurance or copay- ≥65 years at the time Have ≥5 years elapsed ment.11 A direct personal recommendation from of last vaccination? since the first dose? healthcare providers has been shown to increase immunization rates among residents who are opposed Yes* No to vaccination. Although education alone does not Vaccination not indicated significantly affect vaccination rates, medical and sup- port staff who are up-to-date in their knowledge are MS09519 *Note: For any person who has received a dose of pneumococcal vaccine at age more likely to immunize themselves and to credibly ≥65 years, revaccination is not indicated. encourage residents to consent to vaccination.15 Reprinted from Centers for Disease Control and Prevention. Prevention of O’Connor et al. describe decisional conflict associated pneumococcal disease: recommendations of the Advisory Committee on with vaccination in a 2004-2005 survey of direct care Immunization Practices (ACIP). MMWR Recomm Rep 1997 Apr 4;49 providers and in a systematic review of 55 randomized (RR-8):1-24. Vol. 6, No. 4—December 2009 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Page 133 Pennsylvania Patient Safety Advisory immunization because many of the complications of provider reminders) most consistently produce the influenza are the result of exacerbation of underlying greatest increase in vaccination program effectiveness. condition.6 Vaccination reminders can take the form of electronic CDC reports that the risk of adverse events from or paper-based warnings, flags, or stamps on charts repeated pneumococcal vaccinations, other than of residents who need vaccines. Resident reminders self-limited local injection site reactions, is minimal. that are personalized by their physicians have a high A second PPV dose, administered two to five years rate of success. The organization’s on-hold telephone after the first dose, does not represent a contraindi- message can include information about vaccination cation to revaccination, and the vaccine should be during the influenza season. Mass mailings, posters, administered to residents who are uncertain of their leaflets, computer-based programs, and postcards are immunization history.2 useful when combined with other high-level inter- ventions such as standing orders.20 The Agency for See “Novel Influenza A (H1N1) 2009 Vaccine Use in Healthcare Research and Quality21 and CDC22 offer the Elderly” for information about the novel influ- immunization toolkits detailing development and enza (H1N1) virus. implementation of a LTC immunization program, sample guidelines, education brochures, campaign Overcome Barriers to Success—Systems materials, and customizable standing order forms. Interventions The American Medical Directors Association pub- An improved vaccination program is achievable with lished the Immunizations in the Long Term Care Setting implementation of a structured process. A system- Tool Kit in 2006, offering guidance, information, and atic review of evidence-based recommendations to tools to enable medical directors and other practitio- increase the influenza and pneumococcal vaccina- ners to take the lead in initiating and implementing tion rates in the over-65 age group was published in activities to address and prevent influenza and pneu- 2003 by the Rand Corporation for the U.S. Depart- mococcal disease in LTC facilities. The document is ment of Health and Human Services. Reviewers available at http://www.amda.com. examined categories of interventions that included Standing Orders organizational changes in clinical procedures; the designation of a nurse to administer vaccines; the On October 2, 2002, CMS published an interim use of reminders, feedback, education, and financial final rule removing the physician signature require- incentives; regulatory and legislative mandates; and ment for influenza and pneumococcal vaccinations media campaigns. The review concluded that multi- from its Conditions of Participation. Some LTC faceted organizational changes (e.g., standing orders, facilities are unaware of this and continue to send Novel Influenza A (H1N1) 2009 Vaccine Use in the Elderly The H1N1 “swine flu” novel influenza virus, ini- H1N1 strains as a result of previous vaccination tially identified in April 2009 in two children in or infection with an influenza A (H1N1) virus that California, progressed to uncontained world- is more closely related to the novel influenza A wide transmission by June 2009 and is expected (H1N1) virus than the current seasonal H1N1 to continue to spread into the 2009-2010 fall strains.2 The August 2009 Morbidity and Mortal- and winter influenza season. The pandemic was ity Weekly Report describes a low 33% to 43% declared to be an emergency by the U.S. Depart- response to H1N1 vaccine in the over-60 age ment of Health and Human Services in April 2009; group.2 A July 2009 amendment to the Public the emergency declaration was extended in July Readiness and Emergency Preparedness Act, or 2009.1 The Advisory Committee on Immunization PREP provides targeted liability protection for the , Practices determined that the new H1N1 vaccine administration of the vaccine.1 For more infor- will initially be targeted to five specific priority mation on H1N1novel influenza virus, visit the groups and subsequently to a subset group.2 The Pennsylvania Department of Health information remaining available vaccine will then be offered to Web site at http://www.h1n1inpa.com. members of the over-64 age group. The rationale for this determination is that in contrast to seasonal Notes influenza, the new H1N1 virus accounted for only 1. United States Department of Health and Human Ser- 5% of hospitalizations and 8% of reported deaths vices. Public Readiness and Emergency Preparedness in the over-65 age group, including residents in Act. Fed Regist [online] 2009 Jun 29 [cited 2009 Oct long-term care facilities where healthcare person- 15]. Available from Internet: http://edocket.access. nel worked while ill with H1N1, according to July gpo.gov/2009/E9-14948.htm. 2009 unpublished data from the U.S. Centers 2. Centers for Disease Control and Prevention. Use for Disease Control and Prevention (CDC). CDC of influenza A (H1N1) 2009 monovalent vaccine: explains that results of serologic tests suggest that recommendations of the Advisory Committee on adults age 60 years or older may possibly possess Immunization Practices (ACIP). MMWR Recomm Rep some level of preexisting immunity to the novel 2009 Aug 28;58(RR-10):1-8. Page 134 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Vol. 6, No. 4—December 2009 Pennsylvania Patient Safety Advisory out verbal orders for every resident.11,20 Goldstein et patients and to provide information about the risks al. noted that obstacles to adoption of standing order for and benefits of administering vaccinations rou- policies include providers who are unconvinced of tinely upon admission to facilities.23 vaccine benefits, physician discomfort with delegation Consent of responsibility to nursing, lack of administrative Written consent is not required before administration support, need for examples of policies and forms, of vaccines, according to the Pennsylvania Medi- proof of regulatory requirements, resident refusal, cal Care and Reduction of Error (MCARE) Act of and program expense.23 A Health Care Financing 2002, as amended.26 Kissam et al. note that obtaining Administration systematic literature review spanning signed consent sets a precedent for an unneces- 1998 to 2003 assessed the evidence of interventions sary impediment to implementation of a standing designed to improve vaccination rates and showed orders program. The authors also note that requiring that in nearly every study, organizational changes that consent before administering low-risk, high-benefit included standing orders improve vaccination rates.20 vaccines is inconsistent with the current practice ACIP recommends that standing order programs be of not requiring signed consent before prescribing used in LTC facilities to ensure the administration of other common low-risk treatments such as routine recommended vaccinations for adults as a national oral medications. Requiring written consent inappro- public health priority. Nurses and pharmacists are priately gives the impression of risk beyond normal authorized to administer vaccinations without the standards, takes substantial and precious staff time, need for a physician’s examination or direct order and paradoxically discourages residents from receiv- under the supervision of a medical director accord- ing the vaccine. Informed consent is provided by the ing to an institution- or physician-approved protocol. required provision of the VIS.27 Based on the strength of available evidence, successful Outcome Measures/Documentation standing orders programs begin with the formation Outcome measurement by means of standardized data of a committee to develop a program plan and write collection is an essential process to evaluate success protocols for the following procedures:24 and maintain a sustainable immunization program. ■ Assessment of residents eligible for vaccination based CDC recommends that each resident’s chart include on their age, vaccination status, and risk factors a permanent individual vaccination record provid- ■ Education of residents or their guardians regarding ing a history of vaccination events from admission the risks and benefits of vaccine administration through discharge, immunization status on admission, the date vaccinated or reason for refusal, and adverse ■ Documentation of patient refusals and medical reactions. Standardized data collection logs provide contraindications reliable metrics to determine process and outcome ■ Recording the administration of vaccine(s) and measures such as the number of residents with up-to- any postvaccination adverse events date vaccinations, the number of new arrivals vaccinated, the baseline immunization state of current ■ Documentation of education and vaccine residents, the number of residents not vaccinated, and administration the reasons why. A facility vaccination registry would ■ Training and competency of healthcare profession- allow improved ease of reporting on vaccination rates als who administer vaccines to screen patients for and declination reasons. Program effectiveness is also vaccination contraindications, to monitor adverse measured by surveillance data for influenza-like illness reactions, and to report adverse events to the and lower respiratory tract infections for residents federal Vaccine Adverse Events Reporting System and staff, the number of training sessions for staff, as (VAERS) at http://www.vaers.hhs.gov (CDC uses well as assigned versus actual completion of program information from VAERS reports to ensure the saf- tasks. An annual written evaluation of the vaccination est vaccine use strategies and to further reduce the program compared to previous years is suggested to rare risks associated with vaccines.) provide feedback to providers and personnel to moti- vate higher performance and set new goals.22 ■ Use of a standard personal and institutional immu- nization record to verify the immunization status Successful Outcomes of patients and to reduce the risk for inappropriate In August 2009, the Authority conducted interviews of revaccination a sample of LTC facilities reporting vaccination rates ■ Implementation of a quality assurance process to over 90%. Twelve facilities participated in a telephone maintain appropriate standards of care questionnaire discussing strategies that led to their suc- In a 1996 survey of 405 primary care physicians cessful vaccination program. Examples are as follows: specializing in geriatrics, family practice, internal Gwynedd Square Center for Nursing reported vacci- medicine, and general practice, 66% of physicians nation rates of 99% for influenza and 100% for PPV, favored a standing order policy to immunize their attributing its success to the use of standing orders eligible patients.25 Preprinted admissions orders could and a facility vaccination information log and nursing improve the effectiveness of the program, encourag- support of detailed resident assessment and vaccina- ing staff members to assess the vaccination status of tion throughout the influenza season. Residents, Vol. 6, No. 4—December 2009 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Page 135 Pennsylvania Patient Safety Advisory families, and staff receive education and handouts at facilities also incorporate strategies such an annual admission, at resident council meetings, and at orien- in-service by the medical director, physician interviews tation. Vaccination status is reviewed at the resident with declining residents, education at an annual care conference. Critical to success was the active safety fair, and use of a declination form for employ- involvement of the owner, the administrator, and a ees. (See “Improving Healthcare Worker Vaccination committed staff, 63% of whom have more than five Acceptance.”) years longevity. Tel Hai Retirement Community reported a 95% Conclusion influenza vaccination rate and a 98% PPV rate using Immunization is the primary method of preventing standing orders, with onetime orders for annual invasive pneumococcal diseases as well as influenza and influenza vaccines and PPV and a onetime consent its more severe complications. Despite documented on admission, as well as education with VIS. A stan- vaccine safety and numerous regulatory efforts, the rate dardized process for follow-through with reminders, of vaccination among high-risk institutionalized elderly documentation, orders, logs, audits, and risk assess- has not substantially improved. Vaccination program ments contributes to a successful program. success can be enhanced and sustained by applying Davis Manor, with a 98% influenza vaccination rate facility-specific comprehensive strategies such as stan- and a 100% PPV rate, obtains a onetime order on dardized documentation, standing orders, provider admission and attributes its success to the use of an reminders, and vaccine champions and by replacing individual resident vaccination record and constant complicated written consent procedures with informed monthly chart and vaccination log audits. Interviewed consent via the VIS.15 LTC facilities can extend the Improving Healthcare Worker Vaccination Acceptance Transmission of influenza to patients by healthcare indicate the organization’s commitment to the workers is well documented,1 and healthcare set- program and motivates acceptance of the vaccine. tings are favorable environments for outbreaks A sample declination form is available at http:// of febrile respiratory illness. Achieving healthcare www.immunize.org/catg.d/p4068.pdf. Leadership worker vaccination levels of 60% or higher is a commitment is ensured by the involvement of a Healthy People 2010 goal.2 In a 2007 national program leader, role models such as administra- health interview survey, 45% of healthcare work- tors who are photographed getting vaccinated ers self-reported that they protect their patients by or vaccine “deputies.” Feedback to the staff and getting immunized against influenza; the remain- the governing body is measured by the impact of ing unvaccinated 55% greatly increase the risk of vaccination rates related to surveillance of ILI in spreading influenza virus in healthcare facilities.3 patients and staff. The Joint Commission advocates the prioritiza- Notes tion of staff immunization programs over resident programs because the virus can be shed at least 1. Fiore AE, Shay DK, Broder K, et al. Prevention and control of influenza: recommendations of the Advi- one day before symptoms start. Vaccination pro- sory Committee on Immunization Practices (ACIP), vides a reduction in influenza-like illness (ILI), fewer 2008. MMWR Recommend Rep 2008 Aug 8;57 days of illness and absenteeism, and a decrease (RR-7):1-60. in impaired work performance and emphasizes a professional obligation to minimize the risk 2. U.S. Department of Health and Human Services. Healthy People 2010: understanding and improving of virus transmission to patients, to vulnerable health. Vol. 1. 2nd ed. Washington (DC): U.S. Gov- coworkers, and to family members. The 1999 ernment Printing Office; 2000 Nov. p. 103-6. Also Joint Commission collaborative tool “Providing a available: http:// www.healthypeople.gov/document/ Safer Environment for Health Care Personnel and tableofcontents.htm. Patients through Influenza Vaccination”4 describes high vaccine acceptance resulting from visible mar- 3. Centers for Disease Control and Prevention. Self- reported influenza vaccination coverage trends keting strategies and active promotion of annual 1989-2007 among adults by age group, risk educational campaigns (e.g., e-mails, newsletters, group, race/ethnicity, health-care worker status, and screen savers, gift card incentives). pregnancy status, United States, National Health Interview Survey (NHIS) Table 31 [online]. 2008 Data from staff surveys that determine reasons [cited 2009 Aug 24]. Available from Internet: http:// for vaccine acceptance can be used to design www.cdc.gov/flu/professionals/vaccination/pdf/ future campaigns. Staff feel supported during the NHIS89_07fluvaxtrendtab.pdf. decision-making process when provided with facts that clarify personal issues such as fear of needles, 4. Joint Commission. Providing a safer environment for health care personnel and patients through avoidance of medication, and peer pressure. influenza vaccination: strategies from research and Access to vaccination is improved by the use of practice [monograph online]. 2009 Jul 22 [cited mobile carts on all shifts or when it is linked to a 2009 Aug 24]. Available from Internet: http://www. group activity. Signed declinations with statements jointcommission.org/PatientSafety/InfectionControl/ of declination risks and of leadership expectations flu_monograph.htm. Page 136 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Vol. 6, No. 4—December 2009 Pennsylvania Patient Safety Advisory benefits of vaccinations to all recommended residents 13. Centers for Medicare & Medicaid Services. Long-term and improve their vaccination rates by approaching the care facility resident assessment instrument users resident immunization program as a regulatory and manual. Version 2.0 [online]. 2005 Dec [cited 2009 Aug patient safety priority.10 14]. p. 240-6. Available from Internet: http://www.cms. hhs.gov/nursinghomequalityinits/20_NHQIMDS20.asp. Notes 14. Jessop AB, Hausman AJ. Pneumococcal vaccination in 1. Fiore AE, Shay DK, Broder K, et al. Prevention and Pennsylvania nursing homes: factors associated with control of influenza: recommendations of the Advisory vaccination level. J Am Med Dir Assoc 2002 Nov-Dec; Committee on Immunization Practices (ACIP), 2008. 3(6):347-51. MMWR Recomm Rep 2008 Aug 8;57(RR-7):1-60. 15. Stinchfield PK. Practice-proven interventions to increase 2. Centers for Disease Control and Prevention. Preven- vaccination rates and broaden the immunization season. tion of pneumococcal disease: recommendations of the Am J Med 2008 Jul;121(7 Suppl 2):S11-21. Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1997 Apr 4;49(RR-8):1-24. 16. Davis MM, McMahon SR, Santoli JM. A national survey 3. U.S. Department of Health and Human Services. Healthy of physician practices regarding influenza vaccine. J Gen People 2010: understanding and improving health. Intern Med 2002 Sep;17(9):670-6. Vol. 1. 2nd ed. Washington (DC): U.S. Government 17. O’Connor AM, Bennett CL, Stacey D, et al. Decision Printing Office; 2000 Nov: 103-6. Also available: http:// aids for people facing health treatment or screening deci- www.healthypeople.gov/document/tableofcontents.htm. sions. Cochrane Database Syst Rev 2009 Jul;(3):CD001431. 4. Thompson WW, Shay DK, Weintraub E, et al. Mortality 18. Sullivan SM, Pierrynowski-Gallant D, Chambers L, et associated with influenza and respiratory syncytial virus al. Influenza vaccination and decisional conflict among in the United States. JAMA 2003 Jan 8;289(2):179-86. regulated and unregulated direct nursing care providers in 5. National Center for Health Statistics: Healthy People long-term care homes. AAOHN J 2008 Feb;56(2):77-84. 2010 progress review: focus area 14. Immunization 19. Nichol K, Nordin J, Mulloly J, et al. Influenza vac- and infectious diseases: data summary table [online]. cination and reduction in hospitalizations for cardiac 2007 Jul 20 [cited 2009 Aug 10]. Available from Inter- disease and stroke among the elderly. N Engl J Med 2003 net: http://www.cdc.gov/nchs//about/otheract/ Apr;348(14):1322-32. hpdata2010/focusareas/fa14-immun2.htm. 6. High K. Immunizations in older adults. Clin Geriatr Med 20. Shekelle P, Stone E, Maglione M, et al. Interventions that 2007 Aug;23(3):669-85. increase the utilization of Medicare-funded preventive services for persons age 65 and older. 500-98-0281. Baltimore (MD): 7. Centers for Disease Control and Prevention. National U.S. Department of Health and Human Services Health Center for Health Statistics. Health, United States, Care Financing Administration. 2008. Leading causes of death and numbers of deaths, by age: United States. Table 31 [online]. 2009 Mar [cited 21. Quality Partners of Rhode Island. Immunization toolkit 2009 Aug 11]. Available from Internet: http://www.cdc. [online]. 2004 Nov 15 [cited 2009 Aug 24]. Available gov/nchs/data/hus/hus08.pdf#listtables. from Internet: http://www.immunizewa.org/files/ Immunization%20Toolkit-%20Rhode%20Island.pdf. 8. Muder RR. Pneumonia in residents of long-term care facilities: epidemiology, management, and prevention. 22. Centers for Disease Control and Prevention. Prevention Am J Med 1998 Oct;105(4):319-30. and control of vaccine-preventable diseases in long-term care [online]. [cited 2009 Aug 24]. Available from Inter- 9. Agency for Healthcare Research and Quality. Nursing net: http://www.cdc.gov/vaccines/pubs/downloads/ home care quality measures and metrics compared to all bk_long-term-care.pdf. states. State performance ratings 2006-2007. [cited 2009 Aug 12]. Available from the Internet: http:// 23. Goldstein AO, Kincade JE, Resnick JE, et al. Policies to statesnapshots.ahrq.gov/snaps08/meter_metrics.jsp?men increase influenza and pneumococcal immunizations in uId=14&state=PA&level=6®ion=0&compGroup=N. chronically ill and institutionalized settings. Am J Infect Control 2005 Oct;33(8):463-8. 10. Nace DA. Improving immunization rates in long-term care: where the forest stops and the trees begin. J Am 24. McKibben LJ, Stange PV, Sneller VP, et al. Use of stand- Med Dir Assoc 2008 Nov:9(9):617-21. ing orders programs to increase adult vaccination rates. MMWR Recomm Rep 2000 Mar 24;49(RR-1):15-6. 11. Centers for Medicare & Medicaid Services. Medicare and Medicaid programs; condition of participation: 25. Noe CA, Markson LJ. Pneumococcal vaccination: immunization standard for long term care facilities. Fed perceptions of primary care physicians. Prev Med 1998 Regist 2005 Oct 7;70(194):58833-52. Nov-Dec;27(6):767-72. 12. Centers for Medicare & Medicaid Services. Appendix 26. Medical Care Availability and Reduction of Error PP. State operations manual: guidance to surveyors (MCARE) Act. 40 P.S. § 1303.504, et seq (2007). for long term care facilities [online]. 2009 Jun 12 ( cited 2009 Aug 13). Available from Internet: http://www. 27. Kissam S, Gifford D, Patry G, et al. Is signed consent for cms.hhs.gov/manuals/Downloads/som107ap_pp_ influenza or pneumococcal polysaccharide vaccination guidelines_ltcf.pdf. required? Arch Intern Med 2004 Jan 12;164(1):13-6. Vol. 6, No. 4—December 2009 REPRINTED ARTICLE - ©2009 Pennsylvania Patient Safety Authority Page 137 PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 6, No. 4—December 2009. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2009 by the Pennsylvania Patient Safety Authority. 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Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web An Independent Agency of the Commonwealth of Pennsylvania site at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.