Improving adult immunizations: Nurses take the lead

Healthcare providers know the importance of immunizing their adult population, especially their most vulnerable patients.

Each year in the United States, thousands of adults age 65 and older die from invasive pneumococcal disease including pneumonia, meningitis, and bloodstream infections.[1] We constantly urge patients to have a flu vaccine – at their primary care visits, at pharmacies, at appointments with specialists, etc. Yet, still we struggle to improve immunization rates for our populations, particularly patients most at risk for complications.

Despite strong public health recommendations supporting adult immunization for vaccine-preventable diseases such as pneumococcal disease, rates among U.S. adults have remained below the U.S. Department of Health and Human Services Healthy People 2020 goals.[2] In the U.S., among adults 65 and older, there are roughly 500,000 cases of pneumococcal pneumonia annually, which leads to 200,000 hospitalizations, 19,200 deaths, and 5.5 billion in costs. (3)

Because of their training, their role on the healthcare team, and the intimate contact with patients, nurses have a vital role in addressing this problem and improving immunizations rates in their communities.

Collaborating for Improvement
Recently AMGA brought together seven medical groups in a Best Practices Learning Collaborative focused on improving adult immunization rates for pneumococcal and influenza, thereby reducing the clinical and economic burden of these vaccine-preventable diseases. Working together, the participating groups identified optimal and efficient ways to improve adult immunizations, with a specific focus on pneumococcal and influenza vaccines.

Members of the Collaborative sought a way to comprehensively improve immunization rates, especially for their most vulnerable patients. One focus of the Adult Immunization (AI) Best Practices Learning Collaborative, facilitated by AMGA Foundation, was centered on the August 13, 2014 Advisory Committee on Immunization Practice (ACIP) recommendation on the routine use of 13-valent pneumococcal conjugate vaccine (PCV13) among adults aged ≥65 years. The Collaborative began soon after the change in the recommendations, and participants showed significant improvement in pneumococcal immunization rates among these patients.

Nurses Take the Lead
During the Collaborative, nurses played a key role in helping to improve the pneumococcal vaccine rates within their organization and community.

Leading and Reporting
They contributed significantly to the success of the Collaborative by serving in key leadership roles, such as the Quality Improvement Director who was responsible for managing their group's progress during the Collaborative. In addition, clinical quality nurses and nurse care coordinators were responsible for collecting quality data and reporting quarterly on pneumococcal quality measurements to demonstrate if they were meeting the immunization quality performance standards. These "care gap" and performance reports were also shared transparently with providers and staff in the medical groups to educate and encourage improvement in their pneumococcal rates. Transparent reporting was vital to successful improvement.

Empowered to Vaccinate
The implementation of standing orders and adult immunizations algorithms allowed nurses the opportunity to assess and vaccinate patients during their Annual Wellness Visits without the need of a clinical examination or a direct order from the attending physician. Multiple organizations utilized seasonal flu shot clinics where nurses could administer immunizations, and some of those clinics also administered pneumococcal shots. One organization used their walk-in, nurse-run clinic as an additional location to provide the pneumococcal vaccine. Immunization assessments were added to the clinic intake forms to encourage discussion with patients about the need for adult immunizations and provide an opportunity for nurses to offer vaccines while they were rooming the patients. The physician only had to intervene if they refused vaccination. This allowed the physician to focus on other areas of the patient's care.

Outside Primary Care
Specialty departments were seen as another area to identify and capture high-risk patients who haven't received the pneumococcal vaccine. Because adult immunizations were not routinely given to high-risk patients in all specialty departments, nurses provided training on vaccine screening, administration, storage, and handling to staff and providers.

Promotion and Communication
Nurses worked with their marketing department to use social media to promote the importance of adult immunizations within the community. Communication was vital to educating the public and increasing immunizations rates.

Clearly, nurses are crucial to any efforts to systematically improve immunization rates. The National Vaccine Advisory Committee recommends assessment of vaccination needs at every patient encounter [4]. With nurses' training and skills in patient assessment and education, and their place on the care team in most care settings throughout the U.S. healthcare community, nurses are ideally positioned to play a leading role in improving adult immunization rates.

References
[1] National Foundation for Infectious Diseases. Facts about Pneumococcal Disease for Adults. http://www.adultvaccination.org/vpd/pneumococcal/facts.html. Accessed Sept. 7, 2016.
[2] US Department of Health and Human Services. Healthy People 2020. https://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases. Accessed November 9, 2016.
[3] The Value and Imperative of Quality Measures for Adult Vaccines
http://www.adultvaccinesnow.org/wp-content/uploads/2016/07/Value-Imperative-Adult-Vaccines-Final.pdf
[4] U.S. Department of Health and Human Services, National Vaccine Program Office. National Adult Immunization Plan. Retrieved from: https://www.hhs.gov/nvpo/national-adult-immunization-plan/

About the authors
Jill Powelson, RN, MBA, MPH, CPC, is director or clinical translation at AMGA; Earlean Chambers, RN, MS, is assistant director of population health initiatives at AMGA.

BOX
The AI Collaborative
In February 2015, AMGA brought together seven AMGA member organizations to collaborate in an effort to improve adult immunization rates for pneumococcal and influenza, thereby reducing the clinical and economic burden of vaccine-preventable diseases.

The Collaborative led to significant improvement in pneumococcal immunization rates among patients 65+. Across the seven participating groups, an additional 190,000 patients were vaccinated in just 14 months which will prevent long term complications, hospitalizations, and deaths.

Participating Groups
• Community Physician Network, Indianapolis, IN
• The Iowa Clinic, P.C., West Des Moines, IA
• Riverside Medical Group, Newport News, VA
• Springfield Clinic, Springfield, IL
• SwedishAmerican Health System, Rockford, IL
• UMass Memorial Medical Group, Worcester, MA
• Watson Clinic, Lakeland, FL

For more information on the AMGA Adult Immunization Best Practices Learning Collaborative, including case studies from each participant, visit amga.org/ai2.

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