Joint Commission Resources recently announced the results of its third annual Flu Vaccination Challenge, with participating organizations achieving an 80 percent flu vaccination average among staff during the 2010-2011 flu season, about 16 percent higher than the national average among healthcare workers.
William Schaffner, MD, chairman, department of preventive medicine, and professor of infectious diseases at Vanderbilt University School of Medicine in Nashville, and Tom Talbot, MD, MPH, chief hospital epidemiologist and associate professor of infectious diseases at Vanderbilt University School of Medicine and Joint Commission Resources consultant, discuss the success of the program, why participating organizations achieve higher flu vaccination rates and how organizations can improve their own flu vaccination performance.
Q: To what do you attribute the success of the program as a whole?
Dr. William Schaffner: First, there is an increasing national and therefore local interest in making sure that healthcare workers — whatever their particular role in an institution is — are protected against influenza so they cannot transmit influenza to their patients. I think this concept that it is a patient safety issue primarily is gaining traction and there is a deeper understanding of this among workers.
We all recognize that getting immunized against influenza helps us, but what everyone doesn't quite understand is it helps us from making our patients even sicker. We would like our institutions to be a protected cocoon around all of our patients when it comes to influenza — an influenza-free zone. So if you come in to our hospital, or any other hospital, nursing facility or doctor's office — this is one place you are not going to acquire influenza. We would like to make it a protected environment as much as possible.
Second, this is a success because the institutions that sign up for this are institutions that take a particular pride in achieving these goals. These are institutions that are going the extra mile. They accept the concept, they make a commitment to success, they institute activities within their institutions to reach the goals. Then, when they are recognized, they take real pride in it and share the knowledge they have received one of these recognitions from Joint Commission Resources with their personnel. I think some of the institutions, I hear anecdotally, actually post or announce it in their newsletters and even may get the word out beyond the four walls of the institution.
Dr. Tom Talbot: I think [the program] provides institutions interested in this measure a real achievable goal and measure of achievement through a very reputable organization. To be able to target this safety practice and be able to say we obtained "gold status," we really hit that mark, and it's something that a reputable organization like The Joint Commission and Joint Commission Resources have said this is a laudable goal I believe really helps lend some credibility to that effort.
The organizations that participate, they're the key. To achieve success with this measure, as with other quality and safety measures, it cannot come from a part of the organization, it really has to be the entire leadership of the institution because you're trying to drive a practice of a lot of individuals in a hospital or health center. It's trying to educate, encourage and convince each individual that this is an important and worthwhile safety effort for themselves and for their patients. That needs to come not just from the local expert or the director of the program but it has to be from a leadership perspective like you see with any kind of quality effort. The organization's interest and engagement clearly comes from the top down.
Q: Why do you believe participating organizations in the Challenge, on average, surpassed the national average by such a wide margin?
Dr. Tom Talbot: While we don't have a detailed drilldown, I think it goes back to prioritization, devoting resources and using available tools to have a multi-faceted approach. Some programs may be mandating it but not all of them. Even if you mandate vaccinations, you have to have it accessible, you have to have education, you have to have allowances for exemptions, you need massive publicity and awareness of why it's important. For each institution it's going to be a little bit different, but what you'll see as a commonality will be a very diverse, multi-faceted program emphasizing the safety of the healthcare worker, safety to patients, the importance of this as a quality measure and the professional and ethical responsibility that we need to do this as part of protecting ourselves and our patients.
It's also understanding where the barriers are and working through them. So a barrier may be accessibility, it may be tackling misperceptions via some one-on-one dialogue with individuals. There are still a lot of [misconceptions] out there about the perception about vaccines, and flu vaccines in general. I think the key is having that kind of understanding about where you may have some barriers, and that does take some work, particularly in bigger institutions with a lot of employees, recognizing that it's hard to get to everybody, understanding why people may not be getting vaccinated and trying to thoughtfully address those with data and evidence.
Dr. William Schaffner: These are self-selected, motivated institutions. These are institutions that have already made the commitment, they understand the concept, they wish to reach the goal as close to 100 percent as possibly. Also, they are a bit courageous. Some of these institutions let [their staff] know they are in this race and want to run as hard as they can. They're willing to put themselves out and say we're striving for the gold, silver would be great and at the very least we want to get a bronze, so help us out and let's do this. Some of it is a bit self-revelatory and exposes them a little. If you get a bronze, you recognize you didn't get a silver or gold. They have to be sufficiently courageous to be willing to accept that and strive even more for next year and use that as part of their motivation. They're also ready to show their peer institutions that this can done, this can be achieved. They take pride in exceeding the national average and would like to be examples of model institutions.
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Q: Could you offer some suggestions for how organizations can effectively encourage staff regarding flu vaccines? What are some motivators for enhanced flu vaccination interest?
Dr. William Schaffner: There are a whole series of things that can be done [to improve vaccination rates], and I suspect these institutions draw from that menu and try to do them as well as possible. First of all, it is explaining why this is important. You need that knowledge base that this is a patient safety issue and, secondarily, when the flu hits, we as healthcare workers need to be here ready to give our healthcare. We don't want to be home sick ourselves.
You have to have strong administrative support from the most senior level of the institution. If that can be visible — using letters, emails, public announcements, pictures of [leaders] getting their own immunizations, etc., will all help transmit the information down through their rank and file that everyone at the top is doing this and that it is an expectation. It's transmitting the notion that if you are a healthcare worker, this is both a professional and ethical obligation to your patients.
Then the mechanics are very important. The vaccine has to be available conveniently and frequently. That includes the night shift, the weekend workers, doctors who come in and out very quickly, making sure the dietary personnel and the plant operations people are given the same kind of attention and the communication is done in a language they understand. The vaccine should be made free, convenient at all hours and there needs to be publicity about when it can be received, whether at the beginning of the shift, at the end of the shift, perhaps during a shift or perhaps vaccine can be brought to the locations where you work so you don't have to go to the location where the vaccination is given. All of those things are part and parcel of getting it done.
Then it's addressing those influenza concerns, questions and myths that keep coming up so you can do your best to put them to rest. Some institutions hold prize competitions between different wards. Some institutions give prizes to ones that have the highest immunization rates. Putting stickers on your ID badge to let everybody know you've been immunized helps motivate those who have not.
Dr. Tom Talbot: I think it really comes down to emphasizing a couple key messages. I think emphasizing the personal protection [message] is important. Since healthcare workers are often healthy and they're not at the typical age that we think will develop complications from influenza, we need to emphasize the importance that those people can play in spreading the virus to other people. We always focus on not spreading it to our patients; we don't want to do that, but we also want to prevent spread to household contacts, visitors, friends, family members — we don't want to spread it to anyone.
Also, while the vaccine is not a perfect vaccine, [we need to remind our staff that] it's a pretty effective tool, along with other infection control measures like handwashing, to keep from getting other people sick.
Q: For our readers who do not consider flu vaccination necessary, what would you say to them?
Dr. Tom Talbot: The argument I use more and more for the patient perspective is as healthcare professionals, what would we expect for ourselves and our family members? I use this for handwashing and other safety measures as well. For me, I would not be okay with an unvaccinated healthcare worker during the winter caring for my wife in the hospital because of the chance of transmitting influenza to her while she's hospitalized. Some of our patients don't mount the same response to vaccine as a healthy adult and aren't as protected. I think it really does come down to remembering that we are in healthcare and we should do all we can to not transmit [diseases]. It doesn't matter whether you are a doctor, nurse, the environmental services worker, the ward clerk — all play a role in spreading disease to our coworkers, friends, families and our patients.
Dr. William Schaffner: I'll address several things we hear with great frequency not just here but with speaking to colleagues around the country. Number one: "I'm young and healthy and I never get influenza, so why should I get immunized?" The answer to that is you could have a really mild case of the flu, even to the point of being without symptoms. However, you could still transmit the virus to your patients. The only way to avoid that is being vaccinated.
The second thing I hear is "I'll stay home when I'm sick so I won't hazard the patient." I have two responses to that: The first is that's baloney. You'll come in when you're sick, particularly if it's a mild illness, so let's be realistic and honest with ourselves about that. Number two, and much more important, is the biological concept of what happens when you get infected with influenza virus. If I get infected with the influenza virus, within 48-72 hours, I will become ill. It may be mild or more seriously ill. But for the 24 hours before I become ill, I am already exhaling influenza virus in large amounts. So before I become ill, I can be covering my patients with my influenza virus.
Even if you were rigorous about staying home when you got sick, what about the day before you got sick when you had no idea you were going to get sick? That day, you're transmitting influenza virus. There's only one way to prevent that and it is through vaccination.
Another thing I hear is "we recognize the influenza vaccine is a good vaccine but it's not a perfect vaccine. There are times we all recognize when the virus changes and there is not a perfect match between what's in the vaccine and the circulating virus, so I may not be protected completely." That is correct, but, and I quote, "Waiting for perfection is the greatest enemy of the current good." We don't have a perfect vaccine but we have a pretty darn good one. And even if there is deviance between what's in the vaccine and the circulating virus, the vaccine almost always provides at least partial protection, so it gives us some advantage and we should not throw that advantage away. In the meantime, what we have is a good vaccine — we ought to use it.
Then there is that myth that used to have a life of its own. That myth of "I can get flu from the flu vaccine." Malarkey, incorrect, misinformation, not true! That's an excuse, not a reason, because the reason is fallacious. You cannot get flu from the flu vaccine. Your arm can get a little sore and a terribly small proportion of people — less than one percent — may get a day of fever. That's from the local inflammation and the injection site. That's trivial; that's not influenza.
Finally, there are those healthcare workers who don't like shots. I don't particularly care for shots myself but it's a patient safety issue. Shape up, step up, get your vaccine. You're doing this for your patients as well as for yourself and your family members.
Q: Do you see flu shot regulations for healthcare staff ever becoming mandatory?
Dr. William Schaffner: Mandating influenza vaccines and other vaccines for healthcare providers is happening on an individual institutional basis. We have discussed that here at Vanderbilt for going on maybe 3-4 years. In the councils of our own institution, that concept is batted around and we're not there yet. We just conducted an event called Flulapalooza in which we have immunized more people in a healthcare center in an eight-hour period than has ever been done before. I can assure you we are enthusiastic about giving influenza vaccine but we have not decided to mandate it.
HCA, our sister institution, with all of its hospitals in its system and all of its clinics, decided within the past few years to mandate it. They have done that with enormous success and my hat is off to them.
There's now a substantial laundry list of professional and academic societies related to healthcare that have endorsed the concept of mandate. Each institution will need to make its own decision, and each year, we hear about more institutions going mandatory.
Dr. Tom Talbot: I don't see us ever having a national law or regulation, and I don't know if that's the right thing, but what is happening is increasing dissatisfaction with low vaccination rates and how this issue has a role in patient and worker safety and quality. CMS has added healthcare worker vaccination as a potential metric for reimbursement. It's a voluntary program, just like reporting of central line bloodstream infection rates. You don't have to report your performance, but you risk losing substantial payments. Eventually, such payment will be based not just on whether these outcomes are reported but how a facility performs compared to its peers. .
That's really raising the ante and I think that's when you're going to see more places considering a mandatory program. I think with this as part of a quality metric, I don't see we're going to have the need to have a national mandate because I think that's going to drive people to improve.
Editor's note: Joint Commission Resources has launched the 2011-2012 Flu Vaccination Challenge, challenging organizations to achieve at least a 75 percent flu vaccination rate among staff this flu season. To learn more about this year's challenge, click here.
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