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Hospitals face major barriers in tracking worker influenza shots
Even if nationally mandated, 'large inconsistencies' expected
Everyone wants to have high rates of health care worker influenza immunization, but just who gets counted in their numbers? About half of hospitals face major barriers in tracking the immunizations of credentialed or other non-employees, according to a survey by the Centers for Disease Control and Prevention.
The CDC is working to validate a National Quality Forum measure for influenza immunization of health care personnel, but first the agency must show that health care institutions can calculate the rates in a standardized way. A temporary measure has been in place for two years.
The CDC's definition of health care personnel is all-encompassing: "All persons, paid and unpaid, working in healthcare settings who have the potential for exposure to patients and/or to infectious materials, including body substances, contaminated medical supplies and equipment, contaminated environmental surfaces, or contaminated air."
Currently, hospitals use different methods of counting their employees and non-employees who are vaccinated or who decline vaccination, says Megan C. Lindley, MPH, epidemiologist with the CDC's National Center for Immunization and Respiratory Diseases. "We know that things are being counted in different ways and the rates are not necessarily comparable," she says. "It makes it difficult to formally evaluate different policies for increasing influenza immunization rates when it's not certain who's being measured in those rates."
The CDC study involves three online surveys conducted during and at the end of the 2010-2011 influenza season at 216 health care institutions, including 80 hospitals, in four states. (One survey was pending as this issue went to press.) The institutions were asked to rate the ease of counting the vaccinated employees on a scale of 1 to 5. Hospitals responded that counting employees was relatively easy, with a score of 4.1. But counting credentialed non-employees, such as physicians, and other non-employees, such as contract workers or volunteers, was more difficult, with scores of 2.8 and 2.5.
About half of the hospitals said their ability to determine the vaccination status of those non-employees was a major barrier. About a third said the time involved in collecting that information was a major barrier. The hospitals ranged in size from fewer than 75 beds to more than 500 beds.
That mirrors a more informal survey conducted by Melanie Swift, MD, medical director of the Vanderbilt Occupational Health Clinic at Vanderbilt University in Nashville, TN, with 60 of her colleagues at hospitals around the country on an online email list serv. Those hospitals ranged from fewer than 200 beds to more than 1,000 beds.
"By and large, people are able to provide vaccination to their direct employees and to track it," she says. But the ability to track other non-employee groups – contractors, vendors, students, volunteers, credentialed professionals – varied widely, she says.
Can you track your staff?
Even counting employees has its challenges. In testing the National Quality Forum measure, CDC asked health care facilities to count anyone who worked for at least one day between Oct. 1, 2010 and March 31, 2011.
"Not all institutions have the capability to count their employees like that," says Lindley. Some facilities can only provide an employee count for a single date. For example, they could determine how many employees had received their flu vaccine on Dec. 31, 2010. But they didn't have the capacity to keep track of the continual turnover of employees.
The information available to employee health services is not always up-to-date, says Swift. "Occupational tracking systems are not robustly integrated with HR [human resource] systems in the majority of hospitals," she says.
Some receive employment information electronically on a daily or on-demand basis. Others receive information less frequently or rely on paper records. "When you go into an occupational health program and say, 'Show me who works here,' you're going to get a variety of answers," Swift says. For example, at Vanderbilt, "because of continual turnover and replacement, in the course of a flu season, that [employee] population changes quite a bit," she says.
Figuring out who qualifies as "health care personnel" with the potential for exposure to patients and/or infectious materials also can be daunting, says Swift. Hospitals are likely to include all their employees in their vaccination policies, even if they work in an off-site business office or other location without patient contact. In a hospital that is part of a university system, it may be difficult to determine which faculty members only work in a research lab or a classroom and those who work in the hospital setting, she says.
"There's such tremendous variability in organizational structure," Swift says. "In one facility, your business staff might walk down the hallway as other health care workers do. In another facility, they're in a different county."
The current measurement of vaccination rates varies. "About half don't count the doctors, more than half don't count residents," she says.
Seeking a feasible measure
The greater challenge involves tracking the myriad non-employees who enter hospitals, including contract workers such as housekeepers or nurses, vendor representatives, volunteers, students, and credentialed physicians.
The CDC evaluation will determine whether it is feasible to have a national quality measure for non-employees in health care institutions, says Findley. "What we hope from the pilot is that the data and feedback we gather are going to allow us to revise the measure that makes it still useful for the hospitals and other health care institutions but also is something within their capabilities," she says. "The world's greatest measure isn't much use if no one can measure things that way."
Hospitals also need to standardize the way they collect information for the numeratorthe number of personnel who received the vaccine. About a third (34%) accepted a verbal declaration from a health care worker and 40% accepted written or online communication that they had received the vaccine from an external provider.
The measure uses four different numerators: Health care personnel vaccinated at the institution, those vaccinated elsewhere, those with medical contraindications, and those who declined vaccination for non-medical reasons.
Although a growing number of hospitals have adopted mandatory flu vaccination policies, few in the CDC survey reported that influenza vaccination was a condition of employment, says Lindley. About 70% of the hospitals reported having a policy that requires declination statements for health care personnel who did not receive vaccine, she says.
A workgroup of the National Vaccine Advisory Committee, an expert panel that advises the U.S. Department of Health and Human Services, is considering the issue of mandatory influenza vaccination. If that becomes a federal recommendation, Swift predicts: "Everyone would comply in some fashion with that, but there would be large inconsistencies in the populations covered and in the ability to enforce that."