High Risk for Pneumonia Clinical Trial
Official title:
Offering Influenza and Pneumococcal Vaccine to Patients Being Evaluated in the Emergency Department
According to the Advisory Committee on Immunization Practices (ACIP), all people aged 50
years or older and persons aged less than 50 years who have medical conditions that put them
at increased risk for serious influenza disease should receive an annual influenza
vaccination. However, since the mid-1990s, vaccination rates and racial disparities have
mostly remained static, and there has been limited progress towards the Healthy People 2010
objectives for influenza vaccination coverage.
The purpose of this study is to determine what proportion of previously unvaccinated persons
in target groups for whom influenza and pneumococcal vaccine are recommended will accept and
receive influenza and/or pneumococcal vaccine in an urban emergency department (ED), and to
estimate the potential impact of ED vaccination on population-based vaccination coverage.
The intervention will utilize a combination of assessment survey, vaccine information and
pre-printed vaccine order sheets.
The target population for influenza vaccinations includes all patients aged 18 years and
older for whom influenza vaccine is recommended by the ACIP. This includes all persons aged
50 years and older and persons aged 18 to 49 years who are in one of the following groups:
1) health care workers, 2) pregnant women, 3) residents of long-term care facilities, 4)
household contacts and out-of-home caregivers of children aged 0 to 23 months, or 5) persons
with underlying chronic medical conditions which increase their risk of influenza-related
complications. The target population for pneumococcal vaccination includes all patients aged
65 years or older who have not previously been vaccinated against pneumococcus or have not
received the vaccine within 5 years (and were less than 65 years at the time of
vaccination).
PROTOCOL - Baton Rouge General Medical Center
Background
According to the Institute of Medicine, non-institutionalized high-risk adults may present
the greatest challenge to adult immunizations. There are a number of barriers to
implementation of comprehensive strategies for vaccinating adults:
- Routine preventive health visits are infrequent and transient
- Individuals lack knowledge of the vaccines required during adulthood
- Primary care providers may lack time, knowledge, or ability to perform a vaccination
assessment, or it may not be part of their standard practice pattern
- Primary care providers lack the infrastructure (especially time and personnel) to
assist with adequately assessing and documenting immunization status
Emergency departments represent ideal settings for vaccination efforts because each year
millions of adults who have no or limited access to traditional primary care visit hospital
EDs for medical and surgical problems that are non-life threatening. Such EDs often already
provide other medical screening and preventive care services in the management of their
patients. Almost one-quarter of adults aged 65 years and older make one or more visits to an
emergency department each year. Patients who use EDs as their usual source of care are more
likely to be members of minority groups and uninsured. These characteristics suggest that
vaccination programs in EDs could have a significant impact in correcting disparities in
vaccination coverage among patients in older age groups.
Combined with the large volume of patient visits each day, these characteristics would seem
to make EDs ideal settings to implement vaccination services for people who have little
access to primary care. Furthermore, influenza vaccination in EDs could play a substantial
role in correcting disparities in vaccination coverage among this cohort of patients. The
American College of Emergency Physicians recommends that ED personnel consider participating
in influenza vaccine programs for the elderly if other sources of vaccination are not
readily available.
A limited number of studies suggest that about half of patients for whom influenza vaccine
is indicated (based on age or other high risk conditions) who have not yet received
influenza vaccination during the current season would accept vaccination if it was offered
to them during an ED visit. However, since these studies were conducted early in the
vaccination season and involved the use of convenience samples, the results might not be
generalizable to all patients seen in an ED throughout the vaccination season. The
proportion of persons who would not have been vaccinated elsewhere but would accept
vaccination in EDs has not been demonstrated. Therefore, the true potential of vaccination
in EDs to increase vaccination coverage is unknown.
Additional evidence suggests that strong recommendation by a health care professional,
particularly the patient’s primary physician, can further increase the acceptance of
influenza vaccine. However, there is limited evidence regarding the effectiveness of
counseling by providers who are previously unknown to the patient, as is usually the case in
an ED setting, to produce a similar change in patient behavior.
Goals and Objectives The overall goal is to determine the feasibility, sustainability,
acceptability, and effectiveness of hospital-based vaccination efforts and to increase
influenza immunization coverage among persons aged 18 years and older for whom vaccination
is recommended who would otherwise not have been vaccinated. Inherent in feasibility and
sustainability are the ability to recoup some income from those vaccinated.
Objective
For patients aged 18 years and older who seek medical care in the ED, determine
1. the number of vaccinations administered to eligible persons
2. the proportion of patients, among all persons not previously vaccinated, who accept
vaccines in the emergency department.
3. the increase in coverage that can be achieved through a four-month emergency
department-based vaccination program
Study design and methods
1. All patients aged 18 years and older will be approached by the PPS after the chief
complaint is ascertained. The PPS will begin and administer a questionnaire on all
eligible patients for whom vaccine is recommended. If the patient is eligible, the PPS
will read the questionnaire to the patient.
2. If the patient is unsure or states that he or she does not want to receive the flu
vaccine, the PPS will determine the reason for vaccine refusal.
If the patient meets criteria for influenza vaccination and/or pneumococcal vaccination, the
PPS will inform him/her that influenza/pneumococcal vaccine is/are recommended for them and
that the vaccination will be offered to eligible patients in the ED at no additional charge
beyond that which is reimbursed by their insurance. Patients will be referred to a physician
for additional assessment if they have a questionable or possible contraindication. The PPS
will provide all eligible patients with the appropriate Vaccine Information Statement(s) and
answer any questions. If the patient agrees to be vaccinated, the PPS will place a
preprinted order form in the patient’s chart, ask the physician to sign the order, and alert
the patient’s nurse. The patient will be offered vaccination by an ED nurse while they are
undergoing evaluation and treatment in the emergency room. The nurse giving the vaccination
will document the lot number, expiration date, time and location of the injection(s) on a
label that will be placed in the patient’s chart.
Documentation of doses received will be faxed to the patient’s private care physician, if
the information is available for doing so.
How confidentiality will be maintained:
Personal identifiers will not be retained by investigators beyond the time needed to
document dose receipt in the patient medical record.
Exclusion criteria:
All patients under 18 years of age will be excluded. Any patient with a medically unstable
condition, altered mental status, or language barrier will also be excluded. Patients who
present with a contraindication to influenza vaccination (acute febrile illness or a history
of allergic reaction to eggs) or pneumococcal vaccine will not be eligible for receipt of
those vaccines.
Immunization status:
Previous immunization history will be assessed by patient self-report.
Data analysis:
The primary outcome measure will be the number of indicated influenza and pneumococcal
vaccinations received during the course of the study. Data will be collected and analyzed
according to demographic information, contraindications, and clinical consent.
PROTOCOL - Our Lady of the Lake Regional Medical Center
Goals and Objectives:
The overall goal is to determine the feasibility, sustainability, acceptability, and
effectiveness of hospital-based vaccination efforts and to increase influenza immunization
coverage among persons aged 50 years and older who would otherwise not have been vaccinated.
Inherent in feasibility and sustainability are the ability to recoup some income from those
vaccinated.
Objective
For patients aged 50 years and older who seek medical care in the ED, determine
1. the number of vaccinations administered
2. the proportion of patients, among all persons not previously vaccinated, who accept
vaccines in the emergency department.
3. the increase in coverage that can be achieved through a four-month emergency
department-based vaccination program
4. information or incentives that might convince initially reluctant patients to accept
influenza vaccine
Study design and methods
1. All patients aged 50 years and older will be approached by the scribe after the chief
complaint is ascertained. The scribe will begin and administer a questionnaire on all
age eligible patients. Having already taken a history, the scribe will be able to
easily determine if the patient is eligible for the study (i.e. does not meet any of
the exclusion criteria). If the patient is eligible, the scribe will read the
questionnaire to the patient.
2. If the patient is unsure or states that he or she does not want to be vaccinated, the
scribe will determine the reason.
If the patient meets criteria for vaccination (i.e., has not been previously vaccinated
against influenza this season and has no known contraindications to influenza vaccination),
the scribe will inform him/her that influenza vaccine is recommended and that the vaccine
will be offered to eligible patients in the ED at no additional charge beyond that which is
reimbursed by their insurance. Patients will be referred to a physician for additional
assessment if they have a questionable or possible contraindication. The scribe will provide
all eligible patients with a VIS and answer any questions. If the patient agrees to be
vaccinated, the scribe will place a preprinted label in the patient’s chart, ask the
physician to sign the order, and alert the patient’s nurse. The patient will be offered
vaccination by an ED nurse while they are undergoing evaluation and treatment in the
emergency room. The nurse giving the vaccination will document the lot number, expiration
date, time and location of the injection on a label that will be placed in the patient’s
chart.
How confidentiality will be maintained:
Personal identifiers will not be retained by investigators beyond the time needed to
document dose receipt in the patient medical record.
Exclusion criteria:
All patients under 50 years of age will be excluded. Any patient with a medically unstable
condition, altered mental status, or language barrier will also be excluded. Patients who
present with a contraindication to influenza vaccination (acute febrile illness or a history
of allergic reaction to eggs) or previous influenza vaccines will be excluded.
Immunization status:
Previous immunization history will be assessed by patient self-report.
Data analysis:
The primary outcome measure will be the number of indicated influenza vaccinations received
during the course of the study. Data will be collected and analyzed according to demographic
information, contraindications, and clinical consent.
Secondary analysis will be of the effectiveness of systems changes to deliver vaccine in an
emergency department setting. If necessary, surveys will be administered to key staff
persons to assist with data gathering for this analysis.
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Allocation: Non-Randomized, Intervention Model: Single Group Assignment, Masking: Open Label, Primary Purpose: Prevention