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Most adults believe that vaccines are important.
We have learned that from research. Yet most adults are
aware that they need vaccines throughout their lives to
be protected. Many adults, including health care
professionals do not get the vaccinations they need.
The result is that each year thousands of adults
in the U.S. suffer needlessly from illnesses, hospitalizations
and deaths that could be prevented. To improve adult
immunization rates, the National Vaccine Advisory
Committee published a set of recommendations called
the Standards for Adult Immunization Practice.
The Standards call on all health care professionals
to take steps to make sure their adult patients receive
all of their vaccinations. The Standards are not just
for providers that immunize. Even if you do not administer
vaccines, you play an important role in recommending
needed vaccines to your adult patients
whether you work in a clinic, a pharmacy, or a hospital.
The Standards recommend four steps you should take
to make sure your patients are fully immunized.
First, assess your patient's need for immunization at every
clinical encounter. Influenza, Tetanus, Tdap, Zoster, and
Pneumococcal vaccines are routinely recommended
for adults.
Your patients might need other vaccines too based on their
age, medical conditions, occupation, travel plans,
or immunization history. Remember, adults believe that
vaccines are important but many are not aware of all the
vaccines they may need. Second, strongly recommend the
vaccines your patient needs based on your assessment.
Your recommendation as a trusted health care professional
makes a difference. Even if you do not actually provide
immunizations in your health care setting, your
recommendation still matters. Third, administer needed
vaccines or refer your patient elsewhere for vaccination.
Access to vaccines is expanding in many communities. In addition
to physician offices, many pharmacies and work places
now offer immunization services. Be aware of the practices and
locations in your community that offer vaccines. The fourth and
final step is to document the vaccines your patient received
in their medical record and, where available, in the state's
immunization information system. These
systems, also known as vaccine registries,
are confidential databases that keep records of
which vaccines were administered. You can use a
registry to keep track of the vaccines you have administered
to your patients and to see which vaccines your patients
recieve from other providers. Implementing these four steps:
asses, recommend, administer, and document can require changes
that may not seem feasible for your situation or practice. But
there are a number of tools available to help you implement
the Standards, as well as educate adults on immunizations
they need. For example, CDC has a website with information on
the Standards for you and resources for your patients. We
know the Standards work. We have the data to show it. A great
example of successfully implementing the Standards is
the work of the Indian Health Service, or IHS. Consistently
using the four steps in the Standards has resulted in
vaccination rates among IHS patients that are significantly
higher than national rates. We asked Amy Groom with IHS in
Albuquerque, New Mexico, to describe how they implemented
the Standards for adult immunization practice.
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The Indian Health Service, or IHS, is the federal agency
responsible for providing health care to approximately 2.2
million eligible American Indian and Alaska Native people
in the U.S. Services are delivered through a network of
IHS, tribal and urban Indian health care facilities in
35 states. Health care facilities in the IHS network
range from from large hospitals and outpatient facilities to
clinics in remote villages. While the specific population
served by IHS is unique and some of the facilities are
remote, IHS is similar to many managed-care organizations
and health care systems.
In addition, the standards of care and the tools used by
IHS, such as electronic health records or EHRs are
similar to those used in other health care systems. IHS has
been able to achieve adult immunization rates that exceed
the national average. IHS has achieved these rates
by customizing its EHR to include provider reminders for
vaccines that are due, facilite recall of patients if needed,
and monitor immunization cover- age. In 2014, coverage of ever
receiving 1 dose of pneumococcal polysaccharide
vaccine among those 65 years and older was 89.8 percent. IHS
policy supports the implementation of the CDC's
Advisory Committee on Immunization Practices or ACIPs
Recommended Adult Immunization Schedule and the National
Vaccine Advisory Committee or NVAC's Standards for Adult
Immunization Practice. The Standards outline 4 evidence-
based strategies for providers. They are to assess, recommend,
administer, and document. The first strategy is to assess the
immunization status of all patients at every clinical
encounter. Clinical decision support is incorporated into the
IHS EHR for all of the ACIP age- based immunization
recommendations. This makes it very easy to assess which
vaccines are needed. As ACIP recommendations are updated,
they are incorporated into the IHS EHR.
Health care professionals should stay informed about the latest immunization
recommendations. Nevertheless, busy providers also need
convenient and easy-to-use tools to review patient's vaccine
needs and remind them when vaccines are due. Having the
reminders in the EHR allows them to easily incorporate
vaccination assessment into their work flow.
As a health care provider I try to stay informed with the latest
immunization recommendations but it can be challenging. Having
immunization reminders in the EHR is helpful because it allows
us to easily incorporate the vaccine assessment into our
workflow. I check the EHR as part of my pre-visit planning
for each patient to see what vaccines are due. When the
patient arrives the nurse also checks the reminders and notes
what shots are due. So that I know to go over that with the patient.
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The second strategy IHS implements is to strongly
recommend vaccines the patient needs. Clinicians are the most
valued and trusted source of health information. Research
indicates most adults believe that vaccines are
important and are likely to get them if recommended by their
health care professional. And while many adults are aware
vaccines are important many are not aware of the vaccines they
need.
As a part of every visit I go over with the patient
what vaccines are due. Often my patients are not aware that they
need vaccines. If the patient is reluctant to receive one or
more vaccines I try to address their concerns and provide
additional information as to why the vaccine is important.
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The third strategy IHS implements is to administer
needed vaccines. Standing Orders are utilized so eligible nurses,
pharmacists, and other health care professionals can
administer vaccines without a physician exam.
It's really important to reduce barriers to receiving
immunizations. At our facility we have Standing Orders in place
for all recommended vaccines. This means patients come in and
receive vaccines they are due for without having to make an
appointment with a provider. During influenza season many of
our sites use their pharmacists to provide walk-in influenza
vaccines at the pharmacy or another location in the
facility.
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Some sites have even expanded pharmacy-based influenza
immunization clinics to cover other vaccines such as
Pneumococcal, Zoster and Tdap. The final strategy IHS
implements during every vaccine administration encounter is to
document the vaccine in the EHR. This ensures that clinical
decision support can accurately identify vaccines that are due.
Documentation in the EHR also enables providers to use the
tools in the IHS EHR to monitor immunization coverage levels,
generate lists of patients who are due for a vaccine, and print
reminder letters. Many state immunization information systems
offer similar tools which is why IHS works with states to
electronically share immunization information.
I think the process we have for vaccinations at IHS could easily
be replicated in other practice settings that have an EHR. The
provider reminders we have in the IHS EHR are probably one of
the main reasons that vaccine coverage among our adult patient
is so high. Adults served by IHS tribal and urban indian clinics
have higher converage compared to the general U.S. population
with most adult vaccines. We have achieved this by leveraging
existing systems such as our EHR to assist providers in assessing
patient needs and reminding them and their patients when they are
due for vaccines. We have also expanded access to vaccines in
facilities by implementing standing orders and walk-in and
pharmacy-based immunization clinics. All of which makes it
much easier for patients to get recommended vaccines. While all
of these strategies take committment many can be easily
implemented by most health care systems and providers. And the
benefit, protecting adults from serious and life-threatening
vaccine preventable diseases, is worth it.
You can use strategies similar to those of IHS to implement the
Standards in your own practice. Actions as simple as assessing,
and recommending vaccinations can have a tremendous impact on
protecting adults in your community from vaccine-
preventable diseases. And remember, health care
professionals need protection too. Your recommendation to your
patients can be stonger if you have been vaccinated yourself.
So make sure you and your colleagues are up to date on
your vaccinations.
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