An effective and economical vaccine for invasive infections with Streptococcus pneumoniae, the most common cause of pneumonia, has been available since 1983, notes lead researcher Susan Ray, M.D., from the Emory University School of Medicine. Yet vaccination rates remain low, especially among non-white minorities and the elderly. As a result, as many as 30 people in 100,000 develop invasive infections (bloodstream infections, meningitis) with this pneumonia pathogen each year, almost half of them affected by expensive-to-treat antibiotic-resistant strains.
A favored protocol for improving vaccination rates among hospital patients, Ray explains, is a “standing order” – that is, permission for nurses to identify good vaccination candidates and order the shots themselves. Unfortunately, some institutions believe that standing orders for hospital patients are precluded by their state’s medical act and as such would make them vulnerable to malpractice suits.
Working at one such instutition -- a public teaching hospital in Atlanta -- Ray and her colleagues examined the impact of an alternative system. The researchers added screening for pneumonia vaccination to the nursing staff’s routine admitting procedures and added preprinted vaccine orders to patients’ charts on two hospital units. The nurses on those units flagged likely vaccination candidates for review by the doctors, who could rapidly authorize vaccination by signing the preprinted order.
The results showed that in the following month good candidates were 7.8 times more likely to receive the pneumonia vaccine on the test units than on two similar hospital units following standard procedures. Of 205 candidates on the trial units, 38 percent were vaccinated, compared to only 4.9 percent of the 143 good candidates on the comparison units.
Ray observes that while the 38 percent vaccination rate in the first trial is slightly lower than the mid-point of 51 percent seen in previous studies of standing orders, the intervention “reached a comparable vaccination rate to a standing-order program conducted at two community hospitals in Minnesota.” Moreover, the rate could have been even higher had more physicians become involved: “Over half [of the vaccine candidates] received care from a physician who failed to consider vaccination before discharge, creating an unnecessary missed opportunity,” Ray notes.
A second, hospital-wide, trial tested the effect of the new pneumonia vaccination protocol over a five-month period. Of 554 eligible patients identified, 16 percent were vaccinated before discharge.
Ray points to several factors that likely account for the lower vaccination rate in the second trial. Among these are the less frequent presence of surveillance monitors, the lesser intensity of staff training, staff turnover and a growing failure of clerical staff to insert the necessary forms in patient charts during the second study.
While there is evidence that the observed hospital-wide vaccination rate could be improved by addressing these and other factors, Ray concludes that “an intervention such as the one [employed in this study] can save lives and be cost-saving even with a 15 percent vaccination rate.” The researchers’ calculations indicate that “over a two-year period, the provider-reminder system [tested in this study] would result in savings of $924,838 in hospital charges, 76 fewer cases of invasive disease and 11 fewer deaths” at the host institution, according to Ray.
That makes “this type of project an opportunity to save money and lives” for this and similar institutions, Ray concludes.
This research was supported in part by a grant from the National Vaccine Program and the Centers for Disease Control and Prevention.
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