Infection Control feature - Shots on goal

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Providers are under pressure from regulators and others to vaccinate residents – and themselves – against influenza.

Call it a nifty, triple word play. Stephanie Mayoryk knows how to get points across when pushing for more co-workers to get their flu shots.
Her pointed needles make their point to fellow employees to earn – what else? – points at the Levindale Hebrew Geriatric Center and Hospital in Baltimore.
Get a flu shot and that's worth 5,000 LifeBridge points in your employee account. In other words, you're already beyond blender and magazine subscriptions and into the radios and watches realm.
This is the first year of the point-redemption program at Levindale. It comes on the heels of a successful prize-raffle for facility employees who received their flu shot last year.
Three years ago, Levindale suffered an outbreak of flu among resident and staff members. Averting "severe outcomes," the facility still had more than 24 residents fall ill. Routines were altered so much, trips to the dining room were cut off for about two weeks, and new admissions and therapy were interrupted over a three-week period.
More than 20 work shifts were lost, necessitating the use of expensive agency nurses, recalled Mayoryk, the facility's infection control practitioner.
Levindale's flu-shot campaign dovetails with federal regulators' enhanced resident vaccination tracking via MDS forms. It is also the start of the second flu season under the Centers for Medicare & Medicaid Services 2005 mandate that flu shots be offered to all nursing home residents.
On top of that, the Joint Commission on Accreditation of Healthcare Organizations plans to emphasize flu prevention under new national patient safety goals.

Poor role models
Experts trot out serious numbers when discussing flu costs: Each year more than 35,000 people, the majority of them elderly, die from the flu and related complications.
"Influenza is still a major killer of the elderly. It's a very frightening time in nursing homes," said Dr. Michael Carter, Distinguished Professor at the University of Tennessee Health Science Center in Memphis.
"It's always a disconcerting time for us in the nursing home," said Carter, who also is the medical director for a handful of nursing homes.
The most recent figures show resident vaccination rates were about 63% in 2005, according to Dr. Abigail Shefer, an immunizations specialist with the Centers for Disease Control and Prevention.
"It should be 90%," Shefer said, referring to federal goals for 2010.
Just as worrisome is the languishing healthcare worker vaccination rate: 36%, according to the Association for Professionals in Infection Control and Epidemiology. The CDC's Shefer pegs the number at around 42%. Most agree the rate is somewhere within that range and has remained flat lately.
"Offering flu vaccine is a condition of participation for Medicare and Medicaid facilities," Shefer said. "I think you could go one step further. If you look at serious outcomes from the flu, the vaccine's very effective in preventing them."
She said the over-65 crowd always will have lower immunity levels than younger people. But flu vaccine is 30% to 70% successful in preventing illness in seniors, 70% effective against hospitalizations and 80% successful preventing death, she said.
"None of this is really wonderfully good, but (the shots) are better than nothing," said the University of Tennessee's Carter. "Now we have a rapid screening system we didn't have a year ago. In the past, if we had influenza, that was just unfortunate. Now, we have ways of screening residents we think may be having symptoms and then using medication to intervene."
Tamiflu can be used to alter the course of the illness, he said. "We know it won't prevent flu, but it can alter the immune system, so it might be lifesaving. Tamiflu has been around, but we haven't used it a lot."
Tamiflu still presents challenges for providers. For one, it must be started very quickly, before the flu hits hard. It also can be used as a preventative, with providers administering it to unaffected residents once a flu case has been diagnosed. But then significant cost issues can come into play.
"Each five-day course of Tamiflu is $75, so that's three times as costly as vaccine," notes Dr. Greg Gahm, the medical director who oversees care for about 2,500 residents in Evercare's Colorado facilities, as well as 1,000 other seniors.
He said that added costs could soar into the "thousands" if a facility discovers a few flu cases and decides to distribute Tamiflu as a preventive measure to each resident.
Evercare covers the $20 cost for each employee willing to be vaccinated. Gahm noted: "It's much cheaper to prevent than treat."

Peak performance
There is no reason to be comfortable with current flu-fighting efforts, Gahm said.
"We're not getting better (at it)," he said. "The last 14 years, vaccination rates in the elderly have gotten better, but death rates from influenza are not getting better."
Gahm thinks that's because not enough clinicians follow his unorthodox immunization schedule.
"Antibodies peak within two weeks (of vaccination) and then start dropping off quickly" in the elderly, he explained. "In eight to 10 weeks, almost all of them have no antibodies left."
So instead of vaccinating patients in October or November, months the CDC recommends, Gahm said he tracks flu transmission in surrounding states. If he can wait to vaccinate until mid-December, he does.
"It might make some people uneasy, but by doing that, we're getting them two to three weeks before the flu hits Colorado. That way they're peaking with more antibodies," he said.
If there are no earlier outbreaks, he holds off vaccinating his parents, both in their 80s, until the day after Christmas, he said.
Most others, however, follow the CDC guidelines more closely during flu season, which runs from about October to March each year.
"The ideal time is about the end of October, into November," says Jane Potter, M.D., president of the American Geriatrics Society. "They take a few weeks to get protected and get effective immunity for four months."
She said the vaccine works best if about 90% of "the herd, including administrators," is vaccinated. "I don't see that emphasized often enough," she says.
"You can carry the virus asymptomatically and spread it in the facility before you appreciate you're ill and take off work," Potter added. "It's really about education (of employees) and appealing to their sense of correctness to get vaccinated."
The offer of a free lunch or other creative promotions also doesn't hurt, Potter said.
Emphasize to employees that flu vaccine cannot make them sick. Often, other conditions that arise are blamed on flu shots, experts say.
Remind employees, too, that if they get sick, that places a double-burden on the facility. Residents will need to be isolated, work schedules will be jumbled and a sick worker's own family could be put at risk.
That's why basics are drilled into employees, visitors and residents each flu season. Washing hands has become a little easier in some places, thanks to a new federal regulation that allows broader use of alcohol gel dispensers.
With more drug-resistant organisms circulating than ever before, there are more facility-acquired infections occurring, noted Sherry Brereton, vice president of marketing at Care-Tech Labs, a manufacturer of over-the-counter drugs designed to treat or prevent topical infection.
"It's an even more appropriate time for washing hands, but also for a good antimicrobial cleansing of patients," Brereton said.
She also advised scrubbing hard surfaces with disinfectant and having somebody scrub air ducts and vents, "especially in patient rooms" during flu season.

Breathing easier
All is not high anxiety or gloom about flu season. Evercare's Gahm, for example, believes long-term care residents' vaccination rates may be higher than advertised. Because tracking has largely been through billing records, individuals may not be counted if they receive their flu shot from a non-traditional provider.
And when it comes to lingering concerns about federal regulators' 2005 mandate to start offering flu shots to all nursing home residents, there apparently are few or none.
"The rule doesn't distress me particularly," says Evvie Munley, a survey and certification specialist with the American Association of Homes & Services for the Aging. "Documentation was a concern, but CMS didn't specify an exact protocol. There is some more documentation for members, but I haven't heard any feedback yet."
Sandy Fitzler of the American Health Care Association also said previous concerns have not mushroomed into anything serious. She said the new MDS section for vaccinations (Section W) isn't long and is an easier way to collect better data.
Increased focus on flu preparedness recently has helped educate many providers, she added. Supply and then distribution challenges brought the spotlight to flu shots in recent years. Those, combined with a recent wave of flu pandemic concerns, have only made providers more alert, she feels.
"The attention placed on pandemic possibilities has raised the whole awareness of vaccine issues that we have," Fitzler said. "That's been a positive. Many members have been providing vaccine for residents for many years, but this has raised more awareness for the employee population, as well."
With the help of last year's raffle promotion, the staff vaccination rate at Levindale Hebrew soared to 85%, up from 36%, said Mayoryk.
"It brought forth many people who didn't do it before. It curbed their myths. They didn't get sick and didn't have adverse reactions," Mayoryk said. "Peer pressure really works. They see the lines forming and want to be part of the unit that gets the most vaccinated. If you can get 60% of the staff vaccinated, you can really curb outbreaks.
"We were able to eradicate some diseases because people got vaccinated against them," she added. "I think with influenza, you could do the same thing."

Getting your best shots in

The American Geriatrics Society recommends the following vaccinations for most older adults:

Flu shot
What it does: Protects against the influenza virus
Who needs it: Anyone who's 50 or older, lives in a nursing home, or has a serious health condition such as heart disease, diabetes, asthma, lung disease or HIV. However, people who are allergic to eggs and have demonstrated allergic reactions to flu shots or had Guillian-Barre Syndrome should not get the shot.
When to get it: Every year, ideally in October or November.

Pneumococcal shot
What it does: Protects against pneumococcal bacteria, which can cause pneumonia, blood and brain infections.
Who needs it: Anyone who needs a flu shot.
When to get it: Only once, unless you had the shot before turning 65, in which case you'll need a "booster" shot after 5 years.

Tetanus/Diphtheria shot
What it does: Protects against two potentially deadly bacterial infections.
Who needs it: Everyone.
When to Get It: Once every 10 years.

AGS also recommends the new Herpes zoster (Shingles) shot for most adults 60 and older. It recommends additional shots – including the Measles, Mumps, Rubella (MMR) vaccination, and shots for Varicella, Hepatitis A and B, and Meningococcal disease – for older adults at increased risk of these diseases.

Source: American Geriatrics Society, 2006