Improving Immunization Rates: The Impact of Evidence and Personal Practice

Purpose: The purpose of this project was to identify the impact of individual RN provider behavior on pneumococcal immunization rates of an at-risk adult population seen in ambulatory presurgical testing setting. 

 This project builds upon a previous study that investigated the effect of staff and patient education, coupled with monthly feedback to the staff, on pneumococcal immunization rates for eligible patients.  Following completion of the original project, the immunization rate for 12 months increased from 29% to 47% of eligible patients, a statistically significant finding.  However, the goal for that project was to achieve a 50% immunization rate and investigators were interested in what factors accounted for failure to meet that goal.

 Background: Despite compelling evidence that pneumococcal vaccination can significantly decrease the risk of developing pneumonia, a large proportion of the at-risk population have not been immunized. The economic and personal costs far outweigh the cost of effective immunizations but studies continue to indicate the need for effective strategies to immunize our at-risk groups.  Centers for Disease Control and Prevention estimates that only 19% of the at-risk population ages 19 to 64 has been immunized, while 65% of those greater than age 65 have been.

 Strategies for increasing immunization rates have targeted the behaviors of healthcare providers and at-risk groups. Examples of interventions include:a) screening though the use of the electronic medical record, b) use of standing orders to ensure administration of vaccines prior to patient discharge, c) addressing organizational barriers, d) targeted and structured health communications for patients and e) engagement of staff to increase immunization rates.  

These evidence-based strategies were the interventions implemented in the original study.

 In addition, the Institute of Medicine (IOM) strongly advocates the use of assessment (audit) and feedback loops of performance measures as a critical step toward improving quality of care.  This is behavioral intervention  includes key components of timeliness, individualization, and nonpunitiveness and has been effective in improving care in numerous settings. It focuses on the individual provider responsibility for success.

 Study: Investigators were interested in the quantifying individual RN performance to identify the impact of provider behavior on overall pneumococcal immunization rates in a PST? To what extent did variations in provider behavior influence the overall rate? 

 Method:  Retrospective data on individual providers were extracted from the electronic medical record for the 12 months of the study,  November 2013 to October 2014.  Descriptive statistics were calculated, detailing the number of eligible patients screened and the number and percentage successfully immunized.

 Findings: Vaccination rates for individual providers indicated that  26 nurses working in PST screened 2704 eligible patients; 16 of the RNs immunized  from 4.7 to 50% of eligible pts while 10 nurses immunized from 51%  to 87% of eligible patients.  Further breakdown indicated that 5 RNs immunized 20% or fewer than their eligible patients, while on 1 RN immunized more than 80% of her eligible patients.

 The nurse manager for the PST shared individualized data with RNs and explored factors that fostered or impeded successful immunizations. Comments from RNs indicated that some did not believe in immunizations while others found it too time consuming to administer.  On the success side, RNs noted that they told the patients that the pneumococcal vaccination would benefit their health and might prevent pneumonia. 

 Conclusion: Individual variations in practice accounted for an over-all less than successful pneumococcal immunization rate for the eligible patients.  In efforts to improve quality of patient care and measurable outcomes, it is important to analyze the individual provider efforts in achieving success and address personal barriers to compliance.  Availability of detailed information regarding provider behavior, in a timely manner, is essential to the success of this type of feedback.

 Next steps:  This project is part of an on-going study that will look at the impact of monthly, individualized feedback regarding performance. Each month, the nurse manager of the PST will provide each RN with information that includes the numbers of patients screened, the number of patients eligible for the pneumococcal immunization and the number of patients successfully immunized. Overall rates for the department will be tracked and reported at the same time. Staff members who exceed the departmental standard of immunizing 50% of eligible patients will be entered into a drawing for a $25 gift card quarterly. 

 At the time of the presentation, we will have data that details 6 months of data following implementation of the next phase of this work.   

 This study was deemed a quality improvement project by the Institutional Review Board of the hospital.