Research Article
Evaluation of Inpatient Influenza and Pneumococcal Vaccination Acceptance Rates With Pharmacist Education
Journal of Pharmacy Practice 2017, Vol. 30(2) 202-208 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0897190016628963 journals.sagepub.com/home/jpp
Brenda V. Queeno, PharmD1
Abstract Objectives: To detail the implementation of a pharmacist-driven education program targeting patients who originally declined pneumococcal or influenza vaccination upon hospital admission and to evaluate the results. Methods: Patients admitted to a small community hospital who qualified to receive pneumococcal polysaccharide or influenza vaccination but declined upon admission were educated in person by pharmacists or pharmacy interns and reoffered vaccination. Patient education sheets were provided. Data were obtained via pharmacy intervention documentation in the pharmacy order entry system. Staff documented the outcome of counseling for each patient. Results: A total of 214 and 83 patients receiving influenza and pneumococcal vaccination counseling, respectively, were evaluated. As a result, 23.4% (P ¼ .06) and 26.5% (n ¼ 83, P ¼ .18) of patients agreed to receive influenza and pneumococcal vaccines, respectively. An unanticipated subset of patients were undecided after counseling and wanted to consider the information further before making a final decision. Taken together with those who consented to receive the vaccine after counseling, 39.2% (P ¼ .001) and 45.8% (P ¼ .01) of patients were influenced by the influenza and pneumococcal vaccination counseling, respectively. Conclusion: Patient education performed by a pharmacist or pharmacy intern showed a trend toward increased pneumococcal and influenza vaccination acceptance rates for inpatients who had initially declined. Keywords influenza, vaccination, pneumococcal, pharmacist, education
Introduction Pneumococcus pneumonia, invasive pneumococcal infections, and seasonal influenza are preventable diseases that vastly affect the United States. Pneumonia kills more people in the United States each year than all other vaccine-preventable diseases combined.1 Pneumococcal pneumonia has been documented as the most common clinical presentation of pneumococcal disease in the adult population.2 Greater than 95% of deaths attributable to pneumonia in the United States are seen in adults.3 Additionally, approximately 3300 deaths resulted from pneumococcal meningitis and bacteremia in the United States in 2012.3 It is estimated that in the United States in 2007, more than 40 000 cases of pneumococcal disease occurred, resulting in more than 4000 deaths.4 More than half of the cases occurred in adults who were recommended to receive the pneumococcal polysaccharide vaccine. Surveillance of pneumococcal vaccination in 2011 demonstrated that 62.3% of adults 65 years old were vaccinated against pneumococcal disease and only 20.1% of patients aged 64 years old who met high-risk criteria were vaccinated.5 Approximately 70 million high-risk adults remain vulnerable to pneumococcus by remaining unvaccinated according to the 2007 National Health Interview
Survey by the Centers for Disease Control and Prevention (CDC).6 The number of influenza-related deaths have been steadily increasing in the United States since 1990. During the 2012 to 2013 influenza season, the CDC estimated that vaccination resulted in 79 000 (17%) fewer hospitalizations than otherwise may have occurred.3 Based on estimates of the percentage of influenza illnesses that involve hospitalization or medical attention, vaccination also prevented close to 6.6 million influenza illnesses and 3.2 million medically attended illnesses.7 If patients qualify, the best way to protect against influenza and pneumococcal disease is by receiving the respective vaccinations. However, in the United States, only 41.5% of adults 18 years old were vaccinated during the 2012 to 2013 influenza season.8
1
Kenmore Mercy Hospital, Kenmore, NY, USA
Corresponding Author: Brenda V. Queeno, Kenmore Mercy Hospital, 2950 Elmwood Ave, Kenmore, NY 14217, USA. Email: [email protected]
Queeno Today, pharmacists are recognized as immunizers in the community setting in various states in the country after completion of training and certification. An increase in vaccination rates has been shown in the community due to pharmacists becoming accessible immunizers.9,10 Pharmacist-driven interventions including public advertising, personalized letters, and vaccination programs directed toward patients who qualify for immunization have been shown to increase vaccination rates in the community.11,12 In addition to an increase in accessibility and advertising resulting in positive outcomes, pharmacists in the past have demonstrated the effectiveness of patient education resulting in increased medication adherence.13-16 A study was recently published, which detailed the effects of a student pharmacist consultation on patient knowledge and attitudes about vaccines at free health care and immunization clinics.17 The results of the study suggested patient consultation improves attitudes toward vaccines and may potentially increase vaccination rates in the community. During the H1N1 pandemic outbreak, student pharmacists educated patients regarding vaccination.18 Educational interventions were shown to significantly improve patient knowledge and comfort with receiving pharmacist-provided immunization. In addition to the community setting, pharmacists may serve a key role in increasing vaccination rates within a hospital setting.19 In the past, elderly inpatient awareness of the pneumococcal vaccine has been shown to significantly predict vaccination.20 Literature has been published detailing a hospital pharmacistmanaged vaccination standing order program, computerized physician reminder programs, leaving chart reminders for physicians, and flagging of high-risk patients, which all resulted in an increase in hospital vaccinations.21-26 However, literature detailing the effects of pharmacist-driven education on inpatient vaccination acceptance is lacking. In our community hospital, we identified an opportunity to involve our pharmacy department in an attempt to improve vaccination acceptance. A pharmacist-driven counseling program was developed and implemented targeting patients indicated to receive the seasonal influenza and/or pneumococcal polysaccharide vaccine who had initially declined when screened by nursing as part of a nurse-driven protocol. Through our efforts, we hoped to not only increase patient knowledge of vaccine safety and efficacy but also give our patients direct access to our pharmacists who are qualified to answer questions and discuss concerns. Indirectly, we also endeavored to further establish the pharmacist’s role in preventative health.
Background Prior to the initiation of the program, institutional review board approval was obtained. The pharmacist intervention program was initiated in a small 184-bed community hospital from October 2014 through March 2015. The program was executed during the chosen months to target the influenza season. When the program was implemented, there were 9 full-time pharmacists, 1 part-time pharmacist, 1 full-time lead pharmacist, 7 per diem pharmacists, and 12 interns. During the day from 0730 to
203
Patient evaluated for vaccination upon admission
Patient qualifies
Patient accepts
Patient declines
Patient does not qualify
No further action taken
Pharmacy department alerted via daily report
Pharmacist or intern counsels patient regarding safety/efficacy and reoffers vaccination
Patient declines
Figure 1. Pharmacist-based intervention vaccine protocol.
1530, a decentralized clinical pharmacist was responsible for order entry, clinical monitoring, and counseling for one or more assigned patient care units. From 1700 to 2300, an intern was available for patient counseling.
Methods Procedure and Implementation Patients admitted to 5 of the 7 inpatient units were eligible for enrollment (a surgical floor and intensive care unit were excluded). Patients qualified for enrollment into the program if they were adult patients 18 years of age and older who had an indication to receive either the influenza or pneumococcal polysaccharide vaccine per the Advisory Committee on Immunization Practices recommendations, declined receipt of the vaccine after the initial offer by a nurse, were able to make their own health care decisions, and were alert and oriented. Patients were excluded if they had previously received vaccination within CDC time recommendations, did not qualify per CDC guidelines to receive vaccination, surgical or intensive care unit patients, or confused or otherwise unable to make their own health care decisions. Once the protocol was developed, the staff pharmacists and interns were in-serviced oneon-one and/or via an e-mail detailing the program (Figure 1). Patient education sheets were made for each vaccine and were distributed to staff for use during counseling (Figures 2 and 3). Upon admission to the hospital, patients were asked a series of
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Journal of Pharmacy Practice 30(2)
Influenza: Questions and Answers Information about the disease and vaccines What causes influenza? Viruses cause influenza. There are two basic types, A and B, which can cause clinical illness in humans. Their genetic material differentiates them. Influenza A can cause moderate to severe illness in all age groups and infects humans and other animals. Influenza B causes milder disease and affects only humans, primarily children. How serious is influenza? Although many people think of influenza as the ‘‘flu’’ or just a common cold, it is really a specific and serious respiratory disease that can result in hospitalization and death. In the United States, the number of influenza-associated deaths has increased since 1990. Influenza disease can occur among people of all ages. The risk of complications, hospitalizations, and deaths are higher among people age 65 years or older, young children, and people of any age who have certain medical conditions. What are possible complications from influenza? The most frequent complication of influenza is bacterial pneumonia. Viral pneumonia is a less common complication but has a higher fatality rate. Other complications include inflammation of the heart and worsening of pulmonary diseases (e.g., bronchitis). What is the best way to prevent influenza? The best way to prevent influenza is with seasonal vaccination. When did the influenza vaccine first become available? The first influenza vaccine in the United States became available in 1945. What kind of vaccine is it? The most common influenza vaccine is made from inactivated (killed) viruses. Most influenza vaccine contains 3 strains of influenza virus. How is the vaccine given? The inactivated vaccine is generally given as an intramuscular injection. Who should get influenza vaccine? Annual influenza vaccination is recommended for all people ages 6 months and older who do not have a contraindication to the vaccine. Who recommends the influenza vaccine? The Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), and the American College of Obstetricians and Gynecologists (ACOG) all recommend this vaccine. How often should this vaccine be given? Influenza vaccine is given each year because immunity decreases after a year and because each year’s vaccine is formulated to prevent only that year’s anticipated influenza viruses. When should people be vaccinated? Health experts recommend that patients may be vaccinated as soon as vaccine is available in their clinic, which can be as early as August or September. Vaccination should continue into the winter and spring and even as late as April or May. How safe is this vaccine? Influenza vaccine is very safe. The most common side effects of the injectable (inactivated) influenza vaccine include soreness, redness, or swelling at the site of the injection. These reactions are temporary and occur in 15%–20% of recipients. How effective is the influenza vaccine? Protection from influenza vaccine varies by the similarity of the vaccine strains to the circulating strains, and the age and health of the recipient. When the ‘‘match’’ between vaccine and circulating strains is close, the injectable (inactivated) vaccine prevents influenza in about 50%–70% of healthy people younger than age 65 years. Among elderly nursing home residents, the shot is most effective in preventing severe illness, secondary complications, and deaths related to influenza. Can the vaccine cause influenza? No! The injectable influenza vaccine contains only killed viruses and cannot cause influenza disease. Fewer than 1% of people who are vaccinated develop influenza-like symptoms, such as mild fever and muscle aches, after vaccination. These side effects are not the same as having the actual disease. Protective immunity develops 1 to 2 weeks after vaccination. It is always possible that a recently vaccinated person can be exposed to influenza disease before their antibodies are formed and consequently develop disease. Who should NOT receive influenza vaccine? In general, the inactivated (injectable) influenza vaccine can be given to most everyone except children younger than age 6 months, people with a history of a severe allergic reaction to eggs, or to a previous dose of influenza vaccine. People with a history of Guillain-Barre´ syndrome should also consult with their physician before receiving this vaccine. People who are moderately or severely ill at the time of their influenza vaccination appointment should check with their doctor before getting the vaccine. Most brands of influenza vaccine are packaged in vials or syringes that contain natural rubber or latex. People with a severe allergy to latex generally should not receive vaccine packaged in these vials or syringes. There are vaccines available packaged in latex free syringes for such patients. Who can I contact if I have more questions? Please contact the pharmacy department. We will gladly answer any remaining questions you may have at xxx-xxx-xxxx ext x.
Figure 2. Patient education sheet for influenza vaccine.
Queeno
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Pneumococcal Vaccines — How serious is pneumococcal disease? Pneumococcal disease is a serious disease that causes sickness and can be fatal. In fact, it kills more people in the United States each year than all other vaccine-preventable diseases combined. It is estimated that in the United States in 2007, more than 40,000 cases and more than 4,000 deaths occurred from invasive pneumococcal diseases (bacteremia and meningitis). More than half of the cases occurred in adults who were recommended to receive pneumococcal vaccine. Children younger than age 5 and adults older than 65 have the highest incidence of serious disease. Despite appropriate antimicrobial therapy and intensive medical care, the overall case-fatality rate for pneumococcal bacteremia is about 20% among adults. Among elderly patients, the rate may be as high as 60%. Who is recommended to receive pneumococcal polysaccharide vaccine (PPSV23)? PPSV23 is recommended for anyone who meets any of the criteria below: Age 65 years and older Age 2 through 64 years with any of the following conditions cigarette smokers age 19 years and older alcoholism chronic liver disease, cirrhosis chronic cardiovascular disease, excluding hypertension (e.g., congestive heart failure, cardiomyopathies) chronic pulmonary disease (including COPD and emphysema, and for adults age 19 years and older, asthma) diabetes mellitus candidate for or recipient of cochlear implant cerebrospinal fluid (CSF) leak functional or anatomic asplenia (e.g., sickle cell disease, splenectomy) immunocompromising conditions (e.g., HIV infection, leukemia, congenital immunodeficiency, Hodgkin’s disease, lymphoma, multiple myeloma, generalized malignancy, immunosuppressive therapy) solid organ transplantation chronic renal failure or nephrotic syndrome How many doses of PPSV are needed, and when? Usually only one dose of PPSV is needed, but under some circumstances a second dose may be given. A second dose is recommended for people 65 years and older who received their first dose when they were younger than 65 and has been 5 or more years since. A second dose is recommended for people 2 through 64 years of age who: have a damaged spleen or no spleen have sickle-cell disease have HIV infection or AIDS have cancer, leukemia, lymphoma, multiple myeloma have nephrotic syndrome have had an organ or bone marrow transplant are taking medication that lowers immunity (such as chemotherapy or long-term steroids) When a second dose is given, it should be given 5 years after the first dose. What are the risks of the vaccination? About half of people who get PPSV have mild side effects, such as redness or pain where the shot is given. Less than 1% develop a fever, muscle aches, or more severe local reactions. A vaccine could cause a serious reaction like any medicine. However, the risk of a vaccine causing serious harm, or death, is extremely low. What should I look for if I think I am experiencing a severe reaction? Look for any unusual changes such as signs of a severe allergic reaction, very high fever, or behavior changes. Signs of a severe allergic reaction can include hives, swelling of the face and throat, difficulty breathing, a fast heartbeat, dizziness, and weakness. These can start a few minutes to a few hours after vaccination. Who should wait to get vaccinated? Anyone who has had a life-threatening allergic reaction to PPSV should not get another dose. Anyone who has a severe allergy to any component of a vaccine should not receive that vaccine. Tell your doctor if you have any severe allergies. Anyone who is moderately or severely ill when the shot is scheduled may be asked to wait until they recover before receiving the vaccine. Someone with a mild illness can usually be vaccinated. What if I have more questions? Please contact the pharmacy department. We will gladly answer any remaining questions you may have at xxx-xxx-xxxx ext x.
Figure 3. Patient education sheet for pneumococcal vaccine.
questions by nursing to determine whether he or she qualified to receive either the influenza or pneumococcal polysaccharide vaccination per current CDC guidelines. If the patient initially
declined to receive vaccination, the pharmacy department was alerted the following morning via an automatically generated report. Patients appearing on the report were briefly counseled
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Journal of Pharmacy Practice 30(2) Table 1. Reasons for Declining Vaccination.
Influenza Vaccinaon Results n = 214* Number of Paents
60
Influenza (n ¼ 130)
Pneumococcal (n ¼ 45)
47 32 8 1 1 41
18 12 1 2 0 12
50
Declined explanation Fear of adverse effects Does not believe in efficacy Fear of needles Religious Undocumenteda
40 30 20 10 0 October
November December
January
February
March
Month Accepted
Declined
a
Represents the number of interventions where the pharmacist or student failed to document reason for decline.
Uncertain
Figure 4. *Nineteen patients who stated he or she preferred to receive vaccination from primary doctor or community pharmacist or place of employment were excluded from sample size.
Statistical Analysis All data collected are categorical, presented as percentages, and analyzed using the w2 test. A P value less than .05 was considered statistically significant. All statistical calculations were performed using Minitab (version 16.2.2; Minitab Inc, State College, Pennsylvania).
Results During the 6 months that the program was in effect, a total of 323 patients were counseled, of which 233 patients were counseled regarding influenza vaccination and 90 patients for pneumococcal vaccination. When counseled, 26 patients stated that he or she preferred to receive vaccination from his or her primary medical doctor’s office, personal pharmacy, or place of employment (19 patients for influenza and 7 for pneumococcus). These patients were excluded from the total number of evaluable patients since the decision to receive the vaccine had already been made. In effect, our intervention would not have changed the ultimate decision to receive. Therefore, of the entire sample size, only 214 and 83 interventions were evaluable for influenza and pneumococcus, respectively. This resulted in a total of 297 evaluable interventions made. Printed counseling materials were still left with patients wishing to be vaccinated elsewhere.
25 Number of paents
by a pharmacist or intern in person for approximately 5 minutes regarding vaccine safety and efficacy and were provided written information. Once counseling was complete, the patient was reoffered the appropriate vaccine. The outcome of each counseling session was documented as an intervention in the pharmacy order entry system allowing for data extraction. Outcomes were documented as declined vaccine, accepted vaccine, or uncertain. If declined, the staff were instructed to specifically document the patient’s reason for declination. This included fear of adverse effects, religious beliefs, or any other cited reason.
Pneumococcal Vaccinaon Results n = 83* 20 15 10 5 0 October
November December
January
February
March
Month Accepted
Declined
Uncertain
Figure 5. *Seven patients who stated he or she preferred to receive vaccination from primary doctor were excluded from sample size.
For influenza vaccine counseling, a total of 214 evaluable interventions were made. Among the 214 interventions, 50 (23.4%, P ¼ .06) patients consented to vaccination, 34 (15.9%) were uncertain, and 130 (60.7%) still declined (Figure 4 and Table 1). From the initial 214 who refused, 84 (39.2%, P ¼ .001) were influenced by the counseling and either consented or wanted to give it further thought. A total of 83 evaluable interventions were recorded for pneumococcal vaccination counseling. From the 83 interventions, 22 (26.5%) patients consented to vaccination, 16 (19.3%) were uncertain, and 45 (54.2%) still declined (Figure 5 and Table 1). From the initial 83 who refused, 38 (45.8%, P ¼ .01) were influenced by the counseling and either consented or were giving it further thought.
Discussion The goal of this pharmacy-driven education program was to convince patients who on admission declined influenza and/or pneumococcal polysaccharide vaccine of their safety and efficacy and to obtain consent for vaccination. This article describes the impact of this counseling program. Various studies have been conducted in the past to support how valuable pharmacist counseling is in regard to patient knowledge and medication adherence.12-16 This study is similar to the positive outcomes of those studies in the sense that our patients showed an increase in acceptance to preventative
Queeno therapy by way of vaccine secondary to counseling. Our results show that education by a pharmacist or pharmacy intern of patients refusing influenza or pneumococcal vaccination showed a trend toward increased vaccination acceptance rates with 23.4% (n ¼ 214, P ¼ .06) and 26.5% (n ¼ 83, P ¼ .18) agreeing to receive influenza and pneumococcal vaccines, respectively. An unanticipated subset of patients were undecided after counseling and wanted to consider the information further before making a final decision. For influenza, this accounted for 34 (15.9%) patients and for pneumococcal 16 (19.3%) patients. Taken together with those who consented to receive the vaccine, 39.2% (P ¼ .001) and 45.8% (P ¼ .01) of patients were influenced by the influenza and pneumococcal vaccination counseling, respectively. In addition to increased protection for the individual patient once vaccinated, one could extrapolate a potential for decrease in transmission rates in the community as vaccination protects not only the patient but also those who come in contact with them. To our knowledge, no studies have been done to date explaining the effect of pharmacist counseling on inpatient vaccination acceptance rates. When the program was initiated, the possibility of patients remaining uncertain of receiving vaccination after pharmacist counseling was not taken into account. In preparation for next year’s seasonal influenza vaccination program, we will work to establish a process to follow-up with those unsure patients to establish an acceptance or declination to vaccination. It was found that many of the patients who were uncertain preferred to evaluate the printed information alone or with a family member. Perhaps, allowing those patients more time to digest the education materials and revisiting later may have resulted in an increased acceptance. A large amount of patients refused to give any additional explanation for declining vaccination. Upon review of the pharmacist/intern documentation, many of those patients stated they had never received the influenza or pneumococcal vaccine and simply did not want to receive. A similar number of logged interventions failed to document any explanation for the declination. In future seasons, we will reinforce pharmacists and interns the need to document specific reasons for declination. A smaller portion of patients cited the fear of adverse effects to be the reason for decline along with only 1 patient refusing due to religious beliefs. For the future, it may be advantageous to obtain additional information regarding the reason why a patient initially declined vaccination. With such information, the pharmacist or intern would be able to prepare and tailor the presentation to address the concerns of the patient. It was noted that the highest acceptance rate for influenza was seen in October (22 patients, 43.1%) and the lowest was seen in March (1 patient, 3.6%). This can most likely be attributed to the fact that influenza season is nearing its end in April. A larger number of patients were counseled for influenza vaccination at the beginning of the season than compared to the end of the season. At the beginning and peak of flu season, patients appear to be much more aware of the prevalence of disease and thus may be more likely to agree to immunization. Toward the end of flu season, patients are surrounded less with
207 reminders of prevalent disease and thus may lose a sense of urgency. Also, those who could more easily be convinced may have already been convinced by another health care provider. Pneumococcal vaccine acceptance rates varied throughout the program and did not establish a predictable pattern. The pneumococcal portion of the program is not limited to the influenza season and is ongoing since the vaccine can be offered to patients at any time. One limitation of our study was interpersonal reliability in delivery since there were multiple pharmacists and interns involved. Therefore, style of delivery and persuasiveness varied between staff. However, each person involved utilized the same education sheets when presenting information to patients. A second limitation of our study was our delayed start date. Patient evaluation for qualification to receive the influenza vaccine upon hospital admission per hospital protocol began in September. Prior to implementation, pharmacy sought to obtain approval from various disciplines to begin the program. Additionally, educating the pharmacy staff took place through September. If the program had been ready to start at the beginning of September, a potentially much larger number of patients could have been counseled. Lastly, a third limitation was the reported reduced protection of the influenza vaccine for H3N2 virus in the 2014 to 2015 season.27 The CDC reported in February that the updated vaccine effectiveness was estimated at 18% for H3N2 and at 45% for influenza B. The publicity of reduced vaccine effectiveness may have influenced patients’ decision to not receive the vaccination. Despite the limitations to our study, this was the first study done to examine the impact of a pharmacist-driven education program on vaccination acceptance in patients who had originally declined. Future studies focusing on pharmacist-driven education and the impact on acceptance rates are warranted to establish support and a collection of evaluable results.
Conclusion A pharmacist-driven counseling program was implemented in a small community hospital targeting patients who initially declined pneumococcal polysaccharide and influenza vaccination upon admission. Our data suggest that the program resulted in a trend toward greater acceptance rates for both vaccinations. Further studies are needed to determine whether earlier implementation of the program at the beginning of the flu season may have further increased acceptance rates for the influenza vaccination. Acknowledgments Brenda V. Queeno would like to thank Jaclyn Kotula, PharmD, and Ariana Savovic, PharmD (who were both interns at the time), for their significant contributions and initial idea for the vaccination education program. She would also like to graciously thank Jim M. Bartlett, PharmD, BCPS, and Patricia L. Siola, BS Pharmacy, MBA, PhD, FASHP, FACHE (Director of Pharmacy) along with all of the pharmacists and interns at Kenmore Mercy Hospital, which made the success of this program possible.
208 Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Centers for Disease Control and Prevention. Vaccines and immunizations. Web site. www.cdc.gov/vaccines/pubs/pinkbook/ pneumo. Updated September 8, 2015. Accessed May 15, 2015. 2. Atkinson W, Wolfe S, Hamborsky J. Centers for Disease Control and Prevention. Epidemiology and Prevention of VaccinePreventable Diseases. 12th ed. Washington, DC: Public Health Foundation; 2012. 3. Centers for Disease Control and Prevention. Active Bacterial Core Surveillance Report, Emerging Infections Program Network, Streptococcus pneumoniae, 2012. Atlanta, GA: Centers for Disease Control and Prevention; 2013 4. Pilishvili T, Lexau C, Farley MM, et al; Active Bacterial Core Surveillance/Emerging Infections Program Network. Sustained reductions in invasive pneumococcal disease in the era of conjugate vaccine. J Infect Dis. 2010;201(1):32-41. 5. Centers for Disease Control and Prevention. National Health Interview Survey 2011. Web site. www.cdc.gov. Updated December 14, 2011. Accessed May 15, 2015. 6. Centers for Disease Control and Prevention. National Health Interview Survey 2007. Web site. www.cdc.gov. Updated April 16, 2013. Accessed May 5, 2015. 7. Lu PJ, Santibanez TA, Williams WW, et al; Centers for Disease Control and Prevention (CDC). Estimated influenza illnesses and hospitalizations averted by influenza vaccination-United States, 2012-13 influenza season. MMWR Morb Mortal Wkly Rep. 2013; 62(49):997-1000. 8. Centers for Disease Control. Surveillance of influenza vaccination coverage—United States, 2007-08 through 2011-12 influenza seasons. MMWR CDC Surveill Summ. 2013;62(4):1-28. 9. Grabenstein JD, Guess HA, Hartzema AG, et al. Effect of vaccination by community pharmacists among adult prescription recipients. Med Care. 2001;39(4):340-348. 10. Higginbotham S, Stewart A, Pfalzgraf A. Impact of a pharmacist immunizer on adult immunization rates. J Am Pharm Assoc. 2012;52(3):367-371. 11. Wang J, Ford LJ, Wingate L, et al. Effect of pharmacist intervention on herpes zoster vaccination in community pharmacies. J Am Pharm Assoc. 2013;53(1):46-53. 12. Spruil WJ, Cooper JW, Taylor WJ. Pharmacist-coordinated pneumonia and influenza vaccination program. Am J Hosp Pharm. 1982;39(11):1904-1906.
Journal of Pharmacy Practice 30(2) 13. Al-Rashed SA, Wright DJ, Roebuck N, et al. The value of inpatient pharmaceutical counseling to elderly patients prior to discharge. Br J Clin Pharmacol. 2002;54(6):657-664. 14. Lee JK, Grace KA, Taylor AJ. Effect of a pharmacy care program on medication adherence and persistence, blood pressure, and low-density lipoprotein cholesterol a randomized control trial. JAMA. 2006;296(21):2563-2571. 15. Murray MD, Young J, Hoke S, et al. Pharmacist intervention to improve medication adherence in heart failure: a randomized trial. Ann Intern Med. 2007;146(10):714-725. 16. Faulkner MA, Wadibia EC, Lucas BD, et al. Impact of pharmacy counseling on compliance and effectiveness of combination lipidlowering therapy in patients undergoing coronary artery revascularization: a randomized, controlled trial. Pharmacotherapy. 2000;20(4):410-416. 17. Chou TI, Lash DB, Malcolm B, et al. Effects of a student pharmacist consultation on patient knowledge and attitudes about vaccines. J Am Pharm Assoc. 2014;54(2):130-137. 18. Miller S, Patel N, Vadala T, et al. Defining the pharmacist role in the pandemic outbreak of novel H1N1 influenza. J Am Pharm Assoc. 2012;52(6):763-767. 19. Sokos DR. Pharmacists’ role in increasing pneumococcal and influenza vaccination. Am J Health Syst Pharm. 2005;62(4): 367-377. 20. Wong-Beringer, Brodetsky E, Quist R. Pneumococcal vaccination in hospitalized elderly patients: role of the pharmacist. Pharmacotherapy. 2003;23(2):199-208. 21. Bourdet SV, Kelley M, Rublein J, et al. Effect of a pharmacist managed program on pneumococcal and influenza vaccination rates among adult inpatients. Am J Health Syst Pharm. 2003; 60(17):1767-1771. 22. Klein RS, Adachi N. Pneumococcal vaccine in the hospital: improved use and implications for high-risk patients. Arch Intern Med. 1983;143(10):1878-1881. 23. Vondracek TG, Pham TP, Huycke MH. A hospital-based pharmacy intervention program for pneumococcal vaccination. Arch Intern Med. 1998;158(14):1543-1547. 24. Clancy CM, Gelfman D, Poses RM. A strategy to improve the utilization of pneumococcal vaccine. J Gen Intern Med. 1992; 7(1):14-18. 25. Dexter PR, Perkins S, Overhage JM, et al. A computerized reminder system to increase the use of preventive care for hospitalized patients. N Engl J Med. 2001;345(13):965-970. 26. Skledar SJ, McKaveney TP, Sokos DR, et al. Role of student pharmacist interns in hospital-based standing orders pneumococcal vaccination program. J Am Pharm Assoc. 2007;47(3): 404-409. 27. Centers for Disease Control and Prevention. Early estimates of seasonal influenza vaccine effectiveness- United States, January 2015. MMWR Morb Mortal Wkly Rep. 2015;64(1):10-15.
Evaluation of Inpatient Influenza and Pneumococcal Vaccination Acceptance Rates With Pharmacist Education
Journal of Pharmacy Practice 2017, Vol. 30(2) 202-208 ª The Author(s) 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0897190016628963 journals.sagepub.com/home/jpp
Brenda V. Queeno, PharmD1
Abstract Objectives: To detail the implementation of a pharmacist-driven education program targeting patients who originally declined pneumococcal or influenza vaccination upon hospital admission and to evaluate the results. Methods: Patients admitted to a small community hospital who qualified to receive pneumococcal polysaccharide or influenza vaccination but declined upon admission were educated in person by pharmacists or pharmacy interns and reoffered vaccination. Patient education sheets were provided. Data were obtained via pharmacy intervention documentation in the pharmacy order entry system. Staff documented the outcome of counseling for each patient. Results: A total of 214 and 83 patients receiving influenza and pneumococcal vaccination counseling, respectively, were evaluated. As a result, 23.4% (P ¼ .06) and 26.5% (n ¼ 83, P ¼ .18) of patients agreed to receive influenza and pneumococcal vaccines, respectively. An unanticipated subset of patients were undecided after counseling and wanted to consider the information further before making a final decision. Taken together with those who consented to receive the vaccine after counseling, 39.2% (P ¼ .001) and 45.8% (P ¼ .01) of patients were influenced by the influenza and pneumococcal vaccination counseling, respectively. Conclusion: Patient education performed by a pharmacist or pharmacy intern showed a trend toward increased pneumococcal and influenza vaccination acceptance rates for inpatients who had initially declined. Keywords influenza, vaccination, pneumococcal, pharmacist, education
Introduction Pneumococcus pneumonia, invasive pneumococcal infections, and seasonal influenza are preventable diseases that vastly affect the United States. Pneumonia kills more people in the United States each year than all other vaccine-preventable diseases combined.1 Pneumococcal pneumonia has been documented as the most common clinical presentation of pneumococcal disease in the adult population.2 Greater than 95% of deaths attributable to pneumonia in the United States are seen in adults.3 Additionally, approximately 3300 deaths resulted from pneumococcal meningitis and bacteremia in the United States in 2012.3 It is estimated that in the United States in 2007, more than 40 000 cases of pneumococcal disease occurred, resulting in more than 4000 deaths.4 More than half of the cases occurred in adults who were recommended to receive the pneumococcal polysaccharide vaccine. Surveillance of pneumococcal vaccination in 2011 demonstrated that 62.3% of adults 65 years old were vaccinated against pneumococcal disease and only 20.1% of patients aged 64 years old who met high-risk criteria were vaccinated.5 Approximately 70 million high-risk adults remain vulnerable to pneumococcus by remaining unvaccinated according to the 2007 National Health Interview
Survey by the Centers for Disease Control and Prevention (CDC).6 The number of influenza-related deaths have been steadily increasing in the United States since 1990. During the 2012 to 2013 influenza season, the CDC estimated that vaccination resulted in 79 000 (17%) fewer hospitalizations than otherwise may have occurred.3 Based on estimates of the percentage of influenza illnesses that involve hospitalization or medical attention, vaccination also prevented close to 6.6 million influenza illnesses and 3.2 million medically attended illnesses.7 If patients qualify, the best way to protect against influenza and pneumococcal disease is by receiving the respective vaccinations. However, in the United States, only 41.5% of adults 18 years old were vaccinated during the 2012 to 2013 influenza season.8
1
Kenmore Mercy Hospital, Kenmore, NY, USA
Corresponding Author: Brenda V. Queeno, Kenmore Mercy Hospital, 2950 Elmwood Ave, Kenmore, NY 14217, USA. Email: [email protected]
Queeno Today, pharmacists are recognized as immunizers in the community setting in various states in the country after completion of training and certification. An increase in vaccination rates has been shown in the community due to pharmacists becoming accessible immunizers.9,10 Pharmacist-driven interventions including public advertising, personalized letters, and vaccination programs directed toward patients who qualify for immunization have been shown to increase vaccination rates in the community.11,12 In addition to an increase in accessibility and advertising resulting in positive outcomes, pharmacists in the past have demonstrated the effectiveness of patient education resulting in increased medication adherence.13-16 A study was recently published, which detailed the effects of a student pharmacist consultation on patient knowledge and attitudes about vaccines at free health care and immunization clinics.17 The results of the study suggested patient consultation improves attitudes toward vaccines and may potentially increase vaccination rates in the community. During the H1N1 pandemic outbreak, student pharmacists educated patients regarding vaccination.18 Educational interventions were shown to significantly improve patient knowledge and comfort with receiving pharmacist-provided immunization. In addition to the community setting, pharmacists may serve a key role in increasing vaccination rates within a hospital setting.19 In the past, elderly inpatient awareness of the pneumococcal vaccine has been shown to significantly predict vaccination.20 Literature has been published detailing a hospital pharmacistmanaged vaccination standing order program, computerized physician reminder programs, leaving chart reminders for physicians, and flagging of high-risk patients, which all resulted in an increase in hospital vaccinations.21-26 However, literature detailing the effects of pharmacist-driven education on inpatient vaccination acceptance is lacking. In our community hospital, we identified an opportunity to involve our pharmacy department in an attempt to improve vaccination acceptance. A pharmacist-driven counseling program was developed and implemented targeting patients indicated to receive the seasonal influenza and/or pneumococcal polysaccharide vaccine who had initially declined when screened by nursing as part of a nurse-driven protocol. Through our efforts, we hoped to not only increase patient knowledge of vaccine safety and efficacy but also give our patients direct access to our pharmacists who are qualified to answer questions and discuss concerns. Indirectly, we also endeavored to further establish the pharmacist’s role in preventative health.
Background Prior to the initiation of the program, institutional review board approval was obtained. The pharmacist intervention program was initiated in a small 184-bed community hospital from October 2014 through March 2015. The program was executed during the chosen months to target the influenza season. When the program was implemented, there were 9 full-time pharmacists, 1 part-time pharmacist, 1 full-time lead pharmacist, 7 per diem pharmacists, and 12 interns. During the day from 0730 to
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Patient evaluated for vaccination upon admission
Patient qualifies
Patient accepts
Patient declines
Patient does not qualify
No further action taken
Pharmacy department alerted via daily report
Pharmacist or intern counsels patient regarding safety/efficacy and reoffers vaccination
Patient declines
Figure 1. Pharmacist-based intervention vaccine protocol.
1530, a decentralized clinical pharmacist was responsible for order entry, clinical monitoring, and counseling for one or more assigned patient care units. From 1700 to 2300, an intern was available for patient counseling.
Methods Procedure and Implementation Patients admitted to 5 of the 7 inpatient units were eligible for enrollment (a surgical floor and intensive care unit were excluded). Patients qualified for enrollment into the program if they were adult patients 18 years of age and older who had an indication to receive either the influenza or pneumococcal polysaccharide vaccine per the Advisory Committee on Immunization Practices recommendations, declined receipt of the vaccine after the initial offer by a nurse, were able to make their own health care decisions, and were alert and oriented. Patients were excluded if they had previously received vaccination within CDC time recommendations, did not qualify per CDC guidelines to receive vaccination, surgical or intensive care unit patients, or confused or otherwise unable to make their own health care decisions. Once the protocol was developed, the staff pharmacists and interns were in-serviced oneon-one and/or via an e-mail detailing the program (Figure 1). Patient education sheets were made for each vaccine and were distributed to staff for use during counseling (Figures 2 and 3). Upon admission to the hospital, patients were asked a series of
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Journal of Pharmacy Practice 30(2)
Influenza: Questions and Answers Information about the disease and vaccines What causes influenza? Viruses cause influenza. There are two basic types, A and B, which can cause clinical illness in humans. Their genetic material differentiates them. Influenza A can cause moderate to severe illness in all age groups and infects humans and other animals. Influenza B causes milder disease and affects only humans, primarily children. How serious is influenza? Although many people think of influenza as the ‘‘flu’’ or just a common cold, it is really a specific and serious respiratory disease that can result in hospitalization and death. In the United States, the number of influenza-associated deaths has increased since 1990. Influenza disease can occur among people of all ages. The risk of complications, hospitalizations, and deaths are higher among people age 65 years or older, young children, and people of any age who have certain medical conditions. What are possible complications from influenza? The most frequent complication of influenza is bacterial pneumonia. Viral pneumonia is a less common complication but has a higher fatality rate. Other complications include inflammation of the heart and worsening of pulmonary diseases (e.g., bronchitis). What is the best way to prevent influenza? The best way to prevent influenza is with seasonal vaccination. When did the influenza vaccine first become available? The first influenza vaccine in the United States became available in 1945. What kind of vaccine is it? The most common influenza vaccine is made from inactivated (killed) viruses. Most influenza vaccine contains 3 strains of influenza virus. How is the vaccine given? The inactivated vaccine is generally given as an intramuscular injection. Who should get influenza vaccine? Annual influenza vaccination is recommended for all people ages 6 months and older who do not have a contraindication to the vaccine. Who recommends the influenza vaccine? The Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), and the American College of Obstetricians and Gynecologists (ACOG) all recommend this vaccine. How often should this vaccine be given? Influenza vaccine is given each year because immunity decreases after a year and because each year’s vaccine is formulated to prevent only that year’s anticipated influenza viruses. When should people be vaccinated? Health experts recommend that patients may be vaccinated as soon as vaccine is available in their clinic, which can be as early as August or September. Vaccination should continue into the winter and spring and even as late as April or May. How safe is this vaccine? Influenza vaccine is very safe. The most common side effects of the injectable (inactivated) influenza vaccine include soreness, redness, or swelling at the site of the injection. These reactions are temporary and occur in 15%–20% of recipients. How effective is the influenza vaccine? Protection from influenza vaccine varies by the similarity of the vaccine strains to the circulating strains, and the age and health of the recipient. When the ‘‘match’’ between vaccine and circulating strains is close, the injectable (inactivated) vaccine prevents influenza in about 50%–70% of healthy people younger than age 65 years. Among elderly nursing home residents, the shot is most effective in preventing severe illness, secondary complications, and deaths related to influenza. Can the vaccine cause influenza? No! The injectable influenza vaccine contains only killed viruses and cannot cause influenza disease. Fewer than 1% of people who are vaccinated develop influenza-like symptoms, such as mild fever and muscle aches, after vaccination. These side effects are not the same as having the actual disease. Protective immunity develops 1 to 2 weeks after vaccination. It is always possible that a recently vaccinated person can be exposed to influenza disease before their antibodies are formed and consequently develop disease. Who should NOT receive influenza vaccine? In general, the inactivated (injectable) influenza vaccine can be given to most everyone except children younger than age 6 months, people with a history of a severe allergic reaction to eggs, or to a previous dose of influenza vaccine. People with a history of Guillain-Barre´ syndrome should also consult with their physician before receiving this vaccine. People who are moderately or severely ill at the time of their influenza vaccination appointment should check with their doctor before getting the vaccine. Most brands of influenza vaccine are packaged in vials or syringes that contain natural rubber or latex. People with a severe allergy to latex generally should not receive vaccine packaged in these vials or syringes. There are vaccines available packaged in latex free syringes for such patients. Who can I contact if I have more questions? Please contact the pharmacy department. We will gladly answer any remaining questions you may have at xxx-xxx-xxxx ext x.
Figure 2. Patient education sheet for influenza vaccine.
Queeno
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Pneumococcal Vaccines — How serious is pneumococcal disease? Pneumococcal disease is a serious disease that causes sickness and can be fatal. In fact, it kills more people in the United States each year than all other vaccine-preventable diseases combined. It is estimated that in the United States in 2007, more than 40,000 cases and more than 4,000 deaths occurred from invasive pneumococcal diseases (bacteremia and meningitis). More than half of the cases occurred in adults who were recommended to receive pneumococcal vaccine. Children younger than age 5 and adults older than 65 have the highest incidence of serious disease. Despite appropriate antimicrobial therapy and intensive medical care, the overall case-fatality rate for pneumococcal bacteremia is about 20% among adults. Among elderly patients, the rate may be as high as 60%. Who is recommended to receive pneumococcal polysaccharide vaccine (PPSV23)? PPSV23 is recommended for anyone who meets any of the criteria below: Age 65 years and older Age 2 through 64 years with any of the following conditions cigarette smokers age 19 years and older alcoholism chronic liver disease, cirrhosis chronic cardiovascular disease, excluding hypertension (e.g., congestive heart failure, cardiomyopathies) chronic pulmonary disease (including COPD and emphysema, and for adults age 19 years and older, asthma) diabetes mellitus candidate for or recipient of cochlear implant cerebrospinal fluid (CSF) leak functional or anatomic asplenia (e.g., sickle cell disease, splenectomy) immunocompromising conditions (e.g., HIV infection, leukemia, congenital immunodeficiency, Hodgkin’s disease, lymphoma, multiple myeloma, generalized malignancy, immunosuppressive therapy) solid organ transplantation chronic renal failure or nephrotic syndrome How many doses of PPSV are needed, and when? Usually only one dose of PPSV is needed, but under some circumstances a second dose may be given. A second dose is recommended for people 65 years and older who received their first dose when they were younger than 65 and has been 5 or more years since. A second dose is recommended for people 2 through 64 years of age who: have a damaged spleen or no spleen have sickle-cell disease have HIV infection or AIDS have cancer, leukemia, lymphoma, multiple myeloma have nephrotic syndrome have had an organ or bone marrow transplant are taking medication that lowers immunity (such as chemotherapy or long-term steroids) When a second dose is given, it should be given 5 years after the first dose. What are the risks of the vaccination? About half of people who get PPSV have mild side effects, such as redness or pain where the shot is given. Less than 1% develop a fever, muscle aches, or more severe local reactions. A vaccine could cause a serious reaction like any medicine. However, the risk of a vaccine causing serious harm, or death, is extremely low. What should I look for if I think I am experiencing a severe reaction? Look for any unusual changes such as signs of a severe allergic reaction, very high fever, or behavior changes. Signs of a severe allergic reaction can include hives, swelling of the face and throat, difficulty breathing, a fast heartbeat, dizziness, and weakness. These can start a few minutes to a few hours after vaccination. Who should wait to get vaccinated? Anyone who has had a life-threatening allergic reaction to PPSV should not get another dose. Anyone who has a severe allergy to any component of a vaccine should not receive that vaccine. Tell your doctor if you have any severe allergies. Anyone who is moderately or severely ill when the shot is scheduled may be asked to wait until they recover before receiving the vaccine. Someone with a mild illness can usually be vaccinated. What if I have more questions? Please contact the pharmacy department. We will gladly answer any remaining questions you may have at xxx-xxx-xxxx ext x.
Figure 3. Patient education sheet for pneumococcal vaccine.
questions by nursing to determine whether he or she qualified to receive either the influenza or pneumococcal polysaccharide vaccination per current CDC guidelines. If the patient initially
declined to receive vaccination, the pharmacy department was alerted the following morning via an automatically generated report. Patients appearing on the report were briefly counseled
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Journal of Pharmacy Practice 30(2) Table 1. Reasons for Declining Vaccination.
Influenza Vaccinaon Results n = 214* Number of Paents
60
Influenza (n ¼ 130)
Pneumococcal (n ¼ 45)
47 32 8 1 1 41
18 12 1 2 0 12
50
Declined explanation Fear of adverse effects Does not believe in efficacy Fear of needles Religious Undocumenteda
40 30 20 10 0 October
November December
January
February
March
Month Accepted
Declined
a
Represents the number of interventions where the pharmacist or student failed to document reason for decline.
Uncertain
Figure 4. *Nineteen patients who stated he or she preferred to receive vaccination from primary doctor or community pharmacist or place of employment were excluded from sample size.
Statistical Analysis All data collected are categorical, presented as percentages, and analyzed using the w2 test. A P value less than .05 was considered statistically significant. All statistical calculations were performed using Minitab (version 16.2.2; Minitab Inc, State College, Pennsylvania).
Results During the 6 months that the program was in effect, a total of 323 patients were counseled, of which 233 patients were counseled regarding influenza vaccination and 90 patients for pneumococcal vaccination. When counseled, 26 patients stated that he or she preferred to receive vaccination from his or her primary medical doctor’s office, personal pharmacy, or place of employment (19 patients for influenza and 7 for pneumococcus). These patients were excluded from the total number of evaluable patients since the decision to receive the vaccine had already been made. In effect, our intervention would not have changed the ultimate decision to receive. Therefore, of the entire sample size, only 214 and 83 interventions were evaluable for influenza and pneumococcus, respectively. This resulted in a total of 297 evaluable interventions made. Printed counseling materials were still left with patients wishing to be vaccinated elsewhere.
25 Number of paents
by a pharmacist or intern in person for approximately 5 minutes regarding vaccine safety and efficacy and were provided written information. Once counseling was complete, the patient was reoffered the appropriate vaccine. The outcome of each counseling session was documented as an intervention in the pharmacy order entry system allowing for data extraction. Outcomes were documented as declined vaccine, accepted vaccine, or uncertain. If declined, the staff were instructed to specifically document the patient’s reason for declination. This included fear of adverse effects, religious beliefs, or any other cited reason.
Pneumococcal Vaccinaon Results n = 83* 20 15 10 5 0 October
November December
January
February
March
Month Accepted
Declined
Uncertain
Figure 5. *Seven patients who stated he or she preferred to receive vaccination from primary doctor were excluded from sample size.
For influenza vaccine counseling, a total of 214 evaluable interventions were made. Among the 214 interventions, 50 (23.4%, P ¼ .06) patients consented to vaccination, 34 (15.9%) were uncertain, and 130 (60.7%) still declined (Figure 4 and Table 1). From the initial 214 who refused, 84 (39.2%, P ¼ .001) were influenced by the counseling and either consented or wanted to give it further thought. A total of 83 evaluable interventions were recorded for pneumococcal vaccination counseling. From the 83 interventions, 22 (26.5%) patients consented to vaccination, 16 (19.3%) were uncertain, and 45 (54.2%) still declined (Figure 5 and Table 1). From the initial 83 who refused, 38 (45.8%, P ¼ .01) were influenced by the counseling and either consented or were giving it further thought.
Discussion The goal of this pharmacy-driven education program was to convince patients who on admission declined influenza and/or pneumococcal polysaccharide vaccine of their safety and efficacy and to obtain consent for vaccination. This article describes the impact of this counseling program. Various studies have been conducted in the past to support how valuable pharmacist counseling is in regard to patient knowledge and medication adherence.12-16 This study is similar to the positive outcomes of those studies in the sense that our patients showed an increase in acceptance to preventative
Queeno therapy by way of vaccine secondary to counseling. Our results show that education by a pharmacist or pharmacy intern of patients refusing influenza or pneumococcal vaccination showed a trend toward increased vaccination acceptance rates with 23.4% (n ¼ 214, P ¼ .06) and 26.5% (n ¼ 83, P ¼ .18) agreeing to receive influenza and pneumococcal vaccines, respectively. An unanticipated subset of patients were undecided after counseling and wanted to consider the information further before making a final decision. For influenza, this accounted for 34 (15.9%) patients and for pneumococcal 16 (19.3%) patients. Taken together with those who consented to receive the vaccine, 39.2% (P ¼ .001) and 45.8% (P ¼ .01) of patients were influenced by the influenza and pneumococcal vaccination counseling, respectively. In addition to increased protection for the individual patient once vaccinated, one could extrapolate a potential for decrease in transmission rates in the community as vaccination protects not only the patient but also those who come in contact with them. To our knowledge, no studies have been done to date explaining the effect of pharmacist counseling on inpatient vaccination acceptance rates. When the program was initiated, the possibility of patients remaining uncertain of receiving vaccination after pharmacist counseling was not taken into account. In preparation for next year’s seasonal influenza vaccination program, we will work to establish a process to follow-up with those unsure patients to establish an acceptance or declination to vaccination. It was found that many of the patients who were uncertain preferred to evaluate the printed information alone or with a family member. Perhaps, allowing those patients more time to digest the education materials and revisiting later may have resulted in an increased acceptance. A large amount of patients refused to give any additional explanation for declining vaccination. Upon review of the pharmacist/intern documentation, many of those patients stated they had never received the influenza or pneumococcal vaccine and simply did not want to receive. A similar number of logged interventions failed to document any explanation for the declination. In future seasons, we will reinforce pharmacists and interns the need to document specific reasons for declination. A smaller portion of patients cited the fear of adverse effects to be the reason for decline along with only 1 patient refusing due to religious beliefs. For the future, it may be advantageous to obtain additional information regarding the reason why a patient initially declined vaccination. With such information, the pharmacist or intern would be able to prepare and tailor the presentation to address the concerns of the patient. It was noted that the highest acceptance rate for influenza was seen in October (22 patients, 43.1%) and the lowest was seen in March (1 patient, 3.6%). This can most likely be attributed to the fact that influenza season is nearing its end in April. A larger number of patients were counseled for influenza vaccination at the beginning of the season than compared to the end of the season. At the beginning and peak of flu season, patients appear to be much more aware of the prevalence of disease and thus may be more likely to agree to immunization. Toward the end of flu season, patients are surrounded less with
207 reminders of prevalent disease and thus may lose a sense of urgency. Also, those who could more easily be convinced may have already been convinced by another health care provider. Pneumococcal vaccine acceptance rates varied throughout the program and did not establish a predictable pattern. The pneumococcal portion of the program is not limited to the influenza season and is ongoing since the vaccine can be offered to patients at any time. One limitation of our study was interpersonal reliability in delivery since there were multiple pharmacists and interns involved. Therefore, style of delivery and persuasiveness varied between staff. However, each person involved utilized the same education sheets when presenting information to patients. A second limitation of our study was our delayed start date. Patient evaluation for qualification to receive the influenza vaccine upon hospital admission per hospital protocol began in September. Prior to implementation, pharmacy sought to obtain approval from various disciplines to begin the program. Additionally, educating the pharmacy staff took place through September. If the program had been ready to start at the beginning of September, a potentially much larger number of patients could have been counseled. Lastly, a third limitation was the reported reduced protection of the influenza vaccine for H3N2 virus in the 2014 to 2015 season.27 The CDC reported in February that the updated vaccine effectiveness was estimated at 18% for H3N2 and at 45% for influenza B. The publicity of reduced vaccine effectiveness may have influenced patients’ decision to not receive the vaccination. Despite the limitations to our study, this was the first study done to examine the impact of a pharmacist-driven education program on vaccination acceptance in patients who had originally declined. Future studies focusing on pharmacist-driven education and the impact on acceptance rates are warranted to establish support and a collection of evaluable results.
Conclusion A pharmacist-driven counseling program was implemented in a small community hospital targeting patients who initially declined pneumococcal polysaccharide and influenza vaccination upon admission. Our data suggest that the program resulted in a trend toward greater acceptance rates for both vaccinations. Further studies are needed to determine whether earlier implementation of the program at the beginning of the flu season may have further increased acceptance rates for the influenza vaccination. Acknowledgments Brenda V. Queeno would like to thank Jaclyn Kotula, PharmD, and Ariana Savovic, PharmD (who were both interns at the time), for their significant contributions and initial idea for the vaccination education program. She would also like to graciously thank Jim M. Bartlett, PharmD, BCPS, and Patricia L. Siola, BS Pharmacy, MBA, PhD, FASHP, FACHE (Director of Pharmacy) along with all of the pharmacists and interns at Kenmore Mercy Hospital, which made the success of this program possible.
208 Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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