© Geriatric Times. All rights reserved.
Update on Immunizations for Seniors: Meeting the Standards
Diane B. Crutchfield, Pharm.D., C.G.P
Geriatric Times November/December 2001 Vol. II Issue 6
Every year thousands of seniors suffer from influenza or pneumonia, sometimes with fatal outcomes. The combined cause-of-death category "pneumonia and influenza" ranks as the fifth leading cause of death in the United States for people age 65 or older (Murphy, 2000).Immunizations are available for the prevention of both influenza and pneumococcal pneumonia, but very few high-risk seniors receive both vaccines. The Healthy People 2000 agenda set objectives for these two immunizations for institutionalized elderly at 80%. Based on data submitted by nursing homes during 2000 via the Online Survey Certification and Reporting (OSCAR) national database, current immunization levels have not met this goal. Unpublished statistics from the Centers for Medicare & Medicaid Services (CMS) for 2000 show that 58.5% of residents had received an influenza vaccine in the past 12 months prior to the survey, and 27.1% of residents had received a pneumococcal vaccine (T. Clark, personal communication, 2001). The Healthy People 2010 objective for immunizations of institutionalized elderly has been set at 90%.
Anyone over the age of 64 is at an increased risk of infection and, with few exceptions, should receive an annual influenza immunization and a one-time pneumococcal vaccine. Current recommendations for the influenza vaccine include everyone over the age of 50 (Centers for Disease Control and Prevention [CDC], 2001b). All people age 65 and over should receive the pneumococcal vaccine, including anyone previously unvaccinated and anyone who has not received the vaccine within five years (and was younger than 65 years old at the time of vaccination). If vaccination status is not known, the pneumococcal vaccine should be administered (CDC, 1997).
The morbidity and mortality associated with both influenza and pneumonia has prompted the CMS to develop a new investigative protocol, effective in early 2002, related to vaccination programs in long-term care facilities. The CMS has been working with the CDC to increase vaccinations for nursing home residents, in particular. In August, a draft guidance for surveyors was released that will be used to assure that nursing homes adhere to the CDC standard of practice for influenza and pneumonia prevention. Focused regulatory provisions will be under the survey tags for infection control and professional standards of quality (CMS, 2001).
Summary of Guidelines
- Medicare-certified nursing homes will be required to establish and maintain policies and procedures for the prevention and control of influenza and pneumococcal pneumonia based on the CDC standards of practice.
- Policies must be in place to not only define when and how the vaccinations will be administered, but also to address a resident's refusal to receive immunizations and how the facility will respond when immunizations are not available.
- Systems must be in place to assure that residents are immunized, unless the injection is contraindicated. One example would be to include standardized consent forms in the admission packets.
- Residents sampled during a survey must have either received the immunizations or have documentation to indicate why they have not received them.
Surveyors will use OSCAR data to determine if a facility has a low immunization rate compared to national averages. If it is lower than average, the facility's policies and procedures will be investigated further. In a report of the data, influenza information will be compared to the percentage of vaccinations given to residents who were residing in the facility from October through March of the year. All residents should have record of having received (or refused) a pneumococcal vaccine.
The current CDC standards of practice for pneumococcal pneumonia (CDC, 1997) and influenza (CDC, 2001a) can be downloaded from <www.cdc.gov/mmwr/mmwr_wk.html>. The CDC Web site also contains influenza and pneumococcal vaccination information sheets that are appropriate for distribution to residents and to family members.
Promoting Immunizations
Prior to the development of requirements for immunizations, a coalition of 22 health care organizations was formed to promote immunizations in seniors. The product of the coalition was the 100% Immunization Campaign, which is coordinated by the American Society of Consultant Pharmacists. A Web site to support the campaign can be found at <www.immunizeseniors.org>. In addition to the campaign information, organizations can enroll on the Web site as a partner for immunization promotion with the goal of achieving the Healthy People 2010 objective.
The immunization campaign has identified six steps for successful promotion of vaccinations in a nursing facility:
- Step 1: Education of key facility staff. Vaccine information can be found in the CDC Vaccine Information Statements. Additional sources of educational material can be found on the campaign's Web site.
- Step 2: Development and approval of an immunization program by the Quality Assessment and Assurance Committee of the facility. Upon admission, residents or their responsible party should be educated about the importance of vaccinations and consent obtained for immunization. Several forms to assist the facility are available, including a sample consent form and immunization record to be maintained in the resident's chart. Standing orders for immunizations are strongly encouraged by the immunization campaign and also the Advisory Committee on Immunization Practices (CDC, 2000).
- Steps 3 and 4: Immunize current facility residents and new admissions. Follow the established facility program to educate, obtain consent and immunize, followed by completion of the immunization record form.
- Step 5: Bill Medicare, as appropriate. Follow established protocol for accurate and timely billing.
- Step 6: Evaluate the immunization program. Monitor the outcome of the program. Is there an increase in the percentage of residents receiving immunizations? How do these figures compare with the national average? Should changes be made to the established protocols?
Successful immunization programs will assure compliance with regulatory requirements, but, more importantly, will improve the quality of resident care in the facility by preventing serious influenza outbreaks and potentially avoiding deadly pneumococcal infections for some residents. The availability of recommended vaccination procedures, information handout sheets and required forms available from the 100% Immunization Campaign and the CDC make compliance an easy task, and every facility should aspire to meet or exceed national averages for immunizations.
Dr. Crutchfield is president of Pharmacy Consulting Care, an independent consultant pharmacy practice located in Knoxville, Tenn.References
CDC (1997), Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 46(RR-8):1-24. Available at www.cdc.gov/mmwr/preview/mmwrhtml/00047135.htm. Accessed Oct. 22, 2001.
CDC (2000), Use of standing order programs to increase adult vaccination rates: recommendations of the Advisory Committee on Immunization Practices. MMWR 49(RR-01):15-26. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/rr4901a2.htm. Accessed Oct. 22, 2001.
CDC (2001a), Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 50(RR-04):1-46. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/rr5004a1.htm. Accessed Oct. 22.
CDC (2001b), Vaccine information statement: influenza. Available at: www.cdc.gov/nip/publications/VIS/vis-flu.pdf. Accessed Oct. 22.
CMS (2001), Draft State Operations Manual guidance for surveyors. Available at: www.heaton.org/FluVaccineSOMchanges.pdf. Accessed Oct. 23.
Murphy SL (2000), Deaths: Final Data for 1998. National Vital Statistics Reports 48(11):27. National Center for Health Statistics, CDC. Available at: www.cdc.gov/nchs/data/nvsr/nvsr48/nvs48_11.pdf. Accessed Oct. 23, 2001.
