Gaps in hospital policies and practices to prevent perinatal transmission of hepatitis B virus.

OBJECTIVE: The objective of this study was to examine hospital policies and practices to prevent perinatal transmission of hepatitis B virus (HBV) in the United States and to and identify gaps. METHODS: In March 2006, a nationally representative sample of 242 delivery hospitals in the 50 states, District of Columbia, and Puerto Rico (with at least 100 annual births) were surveyed about hospital perinatal hepatitis B prevention policies and asked to review paired maternal-infant medical records for 25 consecutive live births. Main outcome measures were hospital policies related to the prevention of perinatal transmission of hepatitis B and the proportion of infants who received recommended care. RESULTS: A total of 190 of 242 hospitals responded to the survey and completed medical record reviews for 4762 mothers and 4786 infants. The proportion of hospitals that reported each of the 6 policies examined ranged from 63.0% to 80.6%. Among infants who were born to the 18 hepatitis B surface antigen (HBsAg)-positive women with documented prenatal test results, 62.1% received both hepatitis B vaccine and hepatitis B immunoglobulin within 12 hours, but 13.7% were unvaccinated and 19.7% did not receive hepatitis B immunoglobulin before hospital discharge. Among infants who were born to the 320 women with unknown HBsAg status, only 52.4% were vaccinated within 12 hours of birth and 20.1% were unvaccinated before discharge. Among infants who were born to HBsAg-negative mothers, 69.1% received the hepatitis B vaccine before hospital discharge. The strongest predictor of vaccine administration was having a written hospital policy for newborn hepatitis B vaccination. CONCLUSIONS: These findings indicate that significant gaps persist in hospital policies and practices to prevent perinatal HBV transmission in the United States. Efforts to avoid medical errors through appropriate implementation and monitoring of hospital practices are needed to eliminate perinatal HBV transmission.

Factorial design for improving influenza vaccination among employees of a large health system.

OBJECTIVE: As healthcare personnel (HCP) influenza vaccination becomes a quality indicator for healthcare facilities, effective interventions are needed. This study was designed to test a factorial design to improve HCP vaccination rates. DESIGN: A before-after trial with education, publicity, and free and easily accessible influenza vaccines used a factorial design to determine the effect of mobile vaccination carts and incentives on vaccination rates of HCP, who were divided into groups on the basis of their level of patient contact (ie, business and/or administrative role, indirect patient contact, and direct patient contact). SETTING: Eleven acute care facilities in a large health system. PARTICIPANTS: More than 26,000 nonphysician employees. RESULTS: Influenza vaccination rates increased significantly in most facilities and increased system-wide from 32.4% to 39.6% (P<.001). In the baseline year, business unit employee vaccination rates were significantly higher than among HCP with patient contact; rates did not differ significantly across groups in the intervention year. In logistic regression that accounted for demographic characteristics, intervention year, and other factors, the use of incentives and/or mobile carts that provided access to vaccine at the work unit significantly increased the likelihood of vaccination among HCP with direct and indirect patient contact, compared with control sites. CONCLUSIONS: Interventions to improve vaccination rates are differentially effective among HCP with varying levels of patient contact. Mobile carts appear to remove access barriers, whereas incentives may motivate HCP to be vaccinated. Education and publicity may be sufficient for workers in business or administrative positions. Interventions tailored by worker type are likely to be most successful for improving HCP vaccination rates.

Self-reported influenza vaccination rates among health care workers in a large health system.

BACKGROUND: The national health care worker (HCW) influenza vaccination rate is only 42% despite recommendations that HCWs receive influenza vaccine to prevent influenza among patients. METHODS: Following an educational intervention to improve influenza vaccination in 6 facilities in a large health system (University of Pittsburgh Medical Center), surveys were mailed to 1200 nonphysician HCWs to determine factors related to influenza vaccination and inform the following year's intervention. HCWs were proportionally sampled with oversampling for minority HCWs, and analyses were weighted to adjust for the clustered nature of the data. RESULTS: Response rate was 61%. Influenza vaccination rates were 77% overall, 65% for minority HCWs and 80% for white HCWs (P = .02) for ever receiving vaccine; and 57% overall, 45% for minority HCWs and 60% for white HCWs (P = .009) for receiving vaccine in 2005-2006. In logistic regression, belief that getting vaccinated against influenza is wise, physician recommendation, and older age were associated with higher likelihood of vaccination, whereas minority race and good health were associated with lower likelihood of ever receiving influenza vaccine. CONCLUSION: To increase influenza vaccination, interventions should address HCWs' most important reasons for getting vaccinated: convenience and protecting themselves from influenza.

Discussions about preventive services: a qualitative study.

BACKGROUND: Elderly minority patients are less likely to receive influenza vaccination and colorectal cancer screening than are other patients. Communication between primary care providers (PCPs) and patients may affect service receipt. METHODS: Encounters between 7 PCPs and 18 elderly patients were observed and audiotaped at 2 community health centers. Three investigators coded transcribed audiotapes and field notes. We used qualitative analysis to identify specific potential barriers to completion of preventive services and to highlight examples of how physicians used patient-centered communication and other facilitation strategies to overcome those barriers. RESULTS: Sharing of power and responsibility, the use of empathy, and treating the patient like a person were all important communication strategies which seemed to help address barriers to vaccination and colonoscopy. Other potential facilitators of receipt of influenza vaccine included (1) cultural competence, (2) PCP introduction of the discussion, (3) persistence of the PCP (revisiting the topic throughout the visit), (4) rapport and trust between the patient and PCP, and (5) PCP vaccination of the patient. PCP persistence as well as rapport and trust also appeared to facilitate receipt of colorectal cancer screening. CONCLUSION: Several communications strategies appeared to facilitate PCP communications with older patients to promote acceptance of flu vaccination and colorectal cancer screening. These strategies should be studied with larger samples to determine which are most predictive of compliance with prevention recommendations.

Nurses' attitudes and beliefs about influenza and the influenza vaccine: a summary of focus groups in Alabama and Michigan.

BACKGROUND: The U.S. Advisory Committee on Immunization Practices (ACIP) recommends influenza immunization among United States health care workers (HCWs) to reduce the spread of influenza to and from workers and patients. Despite these recommendations, influenza immunization coverage of health care workers is less than 50%. PARTICIPANTS AND METHODS: Eight focus groups of registered nurses (RNs) were conducted in Birmingham, Alabama (n = 34) and Detroit, Michigan (n = 37). In each city, the focus groups consisted of 2 groups each of vaccinated and unvaccinated RNs. RESULTS: These focus groups revealed that many nurses were concerned about influenza vaccine effectiveness and safety; their lack of information about the vaccine plays a part in their willingness to promote it to patients. Unvaccinated nurses tended to be less aware of the ACIP recommendations for HCW vaccination, and overall, nurses were not aware of the rationale for HCW vaccination. Attitudes were mixed regarding mandatory influenza vaccination programs, including the hope that such programs would result in higher vaccination rates and concern about potential disciplinary action if vaccine was declined. Participants believed that increasing convenience was the key to increasing HCW vaccination. CONCLUSIONS: Our findings confirm the importance of comprehensive approaches that combine education and convenience, and suggest that emphasizing the rationale for HCW vaccination may contribute to increasing vaccination rates.

A comprehensive patient assessment and physician reminder tool for adult immunization: effect on vaccine administration.

We determined if a patient-self assessment/provider reminder tool (A/R) would increase administration of the eight vaccines that may be indicated for adults. In three family practice clinics, the A/R was completed by intervention patients and given to their provider. Control patients received an exercise reminder. On the day of the intervention, influenza, pneumococcal polysaccharide, and tetanus-diphtheria (Td) vaccines vaccine were administered significantly (P<0.01) more commonly to intervention patients in one clinic, Td in the second, and none in the third. There were no additional significant differences during one year of follow-up. A number of barriers to comprehensive vaccination were encountered.

Determining indications for adult vaccination: patient self-assessment, medical record, or both?

CONTEXT: Eight or more vaccines may be indicated for adults in the United States. Determining if any vaccines are needed requires integrating information on the patient's demographic and behavioral risk factors and health status, the health status of the patient's close contacts, and the patient's immunization history. This process can be time consuming for providers and their staff. We used patient self-assessment as a method of determining which vaccines are indicated for a patient and whether indicated vaccines had been received. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional convenience sample of 300 adults in three family practice settings. Participants completed a self-assessment tool to determine if influenza, pneumococcal, measles, mumps, and rubella (MMR), tetanus, hepatitis A and hepatitis B vaccines were indicated and previously received. A chart audit was then performed to obtain similar information. MAIN OUTCOME MEASURES: Agreement (kappa statistic [< 0.00: poor agreement; 0.00-0.20: slight; 0.21-0.40: fair; 0.41-0.60: moderate; 0.61-0.80: substantial; 0.81-1.00: almost perfect]) between the self-assessment tool and the audit for (1) indicated vaccines and (2) previous receipt of indicated vaccines indicated according to both the assessment form and the audit. RESULTS: Agreement between the self-assessment tool and chart review was substantial or better only for pneumococcal and MMR vaccines (kappa=0.65 and 0.85, respectively). For influenza vaccine, agreement improved (from kappa = 0.56 to kappa = 0.74) when indications attributable to health conditions of family members were excluded. Agreement regarding receipt of vaccines was highest for influenza vaccine (kappa = 0.70). Only 57% of patients correctly recalled tetanus vaccination that were documented in the medical record (kappa = -0.04). Kappa statistics were unreliable for hepatitis A and B vaccines because so few vaccinations had been received. CONCLUSIONS: Discrepancies in agreement regarding indications for vaccines appeared to result from absence of information in the medical record regarding high risk behaviors and family contacts. Lack of agreement regarding vaccines that had been previously been received appeared due to both poor recall and lack of documentation. Combining medical record audit with self-assessment may be the most complete assessment of vaccination status of adults, but requires reconciling disagreements. Electronic medical records and registries that contain information about risk factors and previously administered vaccines may be necessary to overcome some these problems.

Improving influenza, pneumococcal polysaccharide, and hepatitis B vaccination coverage among adults aged <65 years at high risk: a report on recommendations of the Task Force on Community Preventive Services.

The Task Force on Community Preventive Services conducted systematic reviews to evaluate the effectiveness of interventions to improve targeted vaccination coverage (i.e., coverage with vaccines recommended for some but not all persons in an age range on the basis of risk for exposure or disease) among adults aged <65 years at high risk when implemented alone (single-component interventions) and in combination with other interventions (multicomponent interventions). A 1999 report by the Task Force examined the effectiveness of interventions to increase coverage with universally recommended vaccinations (i.e., vaccines recommended for all persons in particular age groups). Three targeted vaccinations recommended for populations at risk are addressed in this review: influenza, pneumococcal polysaccharide, and hepatitis B. The Task Force identified evidence that certain combinations of interventions have improved vaccination coverage. To increase targeted vaccination coverage, the Task Force recommends a combination of interventions that include selected interventions from two or three categories of interventions (i.e., increasing community demand for vaccinations, enhancing access to vaccination services, and provider- or system-based interventions). The Task Force also recommends provider reminders, when implemented alone, to improve targeted vaccination coverage. This report provides additional information about population-based interventions to improve the coverage of influenza, pneumococcal polysaccharide, and hepatitis B vaccines among populations at risk, briefly describes how the reviews were conducted, and provides information that can help in applying the interventions locally.