Push to Vaccinate Healthworkers is On

New federal regulations mean hospitals must count vaccination rates for anyone who works in a healthcare facility between October 1 and March 31.

This article appears in the July/August 2015 issue of HealthLeaders magazine.

At Lourdes Health System's two hospitals in New Jersey, ensuring that 2,700 workers get their seasonal flu shots—to stay healthy and avoid infecting patients—is such a high priority, that workers who refuse must find work elsewhere.

"We made it mandatory in the fall of 2012," long before many other hospitals in the nation, says Jennifer Moughan, chief human resources officer for the 325-licensed-bed Our Lady of Lourdes Medical Center in Camden and 173-bed Lourdes Medical Center of Burlington County in Willingboro.

Of course, "there were people, and challenges, and we had to work through those," Moughan says. And yes, "a few people were terminated for not getting their shots."

That's one reason Lourdes dramatically bucks a troublesome trend in New Jersey, where hospitals' average rates of influenza immunization have tracked the lowest in the nation. For the 2013–2014 season that ended March 31, 2014, only 59% of healthcare workers in New Jersey hospitals who should get their shots did so. Across the country, healthcare worker compliance rates averaged 79%.

Lourdes' two hospitals did far better. Their healthcare worker vaccination rates that season were 95% and 96%, respectively. Only a "handful" of eligible employees requested and qualified for legitimate medical or religious exemption, for which the system requires strict documentation, Moughan says.

Hospitals Battle Unions Over Mandatory Flu Shots for Nurses

Hospitals must count vaccination rates for anyone who works for any part of one day in the healthcare facility between October 1 and March 31. That includes everyone from volunteers and clerical workers to doctors and executives. Organizations then report their rates to the Centers for Disease Control and Prevention's National Healthcare Safety Network for public reporting, which began late last year for 2013–2014, on Hospital Compare.

Workers also must show documentation if they get their shots somewhere other than Lourdes, although Lourdes, like most hospitals, offers them to employees at no charge.

"You can't just tell us you got it at Rite Aid; I want to see that documentation," Moughan says.

With a goal of getting most workers immunized by December 15, when holiday festivities and travel enable viral spread, Moughan's teams "go floor to floor. We have stationary clinics and carts that roll around at night and on weekends, and there's no way you don't have a vaccine offered to you sometime in this period."

And those teams keep watch for procrastinators. "We're constantly looking at our data to see who's still out there not vaccinated." Leadership steps in to make the point. As soon as the vaccine arrives, Alfred Sacchetti, MD, vice chair of the department of emergency medicine, gathers up his staff in the hospital ED. He challenges a student nurse to "give him his shot, and he's always the first in line," Moughan says. "He's quite a character."

"It's not rocket science," says Alan Pope, MD, vice president of medical affairs and chief medical officer for Lourdes Health. "We don't want workers bringing flu to patients in our hospitals; patients have weakened immune systems or diseases that are prone to serious morbidity—in some cases mortality—if they get the flu. And we know it's important for us to have an intact workforce at the height of flu season."

The system accomplishes this through its education campaign to dispel myths and correct false information, such as the mistaken beliefs that the vaccine formula still contains mercury or that shots can transmit the flu.

Peer pressure, too, is used through distribution of "I got my flu shot" stickers. "You go into a meeting and see everyone around a table wearing a sticker, and you'd say, 'Oh, I better get mine.' " Moughan says. "They've been the biggest hit. You'd think, these are adults, and yet there they are, taking time and talking about how they pick out which one to wear."

Flu Vaccination Pressure Ratchets Up at Hospitals

But in northern New Jersey, another major hospital system struggles with a healthcare worker culture that has resisted vaccination, with only 45% of its 7,600 workers getting their shots in the 2013–2014 season.

"I don't know if we have a higher number of skeptics," says Suzanne Gallagher, administrative director for the Center for Occupational Medicine at the 750-licensed-bed Hackensack University Medical Center, "but the flu vaccine is always a hard sell and this last season, all the more so. Some said, 'It's just not that effective. Why should I bother?'

"We recently had The Joint Commission here," Gallagher says, "and they looked right at me and said, 'What are you doing to increase these rates?' "

So Hackensack UMC has begun to beef up its effort. It has launched what it calls a mandatory attestation requirement that surveys each employee who did not receive the vaccine to learn what their concerns were, Gallagher says.

"They said things like, 'I'm afraid it will make me sick' or 'I don't believe in it.' " A surprising response came from about 200 workers, many of them nurses who routinely give injections, "that they were afraid of needles." An educational program is being planned for this fall to improve employees' understanding of the science and safety of the vaccines.

Then the hospital will get really serious, moving to a mandatory program "for the entire healthcare team," says Lisa Tank, MD, Hackensack UMC's chief of geriatrics. "And if they're exempt, they'll be requested to wear masks in all patient areas." For all physicians, it will be absolutely mandatory.

Gallagher says the flu vaccine committee is exploring the idea of using incentives for employees who comply, similar to incentives in wellness programs.

Why New Jersey has the country's lowest vaccination rates is a mystery, says Kerry McKean Kelly, vice president of communications and member services for the New Jersey Hospital Association, which represents 72 acute care facilities. The fact that almost all facilities have relied on voluntary programs so far, may be part of the reason.

"Clearly, we're not satisfied," Kelly says, adding that "our hospitals are now focusing more attention than ever on this issue" with many organizations moving toward a mandatory requirement for all employees who have patient care responsibilities.

Back on the other end of the spectrum, 355-bed Indiana University Health in Bloomington, which has 3,430 employees, achieved a 99.5% immunization rate in the 2013–2014 flu season, which was rounded to 100% on Hospital Compare.

"It's been a multiyear journey," with two policy changes that tightened restrictions to raise immunization rates from 50%, where they were in the 1990s, to 75% in 2013, says Ruth Ann Morris, RN, MSN, NEA-BC, vice president of patient care and chief nursing officer.

"An important part of what we did was educate our employees that this is about patient safety, and even if the employee does not become ill with the flu, they may pass the flu on to one of our patients who may have a different experience with influenza," she says. Another aspect is how strict the organization is regarding religious or personal belief exemptions, requests for which are reviewed by a panel of ethicists and chaplains.

Medical exemptions are granted sparingly by medical experts, too. Exceptions are made if a staff member has a severe allergy to eggs or an autoimmune disease, or if he or she has had a life-threatening reaction to the vaccine in the past. "Saying things like 'I'm afraid of shots' or 'I'll get the flu if I take the shot' are not acceptable." Now, she says, they receive far fewer requests for exemptions than when the policy first changed.

The programs work smoothly because of the speed with which the immunization campaign swarms the hospital's care teams. "What makes a difference is that we start in September and we're done in October," she says.

A prevailing controversy deals with the lack of the rock-solid evidence of causal links between healthcare worker immunization and reduced hospital-acquired influenza illness or mortality in patients, says Megan Lindley, the CDC's subject matter expert on healthcare worker vaccination.

That's because many illnesses look like influenza but are something else, and because it's extremely difficult to restrict patients' exposure to visitors.

"The strongest evidence for effectiveness would be a randomized controlled trial, but then you'd have to withhold [from some workers] a vaccine we know is effective ... and that would be unethical."

So the CDC tries to look across the nation at what seems to work. "Facilities that offer vaccination to their personnel, on site, at no cost, on multiple days and shifts, and have active programs promoting it have higher healthcare worker vaccination rates," Lindley says.

Still, there are issues. In a CDC Internet survey of healthcare workers who said they would not be vaccinated in November 2014, 20.8% said the vaccine doesn't work, 16.6% said they didn't need it, 13.3% said they might get sick from it, and 6.5% thought the ingredients "are not good for you. "

According to the CDC's Influenza Division, last season's vaccine was a tough one for influencing a national vaccination policy; it was only 19% effective against the prevailing virus, which meant that workers lost confidence in the vaccine's effectiveness.

Palomar Health, a two-hospital system in San Diego County with 395 licensed beds, converted to a mandatory mask requirement for any employees among its 2,754 workers who refused to get vaccinated last flu season. The result: Immunization rates soared, from 73% and 74%, respectively, during the 2013–2014 flu season year, to 90.7% and 93.5%, says Russell Riehl, director of employee, corporate, and retail health. That improvement will be posted later this year on Hospital Compare.

"You can decline the flu vaccine for any reason: medical, religious, or 'just because,' and that's fine. But then during flu season you'll have to wear a surgical mask from the time you enter the building until you leave, except when on break or in the cafeteria," says Valerie Martinez, system director of quality patient safety and infection control. That cuts out the hassle of securing documentation for patients who have a medical or religious reason.

Immunized workers are distinguished from those who must wear a mask by an annual flu shot sticker placed on their badges. The policy starts about four weeks after vaccine distribution begins in the hospital, and when mask dispensers are set up at every doorway for arriving workers.

"When we did that, those people who didn't like needles, or thought they had egg allergies, or said, 'Oh, it got me sick once before' had to wear the mask. And what happened is, they wore it for about a month, found it uncomfortable, and ultimately got the vaccine," Martinez says.

Palomar Health, however does not try to incentivize its workers with stickers or money. "It sends the wrong message," Riehl says. "We're here to take care of people, and to pay to incentivize an employee to ensure they don't pass an illness to a patient—well, you're setting a precedent that would not be good going down the road for many other situations."

Healthcare worker immunization rates now are reported to CDC and the Centers for Medicare & Medicaid Services as part of the inpatient quality reporting program, for which hospitals receive a 2% Medicare payment increase. But the measure is not yet part of hospital value-based purchasing or the hospital-acquired condition penalty, although it could roll in at some point.

Lourdes' Pope says that's a good idea. "I think our infection prevention staff would advocate for it," he says. "We think it's saving lives and preventing serious illness. And if it requires guidance by the regulatory agencies for that to occur, they should seriously consider it.

"You can see from what happened at our hospital in Camden, it's not at all hard to do."

Reprint HLR0815-8

This article appears in the July/August 2015 issue of HealthLeaders magazine.