Influenza vaccination is safe and immunogenic when administered to hospitalized patients.

CONTEXT: Very few high-risk persons receive influenza vaccine while hospitalized. Health care providers may be reluctant to administer the influenza vaccine to hospitalized patients because of insufficient data related to the safety and immunogenicity of vaccinating this population. OBJECTIVE: To evaluate the safety and immunogenicity of the influenza vaccine administered to hospitalized patients compared to ambulatory clinic patients. DESIGN: Prospective cohort study. SETTING: A 711-bed, acute-care, private tertiary hospital and two private internal medicine clinics from October 1 to December 25, 1999. PARTICIPANTS: 51 inpatients; 177 outpatients. INTERVENTION: All study participants received influenza vaccine. Serum samples for antibody assays were collected at baseline and at 3 weeks after vaccination. Study participants were mailed a questionnaire to elicit information about adverse effects of vaccination. MAIN OUTCOME MEASURE: Seroconversion rates (4-fold increase in hemagglutination-inhibiting antibodies) and seroprotection rates (titers > or = 1:40) to the influenza vaccine in hospitalized and ambulatory patients. RESULTS: The seroconversion and post-vaccination seroprotection rates in the inpatient group were 65% (33/51) and 88% (45/51) compared to 55% (98/177) and 94% (167/177) in the ambulatory clinic patients. Soreness at the site of injection was the most common adverse effect, reported by 12% of both the inpatients (5/42) and ambulatory clinic patients (20/171). Seventy-four percent of patients (31/41 inpatients and 127/174 outpatients) reported no significant side effect to vaccination. CONCLUSIONS: Influenza vaccine is at least as safe and immunogenic in hospitalized patients as it is in ambulatory patients. These data can be used to help convince health care providers to order the influenza vaccine for their hospitalized patients.

A users group approach to quality improvement across an integrated healthcare delivery system.

Aurora Healthcare, an integrated healthcare delivery system, wanted to use interhospital collaboration to improve quality. An opportunity for improvement at five Aurora hospitals was identified: Only 71% of patients received timely preoperative antibiotic prophylaxis. A Users Group approach was proposed to foster collaboration among the hospitals in a quality improvement (QI) effort. Although these hospitals differed in size, volume of cases, medical staffs, and antibiotic-delivery processes, they had common objectives and, many times, common barriers to the timely delivery of antibiotics. A Users Group approach to this QI initiative resulted in an 18% improvement in the number of patients who received timely administration of preoperative antibiotic prophylaxis (p < 0.001). This article describes the Users Group approach to QI at Aurora Healthcare in southeastern Wisconsin.

A model for collaboration in quality improvement projects: implementing a weight-based heparin dosing nomogram across an integrated health care delivery system.

BACKGROUND: At Aurora Health Care, an integrated delivery system based in Milwaukee, a system-level clinical quality improvement department was established in 1995 to facilitate collaboration on clinical quality improvement (QI) initiatives. THE COLLABORATIVE MODEL: A model was developed to use expertise within the system and avoid unnecessary duplication of efforts, while maintaining buy-in for the project's interventions at the point of service delivery. It was believed that a single team could design the improvement efforts or guidelines, and then work at a more local level with a different group of people to implement the processes. APPLYING THE MODEL TO THE HEPARIN QI PROJECT: Anticoagulation with heparin is considered the mainstay of treatment for pulmonary embolism and deep venous thrombosis. However, a large gap was found between present anticoagulation practices and published best practice in regards to achieving a key process measure. To reduce the overall time to achieving effective anticoagulation, a system-level team created an intervention primarily consisting of a preprinted order sheet, including the weight-based heparin dosing nomogram, and an education plan for physicians and other health care professionals. Significant improvement was observed at all pilot sites with overall rates of adequate anticoagulation within the first 24 hours improving from 73% to 95%. DISCUSSION: The system was able to standardize care at four of its five major hospitals and provide for better patient outcomes to a larger segment of the community, and then to replicate the heparin project to four additional sites during a six-month period. This model has been successfully applied to other quality improvement projects.

Exceeding the Healthy People 2000 goal for influenza vaccination through a collaborative effort at eight primary care clinics.

The use of trivalent influenza vaccination has been shown to reduce hospitalizations and mortality in high risk persons receiving the vaccine prior to endemic periods. Despite the generally accepted benefit of this vaccine, its use remains relatively low, with less than 40% of high risk persons actually receiving the vaccination. Increasing the vaccination rate is particularly difficult for physicians in small groups, practicing without sophisticated information systems, and for those practices in which small percentages of the patients are in HMO's or capitated plans. The setting for our study was eight primary care clinics, in a predominantly fee for service environment. We used several interventions to achieve the Healthy People 2000 goal of vaccinating 60% of the high risk of population. Those interventions included: mailings to patients recommending they get vaccinated, empowering non physician clinic personnel to administer vaccines without specific physician orders, and distributing comparative data of the vaccination rates at all participating clinic sites. We found that by using these interventions at eight different primary care clinic sites, we were able to achieve an influenza vaccination rate of 66.4% for our high risk population. We concluded that through collaboration eight primary care clinics can exceed the Healthy people 2000 goal of 60% compliance with influenza vaccination.