Immunization: Strategies That Work
St. Mary's Duluth Clinic Health System, Duluth, MN
CDC's Basic Strategy
St. Mary's Duluth Clinic Health System of Duluth, Minnesota, is a 300-bed acute care
medical center with an intensive influenza immunization program. The program is
implemented and overseen by a Process Improvement Team chaired by Cindi Welch, RN,
Infection Control Coordinator.
Offers and encourages influenza vaccine to ANY patient wanting to
avoid influenza. Offers on or prior to day of discharge. Most non-Medicare patients are
reimbursed through their insurance.
Utilizes standing orders for influenza immunization and administers
vaccine to all patients for whom it is indicated or who request it.
Evaluates patients' influenza immunization status via a team approach.
The process is activated by unit-based pharmacists, who are available Monday through
Friday to work with nursing staff. In conjunction with the Charge Nurse, the pharmacists
provide education and evaluate patients' immunization needs. Nursing staff evaluates
patients readiness to receive the vaccine.
Educates nursing staff and pharmacists through educational programs in
Distributes educational brochures to all patients via health unit
coordinators, nursing staff, and volunteers. Volunteers maintain a supply of brochures in
strategic locations throughout the medical center.
Developed a pilot influenza program plan in 1993, to be tested for one
month in one unit. Initial proposal was prepared by the Medical Center's infection Control
Committee in response to a recommendation from the Minnesota Coalition for Adult
Immunization. In pilot program, the nursing staff evaluated patient's risk for influenza
and immunization status at time of admission and completed a form to say immunization was
indicated. Form required physician signature. (This pilot plan was later revised in favor
of standing orders and recruitment near time of discharge.)
Presented plan to Administration and Medical Executive Committees and
received their support.
Implemented pilot plan in 1993.
Expanded program to include all adult nursing units and used nursing
staff to evaluate patients' risk for influenza and immunization status at the time of
admission. If patient met criteria for immunization, "Immunization indicated"
box was checked on the order/evaluation form which then required a physician's signature
before vaccine could be administered.
Obtained Medical Executive Committee approval for standing orders in
1995. Revised process to move the patient evaluation for immunizations from time of entry
to time of discharge, due to other priorities at time of admission.
Intensified efforts and restructured ad hoc committee into formal
Process Improvement Team. New strategies included:
- Better identification of who is responsible for the process (Nursing-Pharmacy). This
ultimately resulted in having unit-based pharmacists serve as "process
activators" in their respective areas of responsibility.
- Developed more user friendly, appealing educational brochures.
- Heightened awareness of program via articles in Medical Center's weekly newsletter.
- Increased staff interest via lobby display "kick-off," which included
influenza Q&A quiz and prize drawings.
- Increased educational programs for staff (also videotaped and contact hour for
- Pharmacy provided outcome data to Nursing units on weekly basis during program months.
Included outpatient surgery and home care patients in program.
Streamlined Medicare Part B billing procedure (Business Services
Increased staff time for meetings, developing and revising standing orders, flyers,
videos, staff education programs, patient education, vaccine administration/documentation,
data collection and analysis, and billing (actual vaccine costs reimbursed by Medicare
This is a short-term annual program, and the process repeats each influenza season. Not
all staff view immunizations and prevention in an acute care facility as a priority, so
continual work is needed to obtain buy-in of physicians and nurses. Education of all
nurses is difficult to achieve due to part-time and casual employees.
Before St. Mary's implemented their strategies, there was no tracking system in place,
but "maybe 30 flu shots per season" were given, according to Cindi Welch.
Evaluation rates improved to 80% compared to 34% in 1995. Last influenza season, 903 shots
were given to inpatients before discharge and outpatient surgery patients, for a 473%
increase in immunizations given over 1995.
CDC Recommends this Basic
- Obtain support of key departments
- Establish administrative systems in inpatient and outpatient settings to prompt and
support activities to identify patients with indications for vaccination and offer
- Involve all key physician and non-physician staff in planning/execution
- Institute standing order policies to facilitate your program
- Display vaccination goals and chart progress in ways visible to patients and staff
- Use provider and patient reminder systems
- Establish Continuous Quality Improvement systems.