American Journal of Infection Control 43 (2015) 409-11
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Correlates of change in health care worker seasonal influenza vaccination rates among dialysis facilities Janet R. Lynch PhD a, *, Nancy Armistead MPA a, Brandy B. Vinson BBA a, Andrew D. Howard MD, FACP b a b
Mid-Atlantic Renal Coalition, Richmond, VA Metropolitan Nephrology Associates, Alexandria, VA
Key Words: Health personnel Evidence-based medicine Health promotion
We conducted a campaign to increase seasonal influenza vaccination of dialysis health care workers (HCWs) in the District of Columbia, Maryland, Virginia, and West Virginia. Between the 2010-2011 and 2011-2012 influenza seasons we examined the correlates of change. HCW vaccination rates improved significantly (P < .01) from a mean standard deviation of 64.5 27.4 to 72.7 23.1. Evidence-based practices were in wide use and although we did not find an association between these and improvement, we did find that lower-performing facilities tended to improve more (P < .01) and there was a positive relationship between patient influenza vaccination rates and improvement in HCW rates (P < .01), with the mean standard deviation patient rate of 88.3 7.9 exceeding the HCW rate during the 2011-2012 season (P < .01). Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
The National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination1 recommends offering the influenza vaccine annually to health care workers (HCWs) to protect staff, patients, and family members, as well as decrease staff absenteeism. Although research has identified activities, including staff education, that increase HCW vaccination rates,2 the usefulness of these strategies in the dialysis setting has received little attention. Too, the association between staff and patient influenza vaccination has not been explored.
* Address correspondence to Janet R. Lynch, PhD, Corporate Science Officer, MidAtlantic Renal Coalition, West Virginia Medical Institute and Quality Insights, 300 Arboretum Pl, Ste 310, Richmond, VA 23236. E-mail address: [email protected] (J.R. Lynch). The analyses reported here were performed under contract No. HHSM-5002011, End Stage Renal Disease Network 5, funded by the Centers for Medicare & Medicaid Services, an agency of the US Department of Health and Human Services. The content of this publication does not necessarily reflect the policies or positions of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US government. The authors assume full responsibility for the accuracy and completeness of the ideas presented. The Centers for Medicare & Medicaid Services staff had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. The Centers for Medicare & Medicaid Services staff reviewed the manuscript and provided helpful comments. Conflicts of interest: None to report.
METHODS We examined the relationship between change in the HCW vaccination rate between influenza seasons and the initial HCW rate, patient rate, and strategies employed by dialysis facilities to encourage HCW vaccination. We reasoned that improvement was likely to be iterative, building on past performance and that success vaccinating patients was likely to have a spillover effect influencing improvement in HCW vaccination; however, our primary interest was in examining the association between improvement in HCW vaccination rates and evidence-based strategies. Our study was conducted in the context of annual regional influenza vaccination campaigns promoting both patient and HCW vaccination. The campaigns included distributing information to dialysis facilities to support their use of evidence-based strategies, HCW-targeted messaging to increase awareness and motivation, data feedback, and certificates of recognition for achieving 90% or greater HCW vaccination. Although regional campaigns to increase patient vaccination had been ongoing for many years achieving high patient rates, we first incorporated HCWs as a target population during the 2010-2011 influenza season. We requested data, concurrent with the 2010-2011 and 2011-2012 influenza seasons, from all facilities providing hemodialysis and peritoneal dialysis in Maryland, Virginia, West Virginia, and the District of Columbia, excluding military treatment facilities, Veterans Health Administration hospitals, and prisons.
0196-6553/$36.00 - Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2014.12.011
410
J.R. Lynch et al. / American Journal of Infection Control 43 (2015) 409-11
Table 1 Dialysis health care worker (HCW)* and patienty vaccination rates and descriptive statistics for dialysis facilities by response categories, including types of activities used by facilities to encourage HCW influenza vaccination Facilities responding to 2011-2012 and 2010-2011 influenza seasonsz vaccination data collection plus HCW intervention questionnaire (n ¼ 179)
Facilities responding to 2011-2012 and 2010-2011 influenza seasonsz vaccination data collection (n ¼ 250)
Mean % (standard deviation) HCW vaccination rates 2011-2012 Patient vaccination rates 2011-2012
72.7 (23.1) 88.3 (7.9)
74.5 (22.5) 88.2 (7.8) % (n)
Facility size Small ( 30 patients) Medium (> 30 patients and 75) Large (> 75 patients and 150) Very large (> 150) Ownership Large dialysis organizationx Nonlarge dialysis organization Activities used to encourage HCW vaccination Provided staff with vaccine at clinic Free vaccination for staff Provider educationk Visible symbols{ Threats of penalties Rewards#
9.6 40.4 44.8 5.2
(24) (101) (112) (13)
8.9 39.7 45.8 5.6
75.2 (188) 24.8 (62)
(16) (71) (82) (10)
73.7 (132) 26.3 (47)
-
98.9 60.9 88.3 24.0 5.0 3.4
(177) (109) (158) (43) (9) (6)
*HCW was defined as a facility-paid full-time or part-time employee, including nurses, patient care technicians, water/inventory/machine technicians, dietitians, social workers, and administrative personnel. The HCW vaccination rate is the percent of HCWs employed during the influenza season who were vaccinated in the center or who indicated that they received the vaccine in another setting during the influenza season. y Patient was defined as an adult, aged 19 years or older, receiving hemodialysis or peritoneal dialysis. The patient influenza vaccination rate is the percent of patients receiving hemodialysis or peritoneal dialysis during the influenza season who were vaccinated in the center or who indicated that they received the influenza vaccine in another setting during the influenza season. z The 2010-2011 influenza season was defined as September 1, 2010-March 31, 2011; the 2011-2012 influenza season was defined as September 1, 2011-March 31, 2012. x Corporate entities with 200 or more dialysis units nationally. k Information to staff to increase their knowledge about influenza vaccination or change their attitudes about influenza vaccination. { Visible symbols of having received the influenza vaccine; for example, buttons with slogans such as, “I got the flu shot.” # Gifts, for example.
We surveyed facilities at the conclusion of the 2011-2012 season to identify the evidence-based interventions they used to promote the uptake of influenza vaccine among their staff. For example, the literature identifies vaccine availability and staff education as effective in increasing HCW vaccination3 and we asked about these approaches. We performed a 1-sided paired t test to examine the difference in facility vaccination rates from 1 season to the next and used multiple linear regression to examine the relationship between change and variables of interest, controlling for potential extraneous enabling variables of ownership and size. RESULTS Of 309 facilities, 250 responded with complete HCW and patient vaccination data for a return rate of 81.0%. These facilities reported employing 4,565 HCWs during the 2011-2012 influenza season, 3,304 of whom were vaccinated. They cared for 20,853 patients, 18,412 of whom were vaccinated. At the facility level, the mean standard deviation HCW vaccination rate was 72.7 23.1 for the 2011-2012 season, a statistically significant increase over the previous season’s measure of 64.5 27.4 (paired t test ¼ 5.0; df ¼ 249; P < .01). Given 4,565 HCWs, the average increase represents hundreds more vaccinated. During 2011-2012, facilitylevel patient vaccination rates were higher than HCW rates with a mean standard deviation of 88.3 7.9 (paired t test ¼ 10.1; df ¼ 306; P < .01). The 2011-2012 patient rate was also a significant increase over the same measure in the previous season, 86.7 8.5 (paired t test ¼ 2.9; df ¼ 249; P < .01). Given 20,853 patients, the small average increase also represents hundreds more individuals vaccinated.
Responding facilities varied by size and three-quarters were members of large dialysis organizations; that is, corporate entities with 200 or more dialysis units nationally. In total, 179 facilities responded to our questionnaire. All but 1 reported providing influenza vaccine to HCWs at the clinic and many indicated they provided the vaccine free of charge. Otherwise, the most common form of HCW intervention was education. See Table 1. In the multiple regression analysis, we found that the HCW rate for the 2010-2011 season plus the patient rate in the 2011-2012 season explained about 40% of the change in HCW vaccination between the 2 seasons. Size and ownership were not significant. Adding activities to promote HCW vaccination also failed to produce statistically significant results or explain more of the variation. See Table 2. DISCUSSION The average HCW vaccination rate increased over time; however, opportunities for improvement remained. Although it is commendable that facilities succeeded in immunizing patients at rates close to the Healthy People4,5 and National Action Plan goal of 90%, unvaccinated staff may have exposed patients to influenza. Given the potential suboptimal response of patients with end-stage renal disease to the influenza vaccine,6,7 reducing exposure to the virus is important and may reduce patient mortality.8,9 The best single predictor of change in the HCW vaccination rate was where the facility started. Those with more opportunity for improvement tended to improve more. The positive relationship between change in the HCW rate and the patient rate may mean that facilities with higher patient rates are beginning to extend learning from patient vaccination efforts to vaccinating staff.
J.R. Lynch et al. / American Journal of Infection Control 43 (2015) 409-11 Table 2 Change in dialysis health care worker (HCW) influenza vaccination rate between the 2010-2011 and 2011-2012 influenza seasons* as a function of the HCW influenza vaccination rate for 2010-2011, patient vaccination rate for 2011-2012, and facilitylevel activities to encourage HCW vaccination, controlling for ownership and size Variable Intercept Large dialysis organization ownership Medium (> 30 patients and 75) sizey Large (> 75 patients and 150) sizey Very large (> 150) sizey HCW influenza vaccination rate, 2010-2011 Patient influenza vaccination rate, 2011-2012 Provision of free vaccine Provider educationz Visible symbols of receiving influenza vaccinationx F value Adjusted R2
b
P value
b
P value
1.12 2.74 2.63 0.95 3.09 0.63 0.62
.95 .46 .53 .82 .46
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Correlates of change in health care worker seasonal influenza vaccination rates among dialysis facilities Janet R. Lynch PhD a, *, Nancy Armistead MPA a, Brandy B. Vinson BBA a, Andrew D. Howard MD, FACP b a b
Mid-Atlantic Renal Coalition, Richmond, VA Metropolitan Nephrology Associates, Alexandria, VA
Key Words: Health personnel Evidence-based medicine Health promotion
We conducted a campaign to increase seasonal influenza vaccination of dialysis health care workers (HCWs) in the District of Columbia, Maryland, Virginia, and West Virginia. Between the 2010-2011 and 2011-2012 influenza seasons we examined the correlates of change. HCW vaccination rates improved significantly (P < .01) from a mean standard deviation of 64.5 27.4 to 72.7 23.1. Evidence-based practices were in wide use and although we did not find an association between these and improvement, we did find that lower-performing facilities tended to improve more (P < .01) and there was a positive relationship between patient influenza vaccination rates and improvement in HCW rates (P < .01), with the mean standard deviation patient rate of 88.3 7.9 exceeding the HCW rate during the 2011-2012 season (P < .01). Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
The National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination1 recommends offering the influenza vaccine annually to health care workers (HCWs) to protect staff, patients, and family members, as well as decrease staff absenteeism. Although research has identified activities, including staff education, that increase HCW vaccination rates,2 the usefulness of these strategies in the dialysis setting has received little attention. Too, the association between staff and patient influenza vaccination has not been explored.
* Address correspondence to Janet R. Lynch, PhD, Corporate Science Officer, MidAtlantic Renal Coalition, West Virginia Medical Institute and Quality Insights, 300 Arboretum Pl, Ste 310, Richmond, VA 23236. E-mail address: [email protected] (J.R. Lynch). The analyses reported here were performed under contract No. HHSM-5002011, End Stage Renal Disease Network 5, funded by the Centers for Medicare & Medicaid Services, an agency of the US Department of Health and Human Services. The content of this publication does not necessarily reflect the policies or positions of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US government. The authors assume full responsibility for the accuracy and completeness of the ideas presented. The Centers for Medicare & Medicaid Services staff had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. The Centers for Medicare & Medicaid Services staff reviewed the manuscript and provided helpful comments. Conflicts of interest: None to report.
METHODS We examined the relationship between change in the HCW vaccination rate between influenza seasons and the initial HCW rate, patient rate, and strategies employed by dialysis facilities to encourage HCW vaccination. We reasoned that improvement was likely to be iterative, building on past performance and that success vaccinating patients was likely to have a spillover effect influencing improvement in HCW vaccination; however, our primary interest was in examining the association between improvement in HCW vaccination rates and evidence-based strategies. Our study was conducted in the context of annual regional influenza vaccination campaigns promoting both patient and HCW vaccination. The campaigns included distributing information to dialysis facilities to support their use of evidence-based strategies, HCW-targeted messaging to increase awareness and motivation, data feedback, and certificates of recognition for achieving 90% or greater HCW vaccination. Although regional campaigns to increase patient vaccination had been ongoing for many years achieving high patient rates, we first incorporated HCWs as a target population during the 2010-2011 influenza season. We requested data, concurrent with the 2010-2011 and 2011-2012 influenza seasons, from all facilities providing hemodialysis and peritoneal dialysis in Maryland, Virginia, West Virginia, and the District of Columbia, excluding military treatment facilities, Veterans Health Administration hospitals, and prisons.
0196-6553/$36.00 - Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2014.12.011
410
J.R. Lynch et al. / American Journal of Infection Control 43 (2015) 409-11
Table 1 Dialysis health care worker (HCW)* and patienty vaccination rates and descriptive statistics for dialysis facilities by response categories, including types of activities used by facilities to encourage HCW influenza vaccination Facilities responding to 2011-2012 and 2010-2011 influenza seasonsz vaccination data collection plus HCW intervention questionnaire (n ¼ 179)
Facilities responding to 2011-2012 and 2010-2011 influenza seasonsz vaccination data collection (n ¼ 250)
Mean % (standard deviation) HCW vaccination rates 2011-2012 Patient vaccination rates 2011-2012
72.7 (23.1) 88.3 (7.9)
74.5 (22.5) 88.2 (7.8) % (n)
Facility size Small ( 30 patients) Medium (> 30 patients and 75) Large (> 75 patients and 150) Very large (> 150) Ownership Large dialysis organizationx Nonlarge dialysis organization Activities used to encourage HCW vaccination Provided staff with vaccine at clinic Free vaccination for staff Provider educationk Visible symbols{ Threats of penalties Rewards#
9.6 40.4 44.8 5.2
(24) (101) (112) (13)
8.9 39.7 45.8 5.6
75.2 (188) 24.8 (62)
(16) (71) (82) (10)
73.7 (132) 26.3 (47)
-
98.9 60.9 88.3 24.0 5.0 3.4
(177) (109) (158) (43) (9) (6)
*HCW was defined as a facility-paid full-time or part-time employee, including nurses, patient care technicians, water/inventory/machine technicians, dietitians, social workers, and administrative personnel. The HCW vaccination rate is the percent of HCWs employed during the influenza season who were vaccinated in the center or who indicated that they received the vaccine in another setting during the influenza season. y Patient was defined as an adult, aged 19 years or older, receiving hemodialysis or peritoneal dialysis. The patient influenza vaccination rate is the percent of patients receiving hemodialysis or peritoneal dialysis during the influenza season who were vaccinated in the center or who indicated that they received the influenza vaccine in another setting during the influenza season. z The 2010-2011 influenza season was defined as September 1, 2010-March 31, 2011; the 2011-2012 influenza season was defined as September 1, 2011-March 31, 2012. x Corporate entities with 200 or more dialysis units nationally. k Information to staff to increase their knowledge about influenza vaccination or change their attitudes about influenza vaccination. { Visible symbols of having received the influenza vaccine; for example, buttons with slogans such as, “I got the flu shot.” # Gifts, for example.
We surveyed facilities at the conclusion of the 2011-2012 season to identify the evidence-based interventions they used to promote the uptake of influenza vaccine among their staff. For example, the literature identifies vaccine availability and staff education as effective in increasing HCW vaccination3 and we asked about these approaches. We performed a 1-sided paired t test to examine the difference in facility vaccination rates from 1 season to the next and used multiple linear regression to examine the relationship between change and variables of interest, controlling for potential extraneous enabling variables of ownership and size. RESULTS Of 309 facilities, 250 responded with complete HCW and patient vaccination data for a return rate of 81.0%. These facilities reported employing 4,565 HCWs during the 2011-2012 influenza season, 3,304 of whom were vaccinated. They cared for 20,853 patients, 18,412 of whom were vaccinated. At the facility level, the mean standard deviation HCW vaccination rate was 72.7 23.1 for the 2011-2012 season, a statistically significant increase over the previous season’s measure of 64.5 27.4 (paired t test ¼ 5.0; df ¼ 249; P < .01). Given 4,565 HCWs, the average increase represents hundreds more vaccinated. During 2011-2012, facilitylevel patient vaccination rates were higher than HCW rates with a mean standard deviation of 88.3 7.9 (paired t test ¼ 10.1; df ¼ 306; P < .01). The 2011-2012 patient rate was also a significant increase over the same measure in the previous season, 86.7 8.5 (paired t test ¼ 2.9; df ¼ 249; P < .01). Given 20,853 patients, the small average increase also represents hundreds more individuals vaccinated.
Responding facilities varied by size and three-quarters were members of large dialysis organizations; that is, corporate entities with 200 or more dialysis units nationally. In total, 179 facilities responded to our questionnaire. All but 1 reported providing influenza vaccine to HCWs at the clinic and many indicated they provided the vaccine free of charge. Otherwise, the most common form of HCW intervention was education. See Table 1. In the multiple regression analysis, we found that the HCW rate for the 2010-2011 season plus the patient rate in the 2011-2012 season explained about 40% of the change in HCW vaccination between the 2 seasons. Size and ownership were not significant. Adding activities to promote HCW vaccination also failed to produce statistically significant results or explain more of the variation. See Table 2. DISCUSSION The average HCW vaccination rate increased over time; however, opportunities for improvement remained. Although it is commendable that facilities succeeded in immunizing patients at rates close to the Healthy People4,5 and National Action Plan goal of 90%, unvaccinated staff may have exposed patients to influenza. Given the potential suboptimal response of patients with end-stage renal disease to the influenza vaccine,6,7 reducing exposure to the virus is important and may reduce patient mortality.8,9 The best single predictor of change in the HCW vaccination rate was where the facility started. Those with more opportunity for improvement tended to improve more. The positive relationship between change in the HCW rate and the patient rate may mean that facilities with higher patient rates are beginning to extend learning from patient vaccination efforts to vaccinating staff.
J.R. Lynch et al. / American Journal of Infection Control 43 (2015) 409-11 Table 2 Change in dialysis health care worker (HCW) influenza vaccination rate between the 2010-2011 and 2011-2012 influenza seasons* as a function of the HCW influenza vaccination rate for 2010-2011, patient vaccination rate for 2011-2012, and facilitylevel activities to encourage HCW vaccination, controlling for ownership and size Variable Intercept Large dialysis organization ownership Medium (> 30 patients and 75) sizey Large (> 75 patients and 150) sizey Very large (> 150) sizey HCW influenza vaccination rate, 2010-2011 Patient influenza vaccination rate, 2011-2012 Provision of free vaccine Provider educationz Visible symbols of receiving influenza vaccinationx F value Adjusted R2
b
P value
b
P value
1.12 2.74 2.63 0.95 3.09 0.63 0.62
.95 .46 .53 .82 .46
