Mandatory Flu Vaccination of Healthcare Workers: A Patient Safety Imperative

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By Kelly M. Pyrek

Despite knowing that vaccination is a patient-safety imperative, many healthcare professionals are not immunized against influenza. Healthcare institutions are trying to change that by mandating vaccination for its workers, and one of the biggest success stories has been unfolding for the last five years at Virginia Mason Medical Center (VMMC), a tertiary-care, multi-specialty medical center in Seattle with 5,000 employees.

Virginia Mason achieved and sustained influenza vaccination of more than 98 percent of its healthcare workers, a feat written up in the September issue of the journal Infection Control and Hospital Epidemiology by Robert Rakita, MD; Beverly Hagar, BSN, COHNS; Patricia Crome, MN; and Joyce Lammert, MD, PhD. Rakita, et al. (2010) report on their five ‐ year study (from 2005 to 2010) at VMMC, in which all healthcare workers were required to receive influenza vaccination; those who were accommodated for medical or religious reasons were required to wear a mask at work during influenza season.

In the first year of the program, 4,588 of 4,703 healthcare workers (97.6 percent) were vaccinated, and influenza vaccination rates of more than 98 percent were sustained over the subsequent four years of the study. Not only were all employees of the medical center required to receive the influenza vaccine, in addition, other individuals such as students, vendors, volunteers, contractors and outside physicians, were also required to be vaccinated. Less than 0.7 percent of healthcare workers were granted the aforementioned accommodation and less than 0.2 percent refused vaccination and left the medical center.

Although this vaccination rate seems extraordinary, Lammert, chief of medicine and also the main physician sponsor of the VMMC’s vaccination program, says nothing less would have sufficed. “Once we decided that we were going to require mandatory vaccination, we weren’t aiming for anything other than as close to 100 percent as possible,” Lammert emphasizes.

The impetus for the vaccination mandate evolved from conversations during a workshop that was held to increase influenza vaccination rates at VMMC. “One of our healthcare workers had been reading the literature and said she didn’t understand why we don’t require immunization for influenza,” Lammert says. “As we started to think about it, we said, ‘We don’t understand it either.’ So we brought the issue before our community board, comprised of non-medical members of the community – and they were surprised that the national immunization rates were so low. They supported mandatory vaccination from the beginning because they felt it was the right thing to do to protect our patients.” Strong support of the mandatory vaccination program also came from the medical center’s senior leadership, and so a  multi-disciplinary task force – including representatives from infection prevention and control -- was assembled to lead the influenza vaccination campaign during the first year of implementation.

Understanding barriers to vaccination and then addressing them in an educational, non-threatening way was critical to the success of VMMC’s program. As Rakita, et al. (2010) point out, “Multiple reasons exist for healthcare worker resistance to influenza vaccination, including cost, inconvenience, and fear of needles. Some of the more common bits of misinformation associated with influenza vaccine include a belief that one can get influenza from the vaccine, an assumption that flu is a mild illness, and a fear of adverse effects associated with the vaccine. Educational efforts—which explain that the injectable vaccine contains a killed virus and therefore cannot cause influenza, that illness due to influenza may be severe and even fatal, and that adverse effects due to the vaccine are typically mild and (other than a sore arm) are no different than those seen with placebo —are useful but still have not led to a dramatic increase in vaccination rates.”

The researchers say that VMMC managers and staff collected data on these barriers, educational deficits and preferences in receiving information about vaccination, and then in the spring of 2005, a comprehensive educational program was rolled out, including an informational Web site with links to outside sources of information (such as from the CDC), an online learning module, as well as meetings with staff and leadership who functioned as  champions of influenza vaccination, including VMMC’s president and CEO. To boost the “fun” quotient of the immunization program, the researchers report that flu quizzes offered the chance to win prizes; other activities included a vaccination kickoff party with food, games, and members of the local professional football team attending; and an influenza video created by staff members with personal stories. In subsequent years, during the annual fall kickoff party, approximately 20 percent of employees were vaccinated.

The researchers say that creative approaches, such as a mobile flu cart and a drive ‐ through vaccination station, were successful in achieving program goals. “It was important for us to work with the staff to better understand what their fears and concerns were,” Lammert says. “We spent a lot of time conducting staff forums and helping them understand why we thought vaccination was important and connecting the dots between our immunization efforts and patient safety mandates.” Lammert adds, “It’s certainly important to think outside of the box to understand what the barriers are and to address them in any way possible. The drive-through immunization effort was helpful, as were the different types of partnerships we created – the one with the Seattle Seahawks worked particularly well -- they actually require their players to get immunized. Creative partnerships, engaging the staff, and finding new ways of administering the vaccine definitely contributed to the vaccination compliance rates we achieved.”

The difference before and after the start of the mandatory vaccination program are significant, other than a hiccup during the 2005-2006 flu season when vaccination rates dropped to 29.5 percent due to a national vaccine shortage. Rakita, et al. (2010) report that during the 2003-2004 influenza season, 54 percent of employees at VMMC were vaccinated with influenza vaccine; following the 2005-2006 season, the influenza vaccination rate increased to 97.6 percent. The vaccination rate increased slightly during the subsequent influenza seasons, up to 98.9 percent for the 2009-2010 season. As the program unfolded, the researchers report a more efficient vaccination program; for example, at the 2008 kickoff party, 1,010 employees were vaccinated during a three ‐ hour period.

Healthcare institutions, keeping in mind that the average healthcare vaccination rate is about 40 percent to 45 percent, are watching the move toward mandatory immunization very closely. Last year, the state of New York was the first to attempt mandatory influenza vaccination for healthcare workers but later rescinded this mandate due to a vaccine shortage triggered by the H1N1 influenza pandemic. The New York law was also challenged by unions, a situation familiar to VMMC when its policy was challenged by the Washington State Nurses Association (WSNA). The WSNA filed a grievance on behalf of the center’s unionized nurses and an arbitrator agreed that the vaccination mandate should have been negotiated as part of the union's bargaining agreement with Virginia Mason; that decision was upheld on appeal.

Despite this legal decision, Rakita, et al. (2010) report that 515 (85.9 percent) of the 599 unionized inpatient nurses elected to be vaccinated in 2005-2006, increasing to 595 (95.8 percent) of 621 unionized inpatient nurses in 2009-2010. A handful of healthcare workers refused to be vaccinated; five left the medical center voluntarily while two were terminated during the 2005-2006 influenza season. Since then, the researchers report, just two more healthcare workers have left as a result of the vaccination mandate.

The WSNA had also asserted that the requirement for non-vaccinated healthcare workers to wear masks during the influenza season constituted an unfair labor practice; the researchers report that an administrative law judge ruled that it was permissible to require unionized healthcare workers to wear a mask as part of an infection control policy. This ruling is currently pending appeal at the National Labor Relations Board.

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