1. Impact of State Law on Implementation of Standing Orders for Adult Immunizations in Acute Care Hospitals in New York City, 2008 Toni Olasewere 1, Justin Knox 1, Edward Wake 1, 2, Jane Zucker 1, 2 (1)Bureau of Immunization, New York City Department of Health and Mental Hygiene (2)Immunization Services Division, Program Operations Branch, Centers for Disease Control and Prevention

2. Today’s Talk Provide background information Describe two surveys on standing orders conducted by the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) in 2005 and 2008 Discuss the impact of New York State Public Health Law Amendment #2805-h (NYS PHL) in promoting standing orders Discuss the impact of standing orders on vaccination coverage

3. New York City Population: 8.2 million 1 Persons age 65 years and older: 961,000 1 Hospitals: –65 Acute Care Hospitals –Total Beds: 24,525 –Mean Bed Size: 377 [range: 69 – 1200] (1)U.S. Census Bureau. State and County Quick Facts. New York (city)

4. NYC Influenza and Pneumonia Statistics, 2006 Influenza and Pneumonia Combined: Caused 2,577 deaths 1 Third leading causes of death 1 New Yorkers 65 years of age and older: 55% reported influenza vaccination 2 48% reported pneumococcal vaccination 2 (1)NYC DOHMH 2006 Vital Statistics (2)NYC DOHMH 2007 Community Health Survey

5. Non-patient Specific Standing Order Policies Programs that authorize licensed practitioners to administer vaccines to patients, according to a physician-approved or agency policy, without the need for a patient-specific physician’s order Evidence-based best practice Recommended by the Advisory Committee on Immunization Practices (ACIP)

6. NYC DOHMH Standing Order Promotion Efforts Provider Education –Letters to hospitals –Meetings –Presentations Pneumococcal Immunization Initiative Online Resources –Sample standing order protocols –Implementation Plans

7. New York State Public Health Law Amendment #2805-h Effective October 24, 2006 Requires hospitals to offer influenza and pneumococcal vaccination to all patients age 65 years or older admitted to the hospital Influenza vaccination should be offered between September 1 and April 1 Pneumococcal (PPV23) vaccination should be offered throughout the year

8. New York State Public Health Law Amendment #2805-h Encourages hospitals to implement procedures for offering vaccination against influenza virus and pneumococcal disease; specifically promotes non-patient- specific standing order policies All patient records should indicate they were screened for eligibility All records should document the reason vaccine was not administered, including patient refusals

9. Survey Objectives 2005 Describe the use of standing orders in acute care facilities in NYC 2008 Determine the impact of the law in promoting standing order policies Determine the effect of standing order policies on vaccination coverage 2006 NYS PHL becomes effective

10. Survey Methods All acute care hospitals in NYC surveyed Series of questions regarding immunization protocols and monitoring practices in each facility –Same questions asked in both surveys –New questions added for 2008 survey Each hospital received $5,000 from Healthcare Emergency Preparedness Program grant funding for participation

11. Sample Questions Standing Orders Does your facility have standing orders in place in the following departments? Influenza VaccinePneumococcal Vaccine Inpatients Outpatients Emergency Department (ED) Urgent Care/ Fast Track

12. Sample Questions Current Coverage Rates of Patients Vaccinated Does your facility monitor the rate at which immunizations are given? If so, please answer the following in regards to the current coverage rates (in percent) of patients vaccinated with: Percentage Vaccinated with Influenza Vaccine? Inpatients Outpatients ED Urgent Care/Fast Track Clinic

13. Sample Questions Standing Orders: Post Partum (PP) Please indicate which vaccines have standing orders in your PP ward? Standing Orders: Vaccine Administration Did your facility encounter any barriers and/or resistance to the implementation of a standing order? Standing Orders: Vaccine Administration Does your facility have a policy for addressing patients who refuse vaccine(s)?

14. Survey Methods: Differences 2005 Surveys mailed, faxed and e-mailed to Emergency Preparedness Coordinators (EPC) E-mail, fax and hard-copy submissions accepted 97% (N=66) completion Conducted from 4/2005 – 6/2005 2008 Survey available online through Survey Monkey EPCs notified electronically E-mail, fax and hard-copy submissions also accepted 100% (N=65) completion Conducted from 6/2008 – 8/2008

15. Results

16. Presence of Standing Orders for Influenza Vaccination by Hospital Department, 2005 vs. 2008

17. Presence of Standing Orders for Pneumococcal Vaccination by Hospital Department, 2005 vs. 2008

18. Hospitals that Monitor Vaccination Coverage Rates, 2005 vs. 2008

19. Mean Inpatient Influenza and Pneumococcal Vaccination Coverage Rates of Hospitals that Monitor *All vaccination coverage rates do not include hospitals that did not provide a coverage rate or that reported their coverage rate as nil

20. Mean Inpatient Influenza and Pneumococcal Vaccination Coverage Rates by Presence of Standing Order Policy, 2008 Influenza: p-value = NSPneumococcal: p-value < 0.05

21. Mean Outpatient Influenza and Pneumococcal Vaccination Coverage Rates, 2008

22. Mean Outpatient Influenza and Pneumococcal Vaccination Coverage Rates by Presence of Standing Order Policy, 2008 Influenza: p-value = NSPneumococcal: p-value = NS

23. Reported Barriers to the Implementation of Standing Orders 48% of hospitals (N=31) reported barriers: Physician Resistance –Feel responsible/liable for vaccination practices –Want control over vaccination decisions Nurse resistance –Outside scope of practice –Not comfortable vaccinating –Increased paperwork Non-communicative patients –Concern about the accuracy of vaccination eligibility

24. Policies to Address Patient Declinations, 2008

25. Summary of Findings Passage of NYS PHL was associated with increased implementation of standing order policies in inpatient settings, as well as in EDs and Urgent Care/Fast Track facilities in 2008 compared with 2005 In 2008, almost all NYC hospitals (86%) utilize standing order policies in their inpatient facilities Those hospitals with a standing order policy reported higher vaccination coverage rates in both inpatient and outpatient settings

26. Limitations Self-reported data Only four inpatient departments without standing orders monitored vaccination coverage rates Only five outpatient departments without standing orders monitored vaccination coverage rates Variation in ways that coverage rates were calculated

27. Next Steps Provide written feedback to hospitals Promote the expansion of standing order policies in other departments Provide technical assistance –Promote sharing of best practices –92% of hospitals (N=60) reported an interest in working with NYC DOHMH to strengthen vaccination programs

28. Recommendations Guidance on a standardized methodology for calculating vaccination coverage rates is needed –National Quality Forum indicators Advocate for federal regulations that require the use of standing order policies –Set minimum coverage levels –Tie to reimbursement

29. Acknowledgements Debra Berg, NYC DOHMH HEPP Dina Itani, NYC DOHMH Epi Services

30. Thank You Justin Knox Bureau of Immunization, NYC DOHMH jknox@health.nyc.gov