Healthcare worker vaccination rates vary immensely, from 2% to 100%, and hospitals are cracking down because data on rates of vaccination is now public.
With Medicare's latest quality update on Hospital Compare last month, one measure reported for the first time makes some hospitals look relatively unsafe for vulnerable patients and co-workers at risk for influenza.
One of the largest is Broward Health Coral Springs Hospital in South Florida. Only one in five of Broward's 2,500 healthcare workers received a flu shot last season, a rate that put it near the bottom of the list of more than 3,600 hospitals that reported their rates as part of a federal quality reporting program.
Broward is among nearly 200 acute care facilities with fewer than 50% of their workers bothering with influenza immunization, a rate far below national goal of 90%. The national average is 79%.
"A lot of our employees still feel—though we know it's a myth—that if you get the vaccine it will make you sick," says Diana Guevara, a spokeswoman for the 200-bed facility. "It's just one of the hardest things we have to battle through; some people just don't want to take it."
Like many hospitals, Broward has stepped up its effort to vaccinate workers, requesting that all medical and allied health staff, medical students, and contract employees get the vaccine, which it offers it at no charge.
For the current flu season, its vaccination rate is up significantly, from 21% last year to 50%, according to Ava Dobin, Broward's regional quality manager.
Across the country, hospital healthcare worker vaccination rates vary immensely, from 2% to 100%. At the high end, five CHI Health hospitals in Nebraska and Iowa achieved rates of 97% or above. They are among just 58 hospitals in the country with perfect flu shot scores.
"It's all about leadership," says Cary Ward, MD, CMO for CHI Health in Omaha. "We're a culture dead set on getting our people vaccinated," so the hospital mandated that anyone without a health or religious reason had to be vaccinated if they might ever be in a patient care area.
And, he says, staff members can't simply give the excuse that their "faith prohibits" the vaccine. "For those that had a religious reason, we said 'we want an explanation from your clergy,' " Ward says.
The real motivator, however, was CHI's policy mandating that any unvaccinated person must wear a mask during flu season, Ward says.
"It created a scarlet letter," Ward says. "Nobody likes masks, they're not particularly comfortable; they don't look good. Ergo, we had 100% vaccination rates" at those hospitals, and near 100% at the others.
"Here was our rationale," Ward explains, "we know there is a struggle around it and that the issue is hotly debated," with many healthcare workers thinking they won't get sick and can't transmit. "But we also know that theoretically people can transmit influenza up to 24 hours before any symptoms appear."
A Condition of Employment
Linda Greene of the Association for Professionals in Infection Control and Epidemiology takes a similar stance. An APIC position paper she co-authored states influenza immunization should be a healthcare worker condition of employment. At the very least, she says, employees who don't get immunized should be required to wear a mask anywhere in a patient care building.
Greene adds that such policies are starting to be enforced in healthcare facilities throughout the country, in part because, in a year or two, the Centers for Medicare & Medicaid Services is expected to roll the measure into its value-based purchasing program. It may also end up as a factor in CMS's hospital-acquired condition program, financially penalizing hospitals with lower employee immunization rates.
"You're going to see more and more organizations requiring it. First of all, [because] we have to keep patients safe, and second, because they'll say 'we can't afford to lose money because you choose not to be vaccinated,' "Greene says.
3 Pushback Points
There's still considerable pushback from workers for three main reasons, Greene says.
- Younger workers think they're invincible and won't get sick, even though one can transmit the virus without showing severe symptoms.
- Workers fear the vaccine itself will make them sick, although evidence suggests no more than 2% will have a reaction.
- Personal right of choice. "There's a sense that 'no one should be able to force me to take something I don't want,' " Greene says.
Karen Higgins, co-president of National Nurses United and an ICU nurse at Boston Medical Center, says the pushback is justified.
First, she says, "there's nothing in the research that proves to us that it makes any difference in the number of people who get the flu or die from it. And masking healthy people, healthcare workers, doesn't prevent people who are sick from getting it.
The second reason is personal. "Every time I got the flu shot I have gotten sick, so for years I refused," Higgins says. "But the hospital was mandating that you either get the flu shot, or you wear a mask while you're in the building. That's 12-hour days, which is problematic for me because I also have asthma, and can't tolerate the mask that long."
Higgins says that within 36 hours after getting the vaccine two years ago, "I ended up in the ICU because I couldn't breathe. It was a horrific experience. And it's not an isolated instance," she says, estimating that about 10% of healthcare workers she knows have become ill in some way after getting a flu shot.
"We know what to do to prevent flu in a hospital setting, and that's good infection control with good hand washing."
Higgins believes it's right to encourage healthcare workers and the community to get immunized, but that "we also believe it's the person's right to say no." Rather than comparing hospitals with a measure scoring rates of influenza vaccination, she says hospitals should be scored by other means, "like how good is your staffing?"
Dr. Ray Strikas, MD, medical officer for the Centers for Disease Control and Prevention's Immunization Services Division, acknowledges the hospital worker vaccine measure is controversial. And, he says, "there's not as much data as we'd like" to demonstrate the link between influenza vaccination and reduction of nosocomial transmission of flu to patients.
Blurred Lines of Transmission
Several studies have addressed it in limited form, some finding smaller impacts on mortality rates in especially frail seniors. Others, such as a recent one in California, suggest that for every 15 healthcare workers who get a flu shot, one fewer person in the community gets a flu-like illness.
The difficulty is in proving direct transmission between a sick worker and a patient. DNA sequencing of lab-confirmed influenza is expensive, and infectious workers are usually no longer sick when the patient develops symptoms, often after discharge.
There's more evidence linking vaccination of personnel with mortality in nursing homes, Strikas says, but still, the CDC would like more evidence.
As more workers get vaccinated, time will tell if it reduces mortality, with 36,000 people dying every year from influenza, many of them frail seniors who recently had an acute care stay, Strikas says.
The CDC developed the measure in 2008 "to ensure that healthcare worker vaccination rates were comprehensive in a single facility, and comparable across facilities," says Elizabeth Kalayil, a public health analyst working with the CDC.
Kalayil says that in addition to acute care hospitals, ambulatory surgical facilities, long term care hospitals and inpatient rehab facilities must now report worker vaccination.
The measure counts any employee who gets a direct paycheck from a facility; any licensed independent practitioner including physicians, advanced practice nurses and physician assistants; students, trainees, and all volunteers who work at least one day "regardless of clinical responsibility or patient contact."
Dialysis centers and inpatient psych units will start reporting for the 2015–2016 flu season.
Though the CDC, as a matter of policy, doesn't mandate or recommend that states mandate a facility-wide immunization policy for their workers, it's already tracking new laws and regulations in 13 states. Colorado, for example, requires hospital workers who don't get immunized to wear a mask.
And many states are now requiring healthcare facilities to offer the vaccine at no charge or make it available on site.