Los Angeles County Department of Public Health
Increasing Healthcare Personnel Influenza Vaccination Coverage in Hospitals in Los Angeles County
Brief description of LHD
The Los Angeles County Department of Public Health serves a population of approximately 10 million residents, making the County the most populous in the United States. Los Angeles County is a racially and ethnically diverse population. Nearly three-quarters of County residents belong to racial or ethnic groups that historically are considered minorities. Since 2000, the County has served as the nation's primary immigrant port of entry, and 35% of the adult population is foreign-born. The older adult population (aged 65 and older) is projected to double in size from 1.1 million in 2010 to 2.2 million in 2030.
Los Angeles County is also home to nearly 100 acute care hospitals. In Los Angeles County, the hospital services infrastructure is diffusely distributed with no single hospital system or physician group having a dominant share of the marketplace. Most hospitals operate within a region, with some hospital systems having several sites. Slightly over half of the general acute care hospitals are non-profit. Los Angeles County hospitals are also a major source of graduate medical education in the region and nationally and the County is home to many world-renowned teaching hospitals. Total bed capacity for all hospitals is approximately 22,500 licensed beds. The average length of stay at a hospital in the County is 4.8 days. More than 250,000 healthcare personnel work in LAC hospitals.
Describe public health issue
Influenza is a serious and oftentimes deadly infection. In general, hospitalized persons are at greater risk for complications related to influenza infection compared to the general population. In addition, hospitalized persons are exposed to healthcare personnel, who as healthy adults can often serve as vectors for influenza transmission. The vaccination of healthcare personnel has been widely recommended to provide direct protection against influenza infection for themselves and indirect protection for their patients.
In 2013, the Los Angeles County Health Officer issued a health officer order for healthcare personnel in acute care hospitals to either be vaccinated for seasonal influenza or wear a mask. Despite this order, approximately three-quarters of hospitals had not met the Healthy People 2020 goal of 90% vaccination coverage and 16% were below 60% coverage in the 2015-16 influenza season.
Goals and objectives of the proposed practice
The goal of the Healthcare Personnel Influenza Vaccination Improvement Project was to increase influenza vaccination amongst healthcare personnel in acute care hospitals with the lowest vaccination coverage in Los Angeles County (LAC). The objectives were to gather evidence-based practices and successful vaccination strategies employed in LAC hospitals, and to use these strategies to guide 13 targeted hospitals in improving their HCP influenza vaccination coverage through specific, tailored recommendations.
How was the practice implemented/activities?
The steps taken to implement the project include the selection of targeted hospitals, data collection, and providing tailored recommendations to those hospitals. Hospitals with the lowest influenza vaccination coverage were targeted for intervention based on data collected from the National Healthcare Safety Network (NHSN). The Healthcare Outreach Unit liaison public health nurses conducted several meetings with each hospital's infection preventionist and employee health director during the 2016-17 influenza season to ascertain current vaccination campaign strategies and barriers. DPH assessed these data, then created and promoted tailored recommendations for each hospital's 2016-17 influenza vaccination campaign.
Using the 2015-16 influenza season as a baseline, we found that all hospitals that participated in the intervention experienced an increase in vaccination coverage between influenza seasons by an average of 22.6% (range: 4.3%-46.1%).
Were all of the objectives met?
All of the objectives for this project were met. DPH was able to gather information from local hospitals on effective influenza vaccination campaign strategies, and disseminate this knowledge through tailored recommendations to hospitals with the lowest levels of vaccination coverage.
What specific factors led to the success of this practice?
This project leveraged existing relationships between DPH and hospital staff during exchanges with both high-performing and low-performing hospitals. This connection allowed DPH to identify appropriate hospital contacts to quickly deploy the practice. Further, the use of evidence-based and locally effective vaccination campaign strategies was novel and well-received by target hospitals.
Public health impact of practice
The project increased the number of healthcare workers vaccinated against influenza in the 2016-17 season. This practice ultimately aided in protecting hospital patients, visitors, families, and other staff members from becoming infected and transmitting influenza to others. Indirect benefits of vaccinating healthcare workers against influenza include decreased mortality, morbidity, frequency of disease, associated worker absenteeism, and improved attitudes and beliefs regarding influenza vaccination.
Website for LHD: http://www.publichealth.lacounty.gov/
Statement of the problem/public health issue
In 2015-16, there were 70 influenza-associated deaths in Los Angeles County. Acute care hospitals' patient populations are amongst the most vulnerable and are often at greatest risk for influenza-related complications. Influenza vaccination of healthcare personnel is critical to the maintenance of safe healthcare environments by minimizing transmission of the serious virus within healthcare facilities. Influenza vaccination plays an important role not only in protecting patients, but also in protecting the healthcare workforce from acquiring infections in the workplace.
What target population is affected by problem?
Healthcare personnel (HCP) targeted for the Healthcare Personnel Influenza Vaccination Improvement Project included staff at Los Angeles County acute care hospitals. These included all employees, licensed independent practitioners, adult students/trainees and volunteers, and other contract personnel. Between the 13 targeted hospitals, approximately 30,000 HCP were included in the intervention.
What has been done in the past to address the problem?
To encourage vaccination of HCP, a Health Officer Order was issued in 2013 mandating all HCP in licensed acute care facilities to receive influenza vaccination or wear a mask during the influenza season. Following issuance of the order, pooled HCP vaccination coverage increased from 60% to 76% in Los Angeles County hospitals. However, 75 hospitals continued to fail to meet the Healthy People 2020 goal of 90% vaccination coverage in the 2015-16 season.
Why is the current/proposed practice better?
The Healthcare Personnel Influenza Vaccination Improvement Project took a different approach to working with hospitals to increase vaccination coverage. Rather than relying solely on mandated practices to increase coverage, the project compelled DPH staff to work collaboratively with hospital infection prevention and employee health staff. In this way, sustainable relationships were built between DPH and hospitals. Further, the model of the project was to gather best practices from LAC hospitals with high vaccination coverage and impart those on hospitals with lower coverage. The spread of evidence-based local practices was a unique aspect of this intervention.
Is current practice innovative?
To discover best practices and to work with targeted hospitals, the project relied on the innovative structure of the DPH Healthcare Outreach Unit. In 2003, the Healthcare Outreach Unit was created to enhance disease and outbreak reporting between DPH and LAC hospitals. Healthcare Outreach Unit liaison public health nurses have established relationships with hospital staff, and regularly attend infection control committee meetings. When HCP influenza vaccination was detected as an area of concern, DPH was able to utilize this existing rapport. Healthcare Outreach Unit staff successfully identified those in the hospital that oversee the vaccination campaign and have the most influence over improving vaccination coverage. DPH and hospital staff communicated and collaborated openly and efficiently to implement new vaccination campaign strategies.
Is the current practice evidence-based?
The assessment tool used by DPH staff to assess hospital vaccination programs and to provide recommendations was created specifically for this project. While the project incorporated findings from the Community Preventive Services Task Force Worksite: Seasonal Influenza Vaccinations Using Interventions with On-Site, Free, Actively Promoted Vaccinations â€“ Healthcare Workersâ€ review and the National Healthcare Safety Network Healthcare Personnel Safety Component Protocol, the assessment tool also included evidence-based practices from other literature. Most distinctive, the assessment tool included practices deemed effective in other local hospitals. This information was extracted from interviews of staff from hospitals with high vaccination coverage and those that were able to increase coverage in their hospital significantly between seasons.
DPH also used its own data to guide strategies implemented in the project. All LAC hospitals report HCP influenza vaccination data and vaccination campaign elements to the National Healthcare Safety Network (NHSN). DPH analyzed NHSN data to identify those campaign elements most associated with higher vaccination coverage, and encouraged targeted hospitals to implement those elements.
Goal(s) and objectives of practice
The goal of the project was to increase influenza vaccination amongst healthcare personnel in targeted Los Angeles County acute care hospitals. The objectives were to gather evidence-based practices and successful vaccination strategies of LAC hospitals, and to use these strategies to guide 13 targeted hospitals in improving their HCP influenza vaccination campaign through specific, tailored recommendations.
What did you do to achieve the goals and objectives?
The steps taken to implement the project include the selection of targeted hospitals, data collection, and providing tailored recommendations to those hospitals. In August 2016, hospitals were targeted for intervention based on vaccination data collected from the National Healthcare Safety Network (NHSN). If a hospital's HCP vaccination coverage in the 2015-16 season, as reported in NHSN, was in the lowest quartile of all LAC hospitals, a letter was sent to the hospital chief executive officer explaining the importance of HCP vaccination, their hospital's low coverage, and the opportunity to participate in the Healthcare Personnel Influenza Vaccination Improvement Project. DPH liaison public health nurses then followed up with the hospital's infection preventionist and employee health director to secure their buy-in and to begin an assessment of their 2016-17 seasonal influenza vaccination campaign. Thirteen hospitals opted to participate in the project.
A semi-structured interview was conducted with the hospital staff using the tool to determine the hospital's current vaccination campaign strategies to promote influenza vaccination, methods of delivering vaccine to HCP, how HCP vaccination was tracked, methods of promoting and enhancing vaccination uptake, and any perceived barriers the campaign faced.
Based on the results of each interview, DPH provided customized recommendations for hospitals to implement into their campaign in the 2016-17 season. These recommendations were based on a DPH-conducted literature review and from the Community Preventive Services Task Force Worksite: Seasonal Influenza Vaccinations Using Interventions with On-Site, Free, Actively Promoted Vaccinations â€“ Healthcare Workersâ€ review. Additionally, DPH staff used NHSN data to identify hospitals with high HCP vaccination coverage. Employee health directors from those high-performing hospitals were interviewed to identify best practices from their vaccination campaigns. Those best practices specified by high-performing hospitals were then recommended to targeted hospitals.
DPH discussed the tailored recommendations with each hospital's infection preventionist and employee health director. In some cases, DPH also provided supplemental vaccination tracking tools and educational materials to those hospitals.
DPH liaison public health nurses followed up with each hospital at the conclusion of the 2016-17 influenza season to determine which new strategies were implemented. Vaccination coverage was assessed for differences between the baseline (2015-16) and intervention (2016-17) seasons.
Any criteria for who was selected to receive the practice?
Targeted facilities were selected from those with vaccination coverage within the lowest quartile of all hospitals in LAC during the 2015-16 influenza season per NHSN data. From those, 13 hospitals were selected, based on availability during the intervention period.
What was the timeframe for the practice?
The timeframe for selection and intervention with targeted hospitals was August through November 2016. Implementation of DPH-suggested strategies by the targeted hospitals continued through March 2017. Final data collection and analysis was conducted in May 2017.
Were other stakeholders involved? What was their role in the planning and implementation process?
DPH led the project and involved several stakeholders. Community partners from hospitals, including infection preventionists, employee health directors, and chief executive officers, were heavily involved in the project. These hospital staff were consulted to determine best practices. To intervene in hospitals with low vaccination coverage, hospital stakeholders were interviewed to understand specific barriers and worked together with DPH to develop new custom vaccination campaign strategies.
Within DPH, liaison public health nurses and epidemiologists worked together on the project. Epidemiology staff analyzed NHSN data to determine the hospitals with the lowest vaccination coverage to be targeted for the project. Epidemiologists also analyzed those data to calculate outcome and performance measures between the seasons. DPH liaison public health nurses conducted the communication, assessments, and developed the tailored recommendations. Due to the close relationship between the epidemiologists and nurses at DPH, data was used to drive action in a concerted way.
Any start up or in-kind costs and funding services associated with this practice?
No start up or in-kind costs were incurred for this project.
This project's objective was to increase healthcare personnel (HCP) influenza vaccination coverage in Los Angeles County via targeted outreach to acute care hospitals. We partnered with 13 local hospitals (the intervention group), all of which had vaccination coverage within the county's lowest quartile for the 2015-16 influenza season. We sought to improve HCP influenza vaccination coverage for the 2016-17 season among intervention group hospitals. We found that all hospitals in the intervention group experienced an increase in vaccination coverage between influenza seasons by an average of 22.6% (range: 4.3%-46.1%).
List any primary data sources, who collected the data, and how
We leveraged an existing resource as our primary data sourceâ€”the Healthcare Worker Vaccination Module of NHSN. HCP influenza vaccination data are reportable to NHSN annually per California Health and Safety Code Chapter 526, Section 1288.5. It is the facility's responsibility to report their data. Los Angeles County Department of Public Health has access to this data for 90 (93%) local hospitals.
List any secondary data sources used
Our secondary data source was an internally-developed assessment tool used to guide semi-structured interviews with each intervention facility's infection preventionist and employee health director. Liaison public health nurses interviewed each facility before the 2016-17 season to collect qualitative data about the strategies used in the prior season's influenza vaccination campaign. They also gathered information about each facility's barriers to increasing vaccination coverage. An additional interview was performed after the 2016-17 season, in order to assess what changes were made and what the facility considered to be most effective in increasing coverage.
List performance measures used. Include process and outcome measures as appropriate
The outcome measure of interest was the percentage of HCP vaccinated, as reported to NHSN. HCP included employees, licensed independent practitioners, adult students/trainees, volunteers, and other contract personnel. We compared the 2015-16 and 2016-17 seasons with respect to this outcome.
Process measures were captured in semi-structured interviews conducted before and after the 2016-17 influenza season and used to identify barriers to and effective strategies for increasing HCP vaccination coverage. Process measures included perceived barriers, key influenza vaccination campaign messages, involvement of hospital leadership, and whether unit-based tracking and feedback was performed.
Describe how results were analyzed
We reviewed the HCP vaccination coverage data for the 2015-16 and 2016-17 influenza seasons. We compared changes in coverage between influenza seasons via two-tailed Wilcoxon Signed Rank tests, and between intervention and non-intervention groups via two-tailed Wilcoxon Rank-Sum tests. Mean increase in vaccination coverage between seasons was significantly higher among intervention hospitals (22.6%, range: 4.3%-46.1%) versus all others (1.3%, range: -15.8%-26.6%) (p<.0001). Among all facilities (n=90), average vaccination coverage increased from 74.9% to 79.3% for 2015-16 to 2016-17, respectively (p=0.001).
Responses from the semi-structured interviews conducted before the 2016-17 season were reviewed and assessed for barriers to increase vaccination coverage. Tailored recommendations of evidence-based practices were made to each facility for the 2016-17 influenza vaccination campaign based on its unique barriers.
The responses from the interviews conducted after the season were reviewed to assess whether hospitals had implemented the suggested practices and what changes they perceived to be the most impactful. The data were reviewed and common themes were identified. We found that the most commonly implemented strategy was the involvement of department supervisors (n=13, 100%). Specifically, 11 (85%) facilities implemented tracking of department-based vaccination rates. All facilities also cited increased leadership support as key to their success.
Were any modifications made to the practice as a result of the data findings?
Because we observed an increase in each intervention facility's vaccination coverage, we are in the process of conducting this project again for the 2017-18 influenza vaccination campaign, with a new subset of facilities selected from the bottom quartile of LA County hospitals.
In addition, as all intervention facilities cited leadership support as key to their success, we sent a letter to all hospital chief executive officers at the start of the 2017-18 influenza season. The letter stated the facility's HCP vaccination coverage for 2016-17 influenza season, as well as its ranking among LAC acute care hospitals. It also stressed the importance of influenza vaccination for HCP, and urged executives to lend support to vaccination campaigns.
Lessons learned in relation to practice
Successful strategies to increase HCP influenza vaccination coverage include leadership support and tracking unit-based vaccination rates. DPH will continue to promote those strategies in all hospitals. Regarding hospital engagement, DPH staff learned that communication targeted at hospital administration, including chief executive officers, is very effective in engaging these facilities.
Lessons learned in relation to partner collaboration
Communication and collaboration between DPH and hospital counterparts may benefit facilities to improve vaccination coverage and ultimately protect patients. Other local health departments could leverage the knowledge base of their local hospitals to identify best practices, and share evidence-based practices to other hospitals struggling to meet Healthy People goals.
Is there sufficient stakeholder commitment to sustain the practice?
Both hospital and DPH stakeholders are committed to sustaining the project in future years. Participating hospital stakeholders found the project to be very helpful in analyzing their own data and propelled them to make improvements to their vaccination campaign. Many said that DPH intervention allowed them to implement new campaign strategies that they had not considered before.
We are currently conducting this project again for the 2017-18 influenza vaccination season, with a new subset of facilities targeted from the bottom quartile of LA County hospitals. Letters from the DPH Health Officer have been sent to all LAC hospital chief executive officers, touting the success of the project and encouraging the targeted hospitals to participate this season.
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