Concurrent chart reviews identified patients who qualified for the vaccinations and abstractors left requests for physicians to order. Initially, upon audit, we requested the physician to order the vaccine while patient was being treated as an inpatient. Several barriers to accomplishing the actual vaccination were identified during this period including the most frequent problem: requests were not always addressed by the physician during the inpatient stay and the patient would be discharged prior to obtaining an order.

We had to get physician buy-in to move the process upstream to make any significant difference in the vaccination rates.

In May of 2004, CMS clarified that the organization’s Medical Staff could authorize nurses to order and administer the vaccines.

Our Chief Nursing Officer queried the State Board of Nursing about the scope of practice for nursing related to the ordering and administration of the vaccine. Response supported the ability of the nurse to order and administer the vaccine within the parameters set forth by CMS.

VP of Medical Staff presented the data supporting the vaccination of the inpatient population and the CMS condition of participation authorizing organizations to determine nursing’s role in the vaccination practice to our Medical Executive Committee – representative of the entire medical staff. The Medical Executive Committee approved the process of allowing nursing staff to order and administer the vaccinations on admission following a nursing assessment of the patient’s vaccination history and contraindications for vaccination. A form was developed to include the appropriate assessment items along with contraindications and was approved by the Medical Executive Committee.

Education was provided to nursing, physician and pharmacy staff regarding the new process and the literature supporting the efficacy of providing our patients with the vaccine during their inpatient stay. The vaccine assessment was included in the nursing admission assessment process. Concurrent audits continued and nursing staff now received the messages of patient need for vaccination – at which time they could complete the assessment form, order the vaccination and administer without obtaining a separate order from the physician.

We continued to encounter nursing staff resistance to administration without a verbal or written physician order in the chart. It was a major change for the nursing staff and they felt very uncomfortable ordering any “medication”. It took probably 18 months to get maximum buy-in. Occasionally we will still get a new nurse who feels uncomfortable with the process and ask to see proof; so in addition to the fact that the Medical Executive Committee had approved the process as a standard protocol, nursing leadership felt it would be best to have an official hospital policy stating that it was the nursing responsibility to make the assessment on admission and order the vaccine if indicated. It was also explained to the staff in educational presentations at staff meetings that in essence, not administering the vaccines would be against physician direction from the Executive Committee.

Remediation and discipline are implemented if the process is not followed, but it is a rare instance to not have the vaccine assessment completed and ordered if appropriate because it has become a regular standard of care.

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There have been no cost/benefit analysis performed.

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