Bloomfield, Cheryl A., MD

Julia, Ronald R., MD, MS

Sither, Michael J., DO, MPH

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of MedicineImproving Pneumococcal Vaccination Rates UsingExclusive Clinic Visits; a Pilot ProgramRonald R. Julia MD, MSLehigh Valley Health Network, Ronald_R.Julia_Jr@lvhn.orgMichael J. Sither DO, MPHLehigh Valley Health Network, Michael.Sither@lvhn.orgCheryl A. Bloomfield MDLehigh Valley Health Network, Cheryl_A.Bloomfield@lvhn.orgFollow this and additional works at: http://scholarlyworks.lvhn.org/medicinePart of the Medical Sciences CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtJulia, RR., Sither, MJ., Bloomfield, C. (2015, October 24). Improving Pneumococcal Vaccination Rates Using Exclusive Clinic Visits; a PilotProgram. Poster presented at: PA Regional ACP meeting, Hershey, PA.Lehigh Valley Health Network, Allentown, PennsylvaniaRR Julia, Jr. MD MS, MJ Sither DO MPH, C Bloomfield MDImproving Pneumococcal Vaccination Rates Using Exclusive Clinic Visits; a Pilot Program© 2015 Lehigh Valley Health NetworkBackground/ Introduction•	 	Overlooked	during	many	resident	clinic	visits	are	preventative	healthcare	measures.	The	perception	also	exists	that	this	aspect	of	care	is	substandard	in	a	resident	clinic.	Based	on	reports	generated	by	internal	computer	systems,	our	resident	clinic	was	noted	to	have	a	13%	rate	of	pneumococcal	vaccination,	well	below	network	average	(57%)	and	goal	(63%).		Bolstered	by	successes	at	other	practices	in	the	network,	a	pilot	vaccine	fair	was	undertaken	to	assess	if	our	clinic	could	mass	vaccinate	its	patients.Current Conditions•	 	Our	Quality	Improvement	project	was	initiated	upon	review	of	the	Lehigh	Valley	Physician	Practice	(LVPP)	vaccination	rates.	When	our	clinic	was	compared	with	other	practices	within	the	Lehigh	Valley	Physicians	Group	(LVPG),	our	pneumococcal	vaccine	rate	was	listed	as	13.1%	for	patients	over	65	years	old.	The	LVPG	average	was	57%,	and	the	goal	throughout	the	network	is	63%.	This	data	was	collected	from	our	old	disparate	electronic	medical	records	and	aggregated	by	population	management	software.		•	 	Indications	for	prophylactic	vaccination	against	pneumococcus	are	separated	into	two	populations—65	and	older	and	18-64	who	have:	chronic	health	conditions,	compromised	immune	systems,	smokers,	asplenia,	CSF	leak,	cochlear	implants,	and	residents	of	long	term	care	facilities.•	 	Current	recommendations	from	the	Advisory	Committee	on	Immunization	Practices	have	three	categories	for	patients	over	65	(Figure	1).	Naïve	patients	>65	years	old	should	get	the	13-valent	pneumococcal	conjugate	vaccine	(PCV13),	then	in	6-12	months	they	should	receive	23-valent	pneumococcal	polysaccharide	vaccine	(PPSV-23).	For	patients	who	have	received	PPSV-23	after	age	65,	PCV13	should	be	administered	greater	one	year	after	getting	PPSV-23.	If	the	patient	received	PPSV-23	prior	to	turning	65,	they	can	still	receive	PCV-13	one	year	later,	but	should	also	be	revaccinated	with	PPSV-23	five	or	more	years	after	the	first	PPSV-23	vaccination.	(Annals	of	Internal	Medicine	162(3):	214-23)AIM Statement•	 	To	increase	the	number	of	LVPP	patients	65	and	older	who	are	vaccinated	against	pneumococcus	by	15%	using	a	dedicated	immunization	fair.Analysis•	 	Using	a	fishbone	diagram,	potential	causes	of		unrecorded	vaccinations	were	discussed	amongst	the	residents	and	documented.	The	omissions	discussed	not	only	include	why	patients	remained	unvaccinated,	but	potential	delays	in	recording	vaccines,	receiving	duplicate	vaccines	and	sources	of	waste	within	the	practice	and	the	computer	system.	The	causes	were	grouped	into	six	sections:	The	patients	themselves,	the	primary	resident	seeing	them	in	clinic,	the	residents	who	cover	results	when	the	patient’s	primary	resident	is	working	inpatient,	Staff,	Outside	Sources	and	the	EMR	(Figure	2).	These	six	factors	overlap	in	the	critical	aspect	that	the	vaccine,	whenever	and	wherever	it	was	given,	must	be	recorded	in	the	patient’s	office	chart	by	either	a	provider	or	a	staff	member.	In	this	pilot	study,	we	wanted	to	minimize	complexity	by	focusing	on	the	patients	themselves	and	the	staff	and	residents	who	could	administer	the	vaccine.Methods•	 	Our	inspiration	for	the	project	came	from	three	sources:	prior	successes	in	the	network	with	mass	vaccination,	Clinic	staff	undertaking	15	minute	blood	pressure	and	blood	sugar	visits,	and	the	transition	to	a	new	Electronic	Medical	Record.	First,	LVHN	has	undertaken	several	vaccine	drives,	most	prominent	being	the	annual	Dorney	Park	drive-through	flu	clinic.	These	are	well	advertised	events	that	draw	hundreds	of	patients	every	fall.	Second,	one	or	two	staff	members	are	dedicated	to	15	minute	follow	ups	that	focus	vital	signs	like	blood	pressure	and	blood	sugar,	especially	after	recent	mediction	changes	are	made.	These	visits	minimize	disruption	in	the	practice	by	off-loading	these	follow	ups	from	the	residents	and	help	deliver	efficient,	quality	care	our	5000-plus	patients.	Finally,	in	2015,	our	network	switched	computer	systems	from	Centricity	to	Epic,	leading	to	widespread	delays	as	providers	familiarized	themselves	with	the	new	system	and	patient	data	was	integrated	into	the	new	system.	Our	goal	in	this	project	was	minimize	the	reliance	on	either	EMR	and	focusing	on	activities	that	could	be	patient	centered.	Combining	these	three	different	themes	led	to	the	decision	to	create	dedicated	time	for	administering	pneumococcal	vaccines.Results•	 	Our	initial	efforts	to	reach	out	to	the	unvaccinated	led	to	the	discovery	of	data	sharing	errors	between	the	prior	office	EMR	and	prior	hospital	EMR;	only	pneumococcal	vaccinations	in	the	office	were	recorded	in	the	population	management	program.	No	inpatient	vaccinations	were	transferred	to	LVPP’s	outpatient	chart,	nor	were	they	recorded	in	our	population	mangement	software.	This	led	to	short	PDSA	cycle	within	the	main	project	resulting	in	a	manual	audit	of	all	349	patients	listed.	An	additional	59	patients	who	received	pneumcoccal	vaccine	were	discovered	through	this	audit	prior	to	the	initiation	of	the	vaccine	fair.	With	the	transition	to	Epic	and	its	unified	inpatient/outpatient	chart,	this	problem	is	believed	to	be	resolved	at	this	time.	•	 	In	total,	140	patients	out	of	349	that	were	labeled	as	unvaccinated	were	called	or	had	their	charts	amended	in	some	form	(Figure	4).	Of	these,	8	agreed	to	be	vaccinated	and	came	in	to	receive	the	PPSV-23	vaccine,	2	of	these	were	vaccinated	during	their	regular	office	visit.	Four	patients	said	no,	none	gave	a	reason	why	they	declined.	•	 	Difficulties	were	also	encountered	in	contacting	patients:	41	voice	mails	were	left	with	patients,	16	phone	numbers	were	inaccurate,	3	patients	informed	us	they	had	changed	physicians	and	5	patients	had	died	but	were	not	removed	from	the	patient	panel.•	 	The	combination	of	audited	records	and	new	vaccinations	led	to	a	substantial	increase	in	vaccination	rate:	LVPP’s	presumed	13%	pneumococcal	vaccination	rate	among	those	>65	has	increased	to	57%.	Though	not	at	the	network	goal	of	63%,	it	is	above	the	network	average	of	56%.	This	shows	us	that	the	residents	in	our	clinic	can	provide	effective	preventative	care.•	 	Importantly,	the	days	the	vaccine	fair	was	offered	did	not	disrupt	or	delay	usual	operations	of	the	clinic.	Staff	were	not	overburdened	nor	removed	from	other	operations		in	the	clinic.	Follow-up•	 	The	resident	clinic	has	the	logistical	capability	to	undertake	a	vaccine	fair.	In	regards	to	preventative	care,	the	residents	in	the	clinic	also	have	the	medical	knowledge	and	ability	to	perform	at	a	level	similar	to	their	counterparts	in	independent	practice.		Pitfalls	were	discovered	in	our	Electronic	Medical	Records,	both	in	regards	to	data	sharing	and	accurate	patient	contact	information.	By	transitioning	to	a		unified	EMR,	updating	patient	contact	info	with	every	visit,	and	proactively	auditing	patient	charts	for	transfers	and	deaths,	our	clinic	is	striving	to	provide	“Seamless	patient	care”	as	discussed	in	the	ACP	position	statement	on	Electronic	Records.	(Annals	of	Internal	Medicine.	162(4):301-3)•	 	We	at	LVPP	plan	to	continue	improving	on	the	vaccine	fair	concept.	We	are	looking	not	only	to	reach	the	patients	we	did	not	contact	in	the	pilot	study,	but	expanding	to	those	patients	in	our	clinic	who	are	in	the	indicated	group	of	19-64	year-olds.	We	also	now	have	access	to	the	PSV-13	vaccine,	and	can	fully	implement	the	2014	AICP	recommendations	in	Figure	1.	We	are	also	considering	applying	the	lessons	learned	in	this	project	by	diversifying	the	vaccine	fair	concept	to	other	preventative	health	measures	like	Tdap	and	Zoster	vaccines.	•	 	This	Quality	Improvement	project	for	Pneumococcal	vaccinations	not	only	allowed	us	to	enhance	our	preventative	care	for	our	patients,	but	it	also	allowed	us	to	further	review	and	improve	upon	how	our	medical	records	are	viewed	and	maintained.	Through	continual	improvement	processes,	we	at	LVPP	strive	to	deliver	excellent	patient	care	and	continue	to	improve	our	residents	skills	as	physicians.•	 	By	utilizing	directed	calling	to	unvaccinated	patients	in	our	practice	as	our	advertizement,		as	well	as	offering	multiple	vaccination	times	over	mutliple	days,	we	believed	that	patient	care	and	quality	would	be	maximized	and	waste	from	computer	errors	and	data	entry	would	be	minimized.	Using	the	old	patient	population	management	software,	a	list	of	349	patients	over	65	who	were	unvaccinated	was	generated.	At	the	time	of	the	pilot	study,	only	PPSV23	was	available	to	our	clinic,	so	attention	was	focused	on	patients	>	65	years	old	who	where	never	recorded	as	vaccinated.•	 	Selected	patients	were	directly	called	by	residents	or	staff	and	asked	scripted	questions	in	English	or	Spanish	(Figure	3).	If	the	patient	agreed	to	the	vaccine,	they	were	offered	one	of	three	half-day	windows	to	arrive.	If	they	declined,	they	were	asked	why	and	the	explanation	was	recorded.	Reasons	for	declining	were	anticipated	and	scripts	were	developed	for	the	presumed	most	likely	reasons.	Any	non-answers	were	also	recorded	separately.	Residents	were	also	given	the	list	of	patients	as	a	reminder	if	they	saw	the	patient	during	a	regular	office	visit	to	discuss	the	pneumcoccal	vaccine.Figure 1: Advisory	Committee	on	Immunization	Practices	Guidelines	for	Pneumococcal	Vaccination	of	patients	older	than	65.Figure 3: Process	Mapping	for	calling	unvaccinated	patients.Figure 4: Results	of	pilot	vaccine	fair	for	pneumococcal	vaccines	at	LVPP.	The	results	combine	auditing	of	patient	charts	and	calling	patients	listed	as	unvaccinated.Figure 2: Fishbone	diagram	illustrating	possible	causes	of	missing	Pneumococcal	Vaccination	at	Lehigh	Valley	Physician’s	Practice.

Improving Pneumococcal Vaccination Rates Using Exclusive Clinic Visits; a Pilot Program

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Improving Pneumococcal Vaccination Rates Using Exclusive Clinic Visits; a Pilot Program

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