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Pneumococcal Immunization. Vernon Memorial Healthcare Viroqua, Wisconsin Jo Ann Von Ruden, RT, Quality Improvement Coordinator (608)-637-4284 Romelle Heisel, RN, Infection Control Nurse (608)-637-4481. How it all started:.

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pneumococcal immunization
Pneumococcal Immunization

Vernon Memorial Healthcare Viroqua, Wisconsin

Jo Ann Von Ruden, RT, Quality Improvement Coordinator


Romelle Heisel, RN, Infection Control Nurse


how it all started
How it all started:
  • The initial process stemmed from staff participating in a series of webinars and workshops conducted by MetaStar in June of 2004 through February 2005.
beginning process
Beginning Process
  • When we first began reporting the pneumonia data, we found we rarely had documentation for any in-patient vaccination status.
initial data
Initial Data
  • Our first data collection for the pneumococcal vaccination revealed a 10% compliance rate for our organization!!!
obvious changes are needed
Obvious Changes are Needed
  • We informed our Nursing staff and our Medical staff of our poor performance rates and asked for input on how we could improve.
scorecard implementation
Scorecard Implementation
  • We implemented scorecards in August 2004 to get the word out
  • Power point presentations were provided
  • Bulletin boards were posted at the nurses stations
  • We shared the success stories that we received from MetaStar’s training sessions with the Medical Staff
  • We persuaded the Medical Staff to approve the implementation of the pneumococcal standing orders to hopefully improve our scores
who would be responsible
Who would be responsible?
  • It was decided that the floor nurses would not have enough time to accomplish this mission effectively, especially during the peak, high volume winter months
  • We felt this responsibility needed to be accomplished by a small core group of nurses
  • A small amount of personnel would more likely take ownership and hold accountability for the results
selection chosen
Selection Chosen
  • October 2004 – It was decided that our Infection Control staff would best be able to accomplish this goal
standing order implementation
Standing Order Implementation
  • October 2004 – Pneumococcal standing orders were developed and implemented
screening procedure
Screening Procedure
  • Screening process includes:

• Verifying vaccination status with the patient’s clinic

or NH

- If received vaccination prior to admission, RN documents this date on the pneumococcal standing orders

- If it appears that the patient is in need of the vaccination, the RN discusses the procedure with patient first. If the patient is not refusing it, the RN discusses the vaccination with the patient’s physician

screening procedure continued
Screening Procedure Continued
  • If the decision is made to not give the vaccination, the RN documents this reason on the standing order
  • If the patient receives the vaccination, a vaccination notification is sent to the clinic

Notification information consists of:

• Vaccine given

• Date given

• Vaccine manufacturer

• Lot Number

• Who administered it

screening process continued
Screening Process Continued
  • We do not have an electronic record in place yet, so to be sure this information is passed on for any future admissions, a copy is made of the completed standing order. This copy is placed in a plastic folder and is placed in front of the patient’s records by Health Information personnel. Thus, the information travels from one admission to another.
score timeline

1st quarter 2004 – 10%

(initial data collection)

2nd quarter 2004 – 36%

(started to educate staff)

3rd quarter 2004 – 29%

(Additional education)

4th quarter 2004 – 81%

(implemented the standing orders)


1st quarter 2005 – 94%

2nd quarter 2005 – 100%

3rd quarter 2005 – 100%

4th quarter 2005 – 100%

Score Timeline
capturing data during unique situations
Capturing Data During “Unique” Situations
  • Continue to have problems verifying patients’ vaccination status on rare occasions. This problem occurs when:

• Infection Control staff not working

• Times when the clinics are not open

• Clinic information is unavailable

to the staff

help needed
Help Needed
  • Infection Control staff designates specific staff for when they are not able to be on location (vacation, etc.)
  • We are looking into utilizing the Wisconsin Immunization Registry for other rare exceptions when information is unobtainable
time consuming process
Time Consuming Process
  • It is a very lengthy process that takes a team effort to accomplish.
  • Additional staff was added to the Infection Control department in order to successfully reach our goal.
success 2006 score timeline
Success! – 2006 Score Timeline
  • 1st quarter 2006 – 100%
  • 2nd quarter 2006 – 96%
  • 3rd quarter 2006 – 100%
  • 4th quarter 2006 – results not compiled yet
  • This information, along with other CheckPoint measures, continue to be brought up at Medical Staff meetings, Nurses meetings, displays, board member meetings, etc.
  • The Infection Control staff have accepted its purpose and have made it part of their daily routine
additional implementation of standing orders
Additional Implementation of Standing Orders
  • May 2005 – Medical Staff approved of ‘diagnosis-specific’ standing orders. (These were under-utilized and by some physicians, not used at all).
  • November 2006 – Medical Staff approved of reminder ‘check-off’ lists for CHF, AMI, and Pneumonia patients to try and capture other missing data