More Massachusetts health care workers are getting vaccinated against flu, but many facilities lag behind the statewide goal

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St. Vincent Hospital CEO Steve MacLauchlan getting his shot last month to kick off this year’s vaccine drive

As a new flu season approaches, reports from the 2015-16 influenza season show a slight rise in the vaccination rate of Massachusetts health care workers. But more than two-fifths of acute-care hospitals — and an even greater share of other health facilities — failed to reach the 90 percent vaccination level recommended by state and federal health authorities.

The numbers, collected by the Massachusetts Department of Health (DPH), show that an average of 90.9 percent of employees at acute-care hospitals had a flu shot during the 2015-2016 season, compared to 90 percent the season before.

That gain was due mainly to a handful of hospitals with very high scores (see box below: “Ten ways to boost health care worker flu vaccinations”). The number of hospitals that fell short of the 90 percent target actually went up last season, from 22 to 30 out of the 69 acute-care hospitals for which data were available during both years. And employee vaccination levels at other kinds of facilities around the state were lower than those at hospitals; long-term care centers, for example, had an average rate of 73 percent.

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State Rankings

'Low outlier institutions'

The 90 percent vaccination target was set by DPH as well as the U.S. Department of Health and Human Services in its Healthy People 2020 program. Overall, Massachusetts ranks 15th among all states and the District of Columbia for health care worker vaccinations (see chart: State Rankings). 

Dr. Alfred DeMaria, Jr., state epidemiologist for Massachusetts, says the latest DPH numbers actually represent continued progress against this complex patient safety challenge. He notes that nearly all categories of vaccination have shown steady progress since the state first began collecting data eight years ago, when the average hospital vaccination rate was only 53.7 percent. 

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US Reporting, by Facility Type
Updated Flu Vax Rates Ma
MA Reporting, by Facility Type

“So while we are making good gains overall, there are still some low outlier institutions — and generally speaking they are not the same each year,” DeMaria says. “Some hospitals do very well and then drop, while others get better.”

Other health care facilities in Massachusetts also reported slight improvements in the vaccination status of their personnel during the 2015-16 flu season though the data are incomplete.

  • Clinics: On average just 66 percent of clinic workers received flu vaccines, but fewer than half of the state’s 326 licensed clinics reported data to the state. One bright spot: 38 clinics reported vaccination rates over 90 percent.
  • Nursing homes: 73 percent of these health care workers were vaccinated, based on data from 351 out of 419 — or 84 percent — of the state’s nursing homes.
  • Rest homes: These facilities reported a vaccination rate of 76 percent, but only 43 percent of rest homes submitted data.
  • Adult day health programs: Reporting vaccination figures for the first time, 63 percent of personnel in adult day health programs received flu shots. The data come from 114, or 72 percent, of the licensed programs in the state.
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A list of facilities, with their workforce flu vaccine rates, can be found on this page of the DPH's website.

Massachusetts’ experience with health care worker vaccination mirrors national trends. Carla L. Black, PhD, an epidemiologist at the Centers for Disease Control and Prevention (CDC) in Atlanta, GA, noted that CDC’s national Internet-based panel survey shows the same pattern of hospitals having the highest vaccination rates (see chart: US Reporting, by Facility Type). The CDC also examined vaccination rates by occupation, finding that physicians are the most likely to be vaccinated (95.6%), followed by nurse practitioners (90.3%), nurses (90.1%), pharmacists (86.5%), non-clinical staff (77.7%), and clinical aides and assistants (64.1%).

For those who haven’t been vaccinated, the CDC survey asks why. “The most common answer is that they just don’t want the vaccine,” says Black. “While some are afraid of side effects or getting sick from the vaccine, many don’t perceive influenza as enough of a threat to vaccinate against.”

Critical safety issue

In fact, says DeMaria, many health workers are actually at higher risk for flu, since their jobs may bring them into contact with flu-infected people. And if they do become infected, with or without symptoms, they can spread the disease to their patients, many of whom have lowered resistance due to age, illness or treatment. This makes worker vaccination a critical patient safety issue.

That risk is especially great at long-term care facilities, where workers and patients are together for prolonged periods of time. “That’s the one setting where we have good controlled studies that show vaccinating employees decreases all-cause mortality and flu-like illness among patients,” says Black.

So why do some vaccination rates remain low? Experts blame a complex of factors, including:

  • Workplace characteristics: Black says CDC data show rates are much higher at places like hospitals and pharmacies that regularly handle the vaccine than, say, at dental offices, which do not.
  • Worker demographics: Long-term care facilities tend to employ a larger share of workers who are less educated, lower paid and have a higher turnover rate, all factors associated with lower tendency to choose immunization.
  • Institutional policies: Workers are much more likely to be vaccinated if their job requires it (96.5%) than if their employer neither requires nor encourages it, and does not offer vaccine (44.9%), the CDC data show.
  • Contractual issues: a few health care worker unions have opposed mandatory immunization, though many encourage members to get shots voluntarily.

No state mandate

Massachusetts does not require health care workers to be vaccinated. But hospitals, ASCs, dialysis centers and long-term care facilities must offer flu vaccine to their workers at no cost, and document that each person was either immunized or has signed a “declination” form refusing the vaccine. In some facilities, those who decline are asked to wear a mask while in patient care areas. “We also use a lot of incentive programs,” says Gregory DeConciliis, PA-C, CASC, president of the Massachusetts Association of Ambulatory Surgery Centers, “like getting an "I-got-a-flu-shot" sticker or your name on the website if you agree to be immunized. But it’s hard to force people.”

DeMaria says it’s not clear that a vaccine mandate would push numbers much higher. In part, that’s because some workers are not subject to vaccination for either medical or religious reasons (all mandatory vaccine programs allow these two exemptions.) And even if the state achieved full worker vaccination, he says, “you would still get breakthrough cases of influenza because the vaccine is typically about 70 percent effective.”  

Those facts, however, do not diminish the importance of getting vaccinated voluntarily, DeMaria says. 

“If you think you’re indestructible and never get the flu, at least think of your immune-compromised patients or family members,” he says. “Plus, it’s a bad example to your patients not to get the vaccine. Those are the arguments I use.”

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St. Vincent Hospital CMO Dr. Doug Waite getting his shot last month to kick off this year’s vaccine push

In Massachusetts, the battle to encourage employees to get a flu shot is mostly fought at the individual institution level. To find out what strategies work in encouraging immunization, we talked to several organizations that reported large gains last year. Here are ten strategies they used:

1. Make vaccination an annual focus. Every hospital that met with success worked hard to promote immunization, starting in October or November and continuing through the following spring.

2. Put someone in charge. All hospitals, large or small, credited one or a few champions who spearheaded the effort. At tiny Martha’s Vineyard Hospital, for example, that person was Martha Bischoff, RN, who doubles as director of quality and infection-control nurse for the 25-bed facility. Thanks to efforts by Bischoff and her team, the hospital boosted its vaccination rate from 51.4 percent two seasons ago to 85.3 percent last season, the largest percentage gain in the state.

3. Make vaccination easy. The annual push at St. Vincent Hospital in Worcester starts with free flu shots for employees during the month of October. “Within the first few days, we immunize a quick thousand people or so,” says Chief Medical Officer Dr. Douglas Waite. That helped St. Vincent raise its vaccination level to 94.1 percent last season, up from 81.9 percent two seasons ago.

4. Work nights and weekends. Successful hospitals also offer vaccination to remote departments and off-shifts. At Baystate Noble Hospital in Westfield, Ruth Bushey, RN — the hospital’s infection prevention nurse — showed up on nights and weekends to immunize workers who might miss a daytime clinic. “When the night shift people saw her coming in, they knew it was important,” says Michele Urban, RN, chief nursing officer and vice president of patient care services.

5. Provide education and individual counseling. Since the state requires workers who refuse vaccine to sign a “declination” form, nearly all the institutions took that as an opportunity to counsel reluctant workers on the significant benefits and low risks of vaccine.

6. If patient safety isn’t convincing, appeal to self-interest. “If an employee really resists, I tell him, ‘I want you to get the shot so that you and your family don’t get sick,’” says Gregory DeConciliis, PA-C, CASC, administrator at Boston Out-Patient Surgical Suites in Waltham and president of the Massachusetts Association of Ambulatory Surgery. “Once they get the shot, and do all right, then they’re more likely to get it next year.”

7. Require masks for those who decline. For employees who cannot be immunized for medical or religious reasons, wearing a surgical mask at work may help protect them and their patients. For others, the discomfort of wearing a mask is an incentive to choose vaccination.

8. Start at the top. No vaccine program can succeed without genuine backing from institutional leaders. At St. Vincent Hospital, Waite and CEO Steve MacLauchlan underscore that support by getting their picture taken during vaccination. “We even had a vaccinator at our Board of Directors meeting,” Waite says. “As an infectious disease specialist, this project is very close to my heart.”

9. Require vaccination. Some hospitals now require vaccination as a condition of employment, except for those with medical or religious exemptions. CDC data shows this is the single most effective way to boost immunization, though it risks alienating some staff. An alternative strategy, adopted by St. Vincent Hospital back in 2010, is to require vaccination for new employees, but let existing employees continue to make their own choice.

10. Promote culture change. Successful hospitals integrate vaccination into an overall culture of safety, as Baystate Noble did when it switched its emphasis from “infection control” to “infection prevention,” says Urban. And whatever strategies you choose, stick with them. “There’s a theory that for a ‘culture of immunization’ to take hold, an institution must continue these programs for several years until it becomes the norm,” says Black. At that point, she says, peer pressure can do much of the work in encouraging employees get the vaccine.

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