Nurse-Driven Protocol Increased Vaccination for Flu, Pneumonia

Cancer Network had the opportunity to speak with Elizabeth Rodriguez, DNP, RN, OCN about her presentation, “Improving Vaccination Rates for Influenza and Pneumococcus Through a Nurse-Driven Protocol,” made during the 2018 Oncology Nursing Society Congress. Dr. Rodriguez is the outpatient Nurse Leader for Adult Bone Marrow Transplant, Leukemia and Hematology, at Memorial Sloan Kettering Cancer Center (MSK), New York City.

During her discussion, Rodriguez emphasized that cancer patients (and other high-risk groups) are more likely to contract a potentially life-threatening case of invasive pneumococcal disease (IPD), despite the administration of pneumococcal vaccine safety in this immunocompromised population.

MSK’s pilot protocol was initiated to increase vaccination rates with the current pneumococcal and influenza vaccines in the outpatient cancer treatment setting, which resulted in exponential increases in both influenza and pneumococcal vaccinations. At MSK, use of this protocol resulted in a 97% increase in administration of influenza vaccines, and a 684% increase in pneumococcal vaccination.

- Interviewed by Cancer Network Editors

Cancer Network: Can you explain the annual risk of invasive pneumococcal disease (IPD) and pneumonia, especially in immunocompromised cancer patients, and the effect of IPD on those receiving cancer treatments?

Elizabeth Rodriguez: The incidence and severity of pneumococcal infections are much higher in patients undergoing treatment for cancer. The risk of invasive disease may be 50-fold higher than in the general population. Mortality rates from IPD are among the highest in cancer patients, with an estimated risk of 1 in 3.

Cancer Network: What was the existing IPD and pneumonia vaccine protocol at the study institution, and how was this expanded during your pilot program?

Elizabeth Rodriguez: The existing protocol for pneumonia and influenza vaccines focused on patients admitted to the hospital. Upon discharge, nurses assess patients for eligibility to receive the vaccines. If eligible, an order is automatically generated based on the electronic nursing documentation. The vast majority of cancer treatment is administered in the outpatient setting, and many patients are never admitted to the hospital over the course of their illness. In order to capture a larger portion of at-risk patients, this nurse-driven protocol was expanded to the outpatient setting in 2016, whereby nurses assessed patient eligibility to receive the vaccines at each encounter. Modifications to the electronic nursing documentation supported the expansion of the protocol.

Cancer Network: Can you discuss your research findings, and did the increased rate in vaccination result in lower rates of IPD and/or pneumonia in the oncology population?

Elizabeth Rodriguez: The main aim of the pilot [was to determine] whether the addition of nurses assessing vaccine eligibility in the outpatient clinics would negatively impact patient throughput in the clinic. Concerns existed that the visits would lengthen, and thereby increase wait times for patients. Following a 6-month pilot at two large outpatient centers, we found no difference in “in room” times during the same time period pre-pilot, even though vaccination administration rates increased 95% for influenza vaccines and 684% for pneumonia vaccines.

It is unclear whether we have lowered the rates of pneumonia or influenza as a result of this pilot. The 2017–2018 flu season was very different (robust) from others, and vaccine effectiveness was less compared with previous years, so it is premature to conduct this analysis and it may not be informative [given] the low vaccine efficacy.

Our intention was to build in the tools that would allow us to address these questions in the future (ie, compare rates of pneumonia, hospitalization, death, interruption in chemo etc.) by accurately identifying individuals who are vaccinated at MSK and local pharmacies or outside providers versus those who decline the vaccine or are deferred by the provider.

Cancer Network: How will the data from this pilot change the current or existing institutional vaccine protocol in high-risk populations?

Elizabeth Rodriguez: Our experience with this pilot, particularly the significant increase in vaccination rates, supported the expansion to all outpatients at MSK. Beginning in the fall of 2017, this nurse-driven protocol was expanded to all outpatient visits. We hope that information gained from this protocol and the eligibility assessments documented by nurses will inform [our understanding of] why patients are not vaccinated, and the rate of refusals. The documentation will also help demonstrate the number of patients who receive the vaccines from outside providers. With accurate data about vaccine eligibility and the rate of vaccination overall, we can continue to evolve the protocol to best meet patients’ needs.