Abstract
Background
Methods of measuring influenza vaccination of healthcare personnel (HCP) vary substantially, including which groups of HCP are included in measurements. Thus, comparison of vaccination rates across healthcare facilities is difficult.
Purpose
The goal of the study was to determine the feasibility of implementing a standardized measure for reporting HCP influenza vaccination data in various types of healthcare facilities.
Methods
A total of 318 facilities recruited in four U.S. jurisdictions agreed to participate in the evaluation, including hospitals, long-term care facilities, dialysis clinics, ambulatory surgery centers, and physician practices. HCP in participating facilities were categorized as employees, credentialed non-employees, or other non-employees using standard definitions. Data were gathered using cross-sectional web-based surveys completed at three intervals between October 2010 and May 2011 and analyzed in February 2012.
Results
234 facilities (74%) completed all three surveys. Most facilities could report on-site employee vaccination; almost one third could not provide complete data on HCP vaccinated outside the facility, contraindications, or declinations, primarily due to missing non-employee data. Inability to determine vaccination status of credentialed and other non-employees was cited as a major barrier to measure implementation by 24% and 27% of respondents, respectively.
Conclusions
Using the measure to report employee vaccination status was feasible for most facilities; tracking non-employee HCP was more challenging. Based on evaluation findings, the measure was revised to limit the types of non-employees included. Although the revised measure is less comprehensive, it is more likely to produce valid vaccination coverage estimates. Use of this standardized measure can inform quality improvement efforts and facilitate comparison of HCP influenza vaccination among facilities.
Introduction
Influenza is a leading cause of mortality in the U.S., contributing to an estimated average of 23,607 deaths annually from 1976 to 2007.1 Influenza outbreaks can have substantial consequences for healthcare facilities, including prolonged hospital stays, increased patient mortality, and disruption of care provision.2–6 Influenza vaccination prevents influenza-related illness and work absence among healthcare personnel (HCP)2,7–12 and is associated with reduced influenza illness6,9,10,13–16 and death10,13,14,17,18 in their patients.
Measurement of HCP influenza vaccination coverage is an important healthcare quality indicator. The Joint Commission, National Foundation for Infectious Diseases, Society for Healthcare Epidemiology of America (SHEA); and the Advisory Committee on Immunization Practices (ACIP) and Healthcare Infection Control Practices Advisory Committee (HICPAC) of the CDC recommend including such measurement as a component of healthcare facility influenza vaccination programs.19–22 SHEA and ACIP/HICPAC further recommend regularly reporting HCP influenza vaccination coverage to facility administrators and staff.21,22
The Joint Commission recently revised its influenza vaccination standard to require a variety of healthcare organizations to measure and report influenza vaccination coverage among staff and licensed independent practitioners as a condition of accreditation.23 The Task Force on Community Preventive Services recommends provider assessment and feedback as a strategy to improve vaccination coverage in various populations and settings.24 Even voluntary reporting can improve vaccination coverage levels: median employee influenza vaccination coverage at hospitals participating in a voluntary statewide reporting program increased by 20 percentage points over 4 years.25
The National Quality Forum (NQF), a voluntary consensus standards-setting organization dedicated to healthcare quality improvement, gave provisional endorsement to a CDC-sponsored standardized measure of HCP influenza vaccination in 2008 (Measure 0431). The measure’s intent was to ensure that reported HCP influenza vaccination was comprehensive within a single facility and comparable across facilities. Measures considered for full endorsement by NQF must undergo pilot testing to evaluate four major criteria: importance of measurement and reporting; scientific acceptability (i.e., validity and reliability); usability; and feasibility.26 The objectives of the current report are to describe results of a pilot test to determine the feasibility of implementing the provisional measure, to outline revisions made to the measure as a result of the pilot, and to explain how the revised measure will be used nationally. (Validity and reliability of the measure are described elsewhere.27)
Methods
The CDC, in conjunction with four jurisdictions, recruited 318 healthcare facilities to participate in the pilot. Facilities were recruited by project staff in each of the jurisdictions via telephone, mail, fax, and e-mail. Some facilities were recruited from existing networks involved in healthcare surveillance, state/local professional associations and umbrella organizations, and connections from prior collaborations. Eligible facilities included acute care hospitals; long-term care facilities (LTCFs); dialysis clinics; ambulatory surgery centers (ASCs); and physician practices. Recruitment goals and specific inclusion and exclusion criteria for each facility type were defined in a written protocol. The pilot testing took place during the 2010–2011 influenza season (defined as October 1, 2010–March 31, 2011). The pilot was determined to be public health nonresearch by CDC and by participating jurisdictions, as required.
Measure Specifications
Participating facilities reported counts for vaccination status (numerator) and total number of HCP (denominator), which were used to calculate facility-level vaccination coverage. The numerator consisted of four mutually exclusive categories of HCP: vaccinated at the healthcare facility, vaccinated elsewhere, had a medical contraindication to influenza vaccination, and declined vaccination. The total for the denominator consisted of all HCP who worked at the facility full- or part-time for ≥1 day during influenza season, reported in three mutually exclusive groups: employees, credentialed non-employees, and other non-employees.
Employees were defined as those who received a paycheck directly from the healthcare facility. Credentialed non-employees (CNE) were defined as licensed practitioners affiliated with the facility who did not receive a paycheck from the facility; these included physicians or mid-level providers with clinical or admitting privileges and technicians or therapists with professional credentialing. Other non-employees (ONE) were defined as those who did not receive a paycheck from the facility and did not count as CNE, including, but not limited to, contractors; students and trainees; resident physicians and fellows (if not paid by the facility); and volunteers. Level of patient contact was not assessed for any HCP.
Facilities were asked to report numerator data separately for each of the three HCP groups. Vaccination coverage for each denominator group was calculated by dividing the sum of HCP vaccinated at the facility and HCP vaccinated elsewhere by the denominator total for that group and multiplying by 100.
Data Collection and Analysis
Participating facilities completed surveys via a secure, web-based data collection tool hosted by CDC. Primary outcomes were numerator and denominator data as described above, perceived ease of reporting, and barriers to reporting HCP vaccination using the measure. Survey items about ease of use and reporting barriers were developed based on semi-structured interviews conducted among a volunteer subset of 31 participating facilities.28 Participants also reported facility characteristics, data sources, and characteristics of their HCP influenza vaccination programs.
Healthcare facilities were asked to report numerator and denominator data at three time points: (1) denominator data by October 31, 2010; (2) numerator and denominator data as of December 31, 2010; and (3) numerator and denominator data as of March 31, 2011. Reports were cumulative, so data reported at the end of the season represented the total vaccination coverage level achieved by the facility. Influenza vaccinations received by HCP since August 2010 were included in the numerator. Facilities were instructed to include in their reports HCP who began work at the facility after October 1 or who ceased working before March 31. Descriptive statistics were calculated using SAS 9.2. Analyses were completed in February 2012.
Results
Sample
Of 318 facilities recruited, 88% (n=281) completed the first survey; 91% of those (n=257) completed the second survey. Of the remaining facilities, 91% (n=234) completed the final survey for a cumulative response rate of 74%. Response rates ranged from 53% among ASCs to 85% among hospitals. Facilities completing all three surveys did not differ from facilities completing only the first survey by size, ownership, urban location, or years offering influenza vaccine to HCP. However, facilities with less experience measuring HCP influenza vaccination were less likely to complete all surveys. Characteristics of facilities that completed the pilot are described in Table 1.
Table 1.
Sample characteristics overall and by facility type
| All Facilities % (n) |
Acute Care Hospitals % (n) |
ASC % (n) |
Dialysis % (n) |
LTCF % (n) |
Physician Practice % (n) |
|
|---|---|---|---|---|---|---|
| Total | 100.0 (234) | 100.0 (78) | 100.0 (16) | 100.0 (43) | 100.0 (59) | 100.0 (38) |
| Ownership | ||||||
| For-profit, private | 41.9 (98) | 19.2 (15) | 100.0 (16) | 58.1 (25) | 44.1 (26) | 42.1 (16) |
| Not-for-profit, private | 40.2 (94) | 55.1 (43) | 0.0 | 39.5 (17) | 35.6 (21) | 34.2 (13) |
| Public, federal or state/local | 18.0 (42) | 25.6 (20) | 0.0 | 2.3 (1) | 20.3 (12) | 23.7 (9) |
| Area | ||||||
| Urban | 55.1 (129) | 57.7 (45) | 62.5 (10) | 48.1 (21) | 52.5 (31) | 57.9 (22) |
| Suburban | 22.7 (53) | 21.8 (17) | 31.3 (5) | 27.9 (12) | 27.1 (16) | 7.9 (3) |
| Rural | 22.2 (52) | 20.5 (16) | 6.3 (1) | 23.3 (10) | 20.3 (12) | 34.2 (13) |
| Previous experience offering HCP influenza vaccine | ||||||
| Never offered | 0.9 (2) | 0.0 | 12.5 (2) | 0.0 | 0.0 | 0.0 |
| Offered 1–4 years | 9.8 (22) | 5.1 (4) | 12.5 (2) | 16.3 (7) | 13.6 (8) | 5.3 (2) |
| Offered 5 or more years | 89.3 (209) | 94.9 (74) | 75.0 (12) | 83.7 (36) | 86.4 (51) | 94.7 (36) |
| Previous experience measuring HCP vaccination | ||||||
| Never measured | 28.2 (66) | 0.0 | 93.8 (15) | 23.3 (10) | 28.8 (17) | 63.2 (24) |
| Measured during 2009–2010 only | 8.1 (19) | 2.6 (2) | 0.0 | 16.3 (7) | 11.9 (7) | 7.9 (3) |
| Measured 2–4 years | 23.5 (55) | 44.9 (35) | 6.3 (1) | 11.6 (5) | 15.3 (9) | 13.2 (5) |
| Measured 5 or more years | 40.2 (94) | 52.6 (41) | 0.0 | 48.8 (21) | 44.1 (26) | 15.8 (6) |
| Formally share vaccination rates with HCP a | 79.8 (134) | 82.1 (64) | 100.0 (1) | 81.8 (27) | 71.4 (30) | 85.7 (12) |
| Facility policy on HCP vaccination b | ||||||
| Recommended but not required | 39.9 (91) | 24.7 (19) | 50.0 (8) | 57.1 (24) | 26.3 (15) | 69.4 (25) |
| Declination required with no consequences | 54.4 (124) | 66.2 (51) | 37.5 (6) | 40.5 (17) | 68.4 (39) | 30.6 (11) |
| Declination required with consequences | 3.1 (7) | 7.8 (6) | 0.0 | 0.0 | 1.8 (1) | 0.0 |
| No policy | 2.6 (6) | 1.3 (1) | 12.5 (2) | 2.4 (1) | 3.5 (2) | 0.0 |
ASC: Ambulatory Surgery Center; LTCF: Long-Term Care Facility; HCP: healthcare personnel.
Restricted to those who have previously measured influenza vaccination rates among healthcare personnel.
Does not include “other” responses that could not be otherwise categorized.
Ability to Report Using National Quality Forum Measure
Generally, facilities perceived the measure favorably, with over 70% reporting that the measure was comprehensive and easy to use and that measure instructions were easy to understand (Table 2). More than 80% of respondents reported that it was “easy” or “very easy” to assign employees to the correct denominator group; a much lower proportion reported that it was “easy” or “very easy” to assign CNE and ONE to the correct group.
Table 2.
Results for selected survey elements on ease of using measure, overall and by facility type
| All Facilities % (n) |
Acute Care Hospitals % (n) |
ASC % (n) |
Dialysis % (n) |
LTCF % (n) |
Physician Practice % (n) |
|
|---|---|---|---|---|---|---|
| Agreement for CDC tool elements | ||||||
| Easy to use | 74.4 (174) | 74.4 (58) | 68.8 (11) | 72.1 (31) | 81.4 (48) | 68.4 (26) |
| Comprehensive | 76.1 (178) | 71.8 (56) | 75.0 (12) | 76.7 (33) | 81.4 (48) | 76.3 (29) |
| Relevant to my healthcare facility | 68.0 (159) | 73.1 (57) | 50.0 (8) | 69.8 (30) | 76.3 (45) | 50.0 (19) |
| Instructions were easy to understand | 70.1 (164) | 73.1 (57) | 50.0 (8) | 67.4 (29) | 76.3 (45) | 65.8 (25) |
| Definitions were easy to understand | 68.4 (160) | 70.5 (55) | 68.8 (11) | 65.1 (28) | 81.4 (48) | 47.4 (18) |
| Would recommend to other healthcare facilities | 63.7 (149) | 70.5 (55) | 43.8 (7) | 58.1 (25) | 69.5 (41) | 55.3 (21) |
| Agreement for ease of assigning HCP to correct denominator category a | ||||||
| Employees | 82.1 (192) | 83.3 (65) | 87.5 (14) | 83.7 (36) | 83.1 (49) | 73.7 (28) |
| Credentialed non-employees | 51.7 (121) | 41.0 (32) | 87.5 (14) | 72.1 (31) | 47.5 (28) | 42.1 (16) |
| Other non-employees | 44.4 (104) | 39.7 (31) | 50.0 (8) | 55.8 (24) | 49.2 (29) | 31.6 (12) |
| Agreement for ease of counting HCP a | ||||||
| Employees | 83.3 (195) | 80.8 (63) | 93.8 (15) | 83.7 (36) | 84.8 (50) | 81.6 (31) |
| Credentialed non-employees | 47.9 (112) | 32.1 (25) | 81.3 (13) | 69.8 (30) | 39.0 (23) | 55.3 (21) |
| Other non-employees | 37.6 (88) | 24.4 (19) | 43.8 (7) | 51.2 (22) | 35.6 (21) | 50.0 (19) |
ASC: Ambulatory Surgery Center; LTCF: Long-Term Care Facility; HCP: healthcare personnel.
Proportion responding “easy” or “very easy”
Although all participating facilities were able to report denominator data for employees, about 10% of facilities could not provide denominator data for CNE or ONE (see Appendix). For numerator data, most facilities provided information on vaccinations at the facility; other numerator categories were more challenging. One third or more of facilities could not report data on vaccinations outside the facility, medical contraindications, or declinations for non-employees. Ability to report data for non-employees varied by facility type.
Barriers to Using National Quality Forum Measure
Barriers to using the provisional measure to report HCP influenza vaccination were assessed in the second and third surveys, in order to capture changes resulting from increased familiarity with the measure. Results were similar in the two surveys, so proportions from the third survey are reported (Table 3). The primary barriers reported by respondents pertained to non-employees: inability to determine vaccination status of CNE and ONE was identified as a major barrier by 24% and 27% of facilities, respectively. Inability to determine which HCP were vaccinated outside the facility was identified as a major barrier by 21% of all facilities. A little more than 20% of all facilities reported that the time required to collect data on CNE and ONE was a major barrier to using the measure, and 21% identified the number of ONE at the facility as a major barrier. Barriers varied by facility type; in general, dialysis clinics and physician practices reported barriers less frequently than other facilities.
Table 3.
Major barriers to reporting HCP influenza vaccination using measure, overall and by facility type a
| All Facilities % (n) |
Acute Care Hospitals % (n) |
ASC % (n) |
Dialysis % (n) |
LTCF % (n) |
Physician Practice % (n) |
|
|---|---|---|---|---|---|---|
| Ability to determine vaccination status of other non-employees | 27.4 (64) | 29.5 (23) | 37.5 (6) | 25.6 (11) | 32.2 (19) | 13.2 (5) |
| Ability to determine vaccination status of credentialed non-employees | 23.5 (55) | 38.5 (30) | 31.3 (5) | 9.3 (4) | 25.4 (15) | 2.6 (1) |
| Determining vaccination status of HCP vaccinated outside the facility | 21.4 (50) | 29.5 (23) | 18.8 (3) | 7.0 (3) | 27.1 (16) | 13.2 (5) |
| Number of other non-employees working at facility | 20.9 (49) | 24.5 (23) | 12.5 (2) | 16.3 (7) | 23.7 (14) | 7.9 (3) |
| Time required to collect data on vaccination status of credentialed non-employees | 20.5 (48) | 37.2 (29) | 31.3 (5) | 14.0 (6) | 13.6 (8) | 0.0 |
| Time required to collect data on vaccination status of other non-employees | 20.1 (47) | 26.9 (21) | 37.5 (6) | 16.3 (7) | 18.6 (11) | 5.3 (2) |
| Number of credentialed non-employees working at facility | 13.7 (32) | 28.2 (22) | 12.5 (2) | 4.7 (2) | 10.2 (6) | 0.0 |
| Inadequate existing process or system in place to track HCP vaccination | 10.7 (25) | 9.0 (7) | 18.8 (3) | 4.7 (2) | 13.6 (8) | 13.2 (5) |
| Definitions of HCP groups did not match those used at facility | 7.7 (18) | 14.1 (11) | 6.3 (1) | 2.3 (1) | 1.7 (1) | 10.5 (4) |
| Time required to collect data on vaccination status of employees | 7.7 (18) | 10.3 (8) | 6.3 (1) | 4.7 (2) | 8.5 (5) | 5.3 (2) |
| Time required to enter data on vaccination status of HCP | 7.7 (18) | 11.5 (9) | 18.8 (3) | 2.3 (1) | 5.1 (3) | 5.3 (2) |
| Ability to determine vaccination status of employees | 7.3 (17) | 5.1 (4) | 6.3 (1) | 4.7 (2) | 11.9 (7) | 7.9 (3) |
| Distinguishing between medical & non-medical reasons for declination | 6.8 (16) | 10.3 (8) | 6.3 (1) | 4.7 (2) | 5.1 (3) | 5.3 (2) |
| Lack of time to prepare prior to reporting period | 6.8 (16) | 9.0 (7) | 6.3 (1) | 2.3 (1) | 8.5 (5) | 5.3 (2) |
| Privacy concerns reported by individual HCP | 5.1 (12) | 6.4 (5) | 6.3 (1) | 2.3 (1) | 5.1 (3) | 5.3 (2) |
ASC: Ambulatory Surgery Center; LTCF: Long-Term Care Facility; HCP: healthcare personnel. Facilities could report multiple barriers, so responses may sum to greater than 100%.
Items reported as “major barriers” (vs. “somewhat of a barrier” or “not a barrier at all”) to using the NQF measure for reporting HCP influenza vaccination by <5% of facilities overall were: lack of previous experience measuring HCP influenza vaccination, the number of employees working at the healthcare facility, lack of support from administration or leadership for using the measure, lack of support or assistance from other staff members in tracking vaccination, understanding the definitions for different types of HCP, privacy concerns reported by unions, and other.
Discussion
Reporting employee vaccination status using the standardized measure was feasible for various inpatient and outpatient healthcare facilities, whereas tracking vaccination status among non-employee HCP was more challenging. Although most pilot facilities stated that the provisional measure was easy to use, about one third could not fully report non-employee vaccination data. The most commonly reported barrier to measure use was inability to determine vaccination status of non-employee HCP. Perceived barriers and ability to report vaccination data varied by facility type.
Implementing standardized measurement processes for HCP influenza vaccination can confer multiple benefits to healthcare facilities. Increases in HCP influenza vaccination coverage following initiation of measurement programs have been repeatedly observed, although the effect of measurement cannot be separated from other policies or activities implemented in conjunction with vaccination measurement.25,29,30 Observed coverage increases may be partially attributable to improved tracking of vaccinations received outside the healthcare facility.31 In addition, use of standardized HCP definitions increases the accuracy and comparability of vaccination coverage estimates; definitions that are not standardized can produce substantially different estimates of influenza vaccination coverage in the same population.32
An increased ability to generate accurate estimates of HCP influenza vaccination may help facilities reach vaccination coverage goals set either internally or externally. Another potential benefit is greater ease in complying with institutional, state, and national reporting requirements. These are becoming increasingly common now that HCP influenza vaccination has been identified as a recommended measure for healthcare quality reporting.33,34
It is not surprising that facilities reported greater difficulty measuring influenza vaccination coverage among non-employee HCP than among employees. A substantial proportion of U.S. hospitals do not include non-employee HCP in their coverage measurements.35 Although employee counts can easily be determined using payroll records, numerous data sources may be necessary for tracking non-employees, particularly in larger healthcare facilities.
In the current study, acute care hospitals were particularly likely to report number of non-employees and time required to collect non-employee vaccination data as major barriers to using the measure. This is likely because hospitals in this study had the highest median number and the largest proportion of non-employee HCP. (Less difficulty reporting numerator data was reported by dialysis clinics and physician practices, which had few CNE or ONE.) Electronic tracking systems, often linked to existing databases or networks, have allowed hospitals to successfully track vaccination among both employees29,30,36–38 and various types of non-employee HCP29,37,38.
To ensure that the measure was feasible for use, CDC submitted for NQF endorsement a revised measure that limited the types of non-employees included. The CNE category, now called “licensed independent practitioners”, was restricted to non-employee physicians, advanced practice nurses, and physician assistants working at the healthcare facility. The ONE category, now called “adult students/trainees and volunteers,” was restricted to non-employee students; trainees (including interns and residents); and volunteers aged ≥18 years working at the facility.
Only personnel working ≥30 days during the influenza season were included in the revised measure, in order to mitigate the difficulty of tracking temporary non-employee HCP with limited potential exposure. The revised measure is less comprehensive but is more likely to produce valid and reliable estimates of HCP vaccination coverage. The revised measure was fully endorsed by NQF in May 2012. The Centers for Medicare and Medicaid Services has added the NQF-endorsed measure to its quality reporting programs for acute care hospitals and ASCs, which will affect annual payment updates for these facilities.39,40
Limitations
These results are subject to certain limitations. Participating jurisdictions were selected on the basis of prior experience with or interest in reporting HCP influenza vaccination coverage, and facilities were not randomly recruited. Therefore, results may not be generalizable to all healthcare facilities nationally. Facilities with less experience in such measurement were less likely to complete the evaluation; these facilities may have experienced greater barriers to using the measure than those who completed the current study. However, respondents represented a variety of facility types: public and private, urban and non-urban, with various levels of prior experience measuring influenza vaccination (Table 1).
Conclusion
This study demonstrated that reporting HCP employee vaccination status using a standardized measure was feasible for most healthcare facilities. Measuring vaccination status among non-employee HCP, particularly those working in a facility for a limited time, remains difficult. Annual influenza vaccination is recommended for all paid and unpaid HCP with potential exposure to patients or infectious materials, in order to reduce risk of transmitting and acquiring influenza.22
As healthcare facilities gain experience using the NQF-endorsed measure, it can be adapted to include additional non-employee HCP. Continued implementation and expansion of the measure to additional HCP populations and settings will inform quality improvement efforts in healthcare facilities and facilitate national comparisons of HCP influenza vaccination estimates. Despite efforts by numerous professional organizations, increasing HCP influenza vaccination coverage has been challenging. Enhancing measurement of HCP influenza vaccination using this standardized measure should lead to increased vaccination uptake, resulting in healthier patients and providers.
Supplementary Material
Acknowledgments
The authors thank the following individuals for their significant contributions to the process of pilot-testing the HCP vaccination measure: Ms. Erica Boston, Dr. Robert Harrison, MD, Ms. Patricia McLendon, MPH, and Dr. Jon Rosenberg, MD from the California Department of Public Health; Dr. Joan Baumbach, MD and Ms. Lisa Bowdey from the New Mexico Department of Health; Mr. Edward Wake and Dr. Jane R. Zucker, MD, MSc from the New York City Department of Health and Mental Hygiene; Dr. Carol Friedman (deceased), DO, Dr. Taranisia MacCannell, PhD, and Dr. Cindy Weinbaum, MD, MPH from the CDC; and Ms. LaDora O. Woods, contractor with Carter Consulting.
None of the authors of this manuscript has any financial or proprietary interest in this work. This work was supported by the CDC.
Footnotes
At the time this evaluation was conducted, Mr. Miller was a research fellow at the National Center for Immunization and Respiratory Diseases, CDC. Ms. Makvandi was with the Epidemiology and Response Division and Mrs. Smith was a CDC contractor at the New Mexico Department of Health.
No financial disclosures were reported by the authors of this paper.
References
- 1.Centers for Disease Control and Prevention. Estimates of deaths associated with seasonal influenza – United States. 1976–2007. MMWR Wkly Rep. 2010;59(33):1057–1062. [PubMed] [Google Scholar]
- 2.Sartor C, Zandotti C, Romain F, et al. Disruption of services in an internal medicine unit due to a nosocomial influenza outbreak. Infect Control Hosp Epidemiol. 2002;23:615–619. doi: 10.1086/501981. [DOI] [PubMed] [Google Scholar]
- 3.Bridges CB, Kuehnert MJ, Hall CB. Transmission of influenza: implications for control in healthcare settings. Clin Infect Dis. 2003:1094–1101. doi: 10.1086/378292. [DOI] [PubMed] [Google Scholar]
- 4.Cunney RJ, Bialachowski A, Thornley D, Smaill FM, Pennie RA. An outbreak of influenza A in a neonatal intensive care unit. Infect Control Hosp Epidemiol. 2000;21:449–454. doi: 10.1086/501786. [DOI] [PubMed] [Google Scholar]
- 5.Voirin N, Barret B, Metzger M-H, Vanhems P. Hospital-acquired influenza: A synthesis using the Outbreak Reports and Intervention Studies of Nosocomial Infection (ORION) statement. J Hosp Infect. 2009;71:1–14. doi: 10.1016/j.jhin.2008.08.013. [DOI] [PubMed] [Google Scholar]
- 6.Weinstock DM, Eagan J, Malak SA, et al. Control of influenza A on a bone marrow transplant unit. Infect Control Hosp Epidemiol. 2000;21:730–732. doi: 10.1086/501726. [DOI] [PubMed] [Google Scholar]
- 7.Wilde JA, McMillan JA, Serwint J, et al. Effectiveness of influenza vaccine in healthcare professionals: a randomized trial. JAMA. 1999;281:908–913. doi: 10.1001/jama.281.10.908. [DOI] [PubMed] [Google Scholar]
- 8.Lester RT, McGeer A, Tomlinson G, Detsky AS. Use of, effectiveness of, and attitudes regarding influenza vaccine among house staff. Infect Control Hosp Epidemiol. 2003;24:839–844. doi: 10.1086/502146. [DOI] [PubMed] [Google Scholar]
- 9.Salgado CD, Giannetta ET, Hayden FG, Farr BM. Preventing nosocomial influenza by improving the vaccine acceptance rate of clinicians. Infect Control Hosp Epidemiol. 2004;25:923–928. doi: 10.1086/502321. [DOI] [PubMed] [Google Scholar]
- 10.Lemaitre M, Meret T, Rothan-Tondeur M, et al. Effect of influenza vaccination of nursing home staff on mortality of residents: a cluster-randomized trial. J Am Geriatr Soc. 2009;57:1580–1586. doi: 10.1111/j.1532-5415.2009.02402.x. [DOI] [PubMed] [Google Scholar]
- 11.Burls A, Jordan R, Barton P, et al. Vaccinating healthcare workers against influenza to protect the vulnerable—Is it a good use of healthcare resources? A systematic review of the evidence and an economic evaluation. Vaccine. 2006;24:4212–4221. doi: 10.1016/j.vaccine.2005.12.043. [DOI] [PubMed] [Google Scholar]
- 12.Saxen H, Virtanen M. Randomized, placebo-controlled double blind study on the efficacy of influenza immunization on absenteeism of healthcare workers. Pediatr Infect Dis J. 1999;18:779–783. doi: 10.1097/00006454-199909000-00007. [DOI] [PubMed] [Google Scholar]
- 13.Hayward AC, Harling R, Wetten S, et al. Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial. BMJ. 2006;333:1241–1246. doi: 10.1136/bmj.39010.581354.55. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Potter J, Stott DJ, Roberts MA, et al. Influenza vaccination of healthcare workers in long-term-care hospitals reduces the mortality of elderly patients. J. Infect Dis. 1997;175:1–6. doi: 10.1093/infdis/175.1.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Van den Dool C, Bonten MJM, Hak E, Heijne JCM, Wallinga J. The effects of influenza vaccination of health care workers in nursing homes: insights from a mathematical model. PLoS Medicine. 2008;5:1453–1460. doi: 10.1371/journal.pmed.0050200. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Oshitani H, Saito R, Seiki N, et al. Influenza vaccination levels and influenza-like illness in long-term–care facilities for elderly people in Niigata, Japan, during an influenza A (H3N2) epidemic. Infect Control Hosp Epidemiol. 2000;21:728–730. doi: 10.1086/501725. [DOI] [PubMed] [Google Scholar]
- 17.Thomas RE, Jefferson T, Lasserson TJ. Influenza vaccination for healthcare workers who work with the elderly: systematic review. Vaccine. 2011;29:344–356. doi: 10.1016/j.vaccine.2010.09.085. [DOI] [PubMed] [Google Scholar]
- 18.Carman WF, Elder AG, Wallace LA, et al. Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: A randomized controlled trial. Lancet. 2000;355:93–97. doi: 10.1016/S0140-6736(99)05190-9. [DOI] [PubMed] [Google Scholar]
- 19.New infection control requirement for offering influenza vaccination to staff and licensed independent practitioners. Jt Comm Perspect. 2006;26:10–11. [PubMed] [Google Scholar]
- 20.National Foundation for Infectious Diseases. Bethesda, MD: 2004. Improving influenza vaccination rates in health care workers: strategies to increase protection for workers and patients. http://ideha.dhmh.maryland.gov/OIDEOR/IMMUN/Shared%20Documents/hcwmonograph.pdf. [Google Scholar]
- 21.Talbot TR, Babcock H, Caplan AL, et al. Revised SHEA position paper: Influenza vaccination of healthcare personnel. Infect Control Hosp Epidemiol. 2010;31:987–995. doi: 10.1086/656558. [DOI] [PubMed] [Google Scholar]
- 22.Pearson ML, Bridges CB, Harper SA Healthcare Infection Control Practices Advisory Committee (HICPAC); Advisory Committee on Immunization Practices (ACIP). Influenza vaccination of health-care personnel: recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP) (published correction appears in MMWR Recomm Rep 2006; 55: 252) MMWR Recomm Rep. 2006;55(RR-2):1–16. [PubMed] [Google Scholar]
- 23.The Joint Commission. Prepublication standard IC.02.04.01: Influenza vaccination for licensed independent practitioners and staff. [Last updated November 21. 2011]; http://www.jointcommission.org/influenza_vaccination_prepublication. [Google Scholar]
- 24.Guide to Community Preventive Services. Universally recommended vaccinations: provider assessment & feedback (abbreviated). Review completed February 2008. www.thecommunityguide.org/vaccines/universally/providerassessment.html. [Google Scholar]
- 25.Helms C, Polgreen P, Polgreen L, et al. Voluntary reporting of employee influenza vaccination rates by acute care hospitals in Iowa: the impact of a four year provider-based statewide performance improvement project. Vaccine. 2011;29:3483–3488. doi: 10.1016/j.vaccine.2011.02.056. [DOI] [PubMed] [Google Scholar]
- 26.National Quality Forum. Measure Evaluation Criteria. 2011 Jan; http://www.qualityforum.org/Measuring_Performance/Submitting_Standards/Measure_Evaluation_Criteria.aspx. [Google Scholar]
- 27.Libby TE, Lindley MC, Lorick SA, et al. Reliability and validity of a standardized measure of influenza vaccination coverage among healthcare personnel. Infect Control Hosp Epidemiol. 2013 doi: 10.1086/669859. (in press). [DOI] [PubMed] [Google Scholar]
- 28.MacCannell T, Shugart A, Schneider A, et al. A qualitative assessment of a performance measure for reporting influenza vaccination rates among healthcare personnel. Infect Control Hosp Epidemiol. 2012;33(9):945–948. doi: 10.1086/667375. [DOI] [PubMed] [Google Scholar]
- 29.Bertin M, et al. Novel use of the intranet to document health care personnel participation in a mandatory influenza vaccination reporting program. Am J Infect Control. 2007;35:33–37. doi: 10.1016/j.ajic.2006.10.005. [DOI] [PubMed] [Google Scholar]
- 30.Palmore TN, et al. A successful mandatory influenza vaccination campaign using an innovative electronic tracking system. Infect Control Hosp Epidemiol. 2009;30:1137–1142. doi: 10.1086/648084. [DOI] [PubMed] [Google Scholar]
- 31.Bearman G, Fuentes L, Vorenkamp JVL, Drusin LM. Vaccination without documentation: influenza immunization among medical residents at a tertiary-care medical center. Infect Control Hosp Epidemiol. 2003;24:626–628. doi: 10.1086/502266. [DOI] [PubMed] [Google Scholar]
- 32.Russell ML, Henderson EA. The measurement of influenza vaccine coverage among health care workers. Am J Infect Control. 2003;31:457–461. doi: 10.1016/s0196-6553(03)00085-3. [DOI] [PubMed] [Google Scholar]
- 33.McKibben L, Horan T, Tokars JI, et al. Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee. Am J Infect Control. 2005;33:217–226. doi: 10.1016/j.ajic.2005.04.001. [DOI] [PubMed] [Google Scholar]
- 34.Passaretti CL, Barclay P, Pronovost P, Perl TM. Public reporting of health care-associated infections (HAIs): approach to choosing HAI measures. Infect Control Hosp Epidemiol. 2011;32:768–774. doi: 10.1086/660873. [DOI] [PubMed] [Google Scholar]
- 35.Lindley MC, Yonek J, Ahmed F, Perz JF, Torres GW. Measurement of influenza vaccination coverage among healthcare personnel in U.S. hospitals. Infect Control Hosp Epidemiol. 2009;30:1150–1157. doi: 10.1086/648086. [DOI] [PubMed] [Google Scholar]
- 36.Melia M, et al. Development of a flexible, computerized database to prioritize, record, and report influenza vaccination rates for healthcare personnel. Infect Control Hosp Epidemiol. 2009;30:361–369. doi: 10.1086/596043. [DOI] [PubMed] [Google Scholar]
- 37.Babcock HM, Gemeinhart N, Jones M, Dunagan WC, Woeltje KF. Mandatory influenza vaccination of health care workers: translating policy to practice. Clin Infect Dis. 2010;50:459–464. doi: 10.1086/650752. [DOI] [PubMed] [Google Scholar]
- 38.Ribner BS, et al. A web-based program to ensure compliance of medical staff providers with mandated healthcare facility requirements. Am J Infect Control. 2011;39:511–514. doi: 10.1016/j.ajic.2010.08.021. [DOI] [PubMed] [Google Scholar]
- 39.US Department of Health and Human Services. Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and FY2012 rates; hospitals' FTE resident caps for graduate medical education payment; final rules. Federal Register. 2011;76:51631–51633. [PubMed] [Google Scholar]
- 40.US Department of Health and Human Services. Medicare and Medicaid programs; hospital outpatient prospective payment; ambulatory surgical center payment; hospital value-based purchasing program; physician self-referral; and patient notification requirements in provider agreements; final rules. Federal Register. 2011;76:74470–74472. [PubMed] [Google Scholar]
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