In the study published in the Nov.17 issue of the Journal of the American Medical Association, Paul Dexter, M.D., and Clement McDonald, M.D., and their Indiana University School of Medicine and Regenstrief Institute, Inc. colleagues report that computer-assisted standing orders for nurses achieve even higher rates of adult inpatient immunization than computerized physician reminders.
In a previous study published in the New England Journal of Medicine, the same researchers demonstrated that computerized reminders delivered to physicians increased inpatient ordering rates of influenza and pneumonia vaccine dramatically (approximately 50 fold) over non-reminded rates, but fell far short of national vaccination goals.
"Computerized physician reminders would be the preferable approach when physician judgment is required, but decisions about many safe interventions like the administration of flu and pneumonia shots and cancer screening that are based largely on simple criteria such as patient age and diagnoses can be done better by nurses following computer based standing orders," said Dr. Dexter, associate professor of clinical medicine.
The computer can do all the work of scrutinizing the medical record to find the patients who need the preventive care intervention and then signal the nurse about them. The nurse can then verify the criteria with the patient and deliver the intervention. This improves the delivery of care and frees physicians to concentrate on more complex and severe patient problems explained Dr. Dexter.
"For many vulnerable populations who are outside the medical mainstream, the inpatient service may be the best or only opportunity for delivery of such vaccines," said study senior author Clement McDonald, M.D., Regenstrief Professor of Medical Informatics, Distinguished Professor of Medicine, and director of the Regenstrief Institute, Inc.
The new study took place at an urban public teaching hospital over a 14-month period and overlapped two influenza seasons. Participants were randomized into two groups. In both groups, the computer identified patients who were appropriate candidates for the vaccinations -- they were over 65, or had one of the chronic diseases that require vaccinations and also had not already received the vaccine in the required time frame. For patients in the first group, the computer generated a standing order for a required vaccine and a nurse administered that vaccine without direct involvement of the patient's physician. For patients in the second group the computer used the same logic to find patients needing one of the vaccines and the computer reminded the physicians to order such vaccines, but physicians had to accept that reminder before an order would flow to nursing staff for administration. Physicians did not accept 42 percent of the influenza and 51 percent of the pneumonia reminders.
For both groups, a nurse asked the patient a short list of questions to verify that the patient was an appropriate candidate and wanted the vaccine, before delivering the vaccine. The immunization rate among patients eligible for the vaccines was significantly better in the computer-assisted nursing standard orders group than in the physician reminder group; 42 percent of patients in the standing order group received influenza vaccine compared with only 30 percent in the physician reminder group. Similarly, 51 percent of patients in the standing order group received a pneumonia shot compared to only 31 percent in the physician reminder group.
"When we adjust for the fact that some of the patients had received a vaccine unbeknownst to the computer, delivering the computer's "suggestions" about influenza and pneumonia vaccine administration to nurses as standing orders, the percent of eligible patients who get their influenza vaccine goes up to 52 percent in the standing orders group and to 36 percent in the physician reminders group," said Dr. McDonald. "Moreover, standing orders for nurses could be much easier to carry out than physician reminders because the former can be implemented within nurse order management systems which are used widely in U.S. hospitals, while physician reminders require physician order entry systems -- which are deployed in very few US hospitals -- as their basis."
A surprisingly large number of eligible patients from both groups refused the shots.
"Overall nearly a quarter of eligible patients refused a vaccine when it was offered by a nurse and this refusal accounted for about two-thirds of the patients who did not get their vaccination despite standing nurse orders," said Dr. Dexter. "To get closer to 100 percent immunization rates, the medical community will have to work, especially within the older urban population, to change negative beliefs about these vaccinations."
This study was funded by the Agency for Healthcare Research and Quality, the National Library of Medicine, the Regenstrief Foundation, and the Indiana Genomics Initiative (INGEN) of Indiana University.
Journal
JAMA