Proposal for Immunization in Senior Citizens

Introduction

Primary care offices have the most frequent contact with patients and the most opportunity to promote preventative care. Adults over the age of 64 are more vulnerable to acquiring preventable diseases than people 64 years and younger, and dying prematurely from diseases that can be prevented through immunization is more probable, (Annunziata, Rak, Buono, DiBonaventura, & Krishnarajah, 2012), rendering the immunization of older adults a primary concern in health care settings. As important as this issue is, immunization rates in adults 65 and older remain at sub-par rates. This proposal will explain the details for a vaccination protocol in a private family practice setting aimed to discover the reason for sub-par immunization rates in older adults.

Improving rates of immunization in older adults is important for advanced nurse practitioners (APN). APNs in family care settings are most likely to have the first contact with patients and address their ongoing healthcare needs. Immunization status is a focal point in preventative measures. ANPs as primary healthcare providers are productive partners in making healthcare changes to improve health outcomes, such as practice changes in immunization delivery.

This proposal includes the problem of low immunization rates in adults age 65 and older will be explained. The project purpose and the clinical question will be stated. A literature review will be provided.

Problem Statement

Within this primary care setting, sub-par immunization rates in older adults were identified as an ongoing concern. Only half the geriatric patients received immunizations for preventable diseases such as influenza and pneumonia, revealing the need to plan a strategy to increase immunization rates for geriatric patients.

A needs assessment was conducted within the parameters of the organizational structure, the stakeholders, and organizational resources of the facility using the SWOT and GAP analysis methods. The stakeholders were identified as the director, the internal medicine medical doctor, the APN, and the geriatric patients. The needs assessment revealed the faculty in the primary care office, from office workers to the medical doctor, and their patients lacked awareness of the importance of immunization for preventable diseases in older adults. Moreover, no record-keeping procedures or educational protocols were being utilized to track accurate data for immunization rates for geriatric patients who frequented the office. This is due to the lack of a systematic approach to immunization compliance in geriatric patients for this site.

For a 150 geriatric patient’s sample, historical patient data was used to assess the rates of immunization for influenza, pneumococcal, zoster, and tetanus-diphtheria. The historical rates were annotated for baseline measurements then calculated to understand the hardcore data of the problem from this primary care site. The analysis revealed influenza had expected immunization reuptakes of 50%. However, the percentages for pneumococcal (33%), zoster (6.7%), and tetanus-diphtheria (3.3%) were much lower. This is well below the standard the CDC (2013) stipulates: 1 dose for the flu, pneumonia, and zoster every year, and 1 dose for tetanus every decade. These statistics highlight the need for this facility to reevaluate their immunization rates and select a course of action to improve its immunization reuptakes in their geriatric patients. While the costs associated with establishing and implementing an immunization program are high, the costs associated with the treatment of preventable diseases and needless loss of life are higher, as well as the health and wellness of the primary care staff working in this facility. The recent focus upon preventative health care and this site’s low immunization numbers clarify the need for improving immunization reuptake for geriatric patients.

Project Purpose

According to Clarkson Keller, Siktberg, & Hodson-Carlton (2008), it is the nurse’s role to educate; provide timely, accurate, and relevant information to the patient. In fulfilling this role, nurses fulfill the greater purpose of driving down the occurrences of preventable diseases worldwide. This capstone project will address the low rates of immunization uptake within their geriatric patients. The goals of this project are to improve education amongst staff and patients as to the importance of immunizations, and establish a systematic protocol for the office workers and healthcare professionals at the primary care site to improve client education and record-keeping practices for the health care facility. 

The goals of this project align with IOM Aims. The safety of the patient has been assessed for this study. Increased immunization rates benefit the patient, and ill effects from immunizations are extremely low, according to the CDC (2013). One of the goals of this study is to ascertain the patient’s knowledge of the benefits of immunization for preventable diseases, thereby orienting clinic staff to patient-centered care. The measurement of success will ensure the effectiveness of the program. All patient education will occur during office visits, which ensures efficiency in the delivery of information and help to track relevant and immediate successful and unsuccessful outcomes of the program. Equitability is ensured through directing efforts towards all geriatric patients as well as improving immunization rates equitably amongst all geriatric patients who visit the primary care clinic. In aligning with IOM Aims, the project is also aligned to the system’s mission and overall goals, where interest lies in the protection of the patient, equal treatment, quality care, and a continuing desire to improve patient care.

The triumphs and areas for improvement will help hone my skills as a nurse-scholar in the care of geriatric patients. In performing the needs assessment, I learned that even in good practices with caring healthcare workers, there is always room for improvement. This project will help me to continue finding ways to improve patient care using an evidence-based system.

Clinical Question

The problem concentrated upon in this study will be the sub-par rates of immunizations in geriatric patients. The intervention executed will be a system of vaccination procedures utilized by primary care clinics, involving patient inquiry to discover if they have had immunizations and if they are eligible, offering the vaccine, patient education, and administering of the vaccine. The eligible patients before the implementation of the protocol will be compared to eligible patients after the protocol to gain knowledge in the successes of the protocol. The clinical question will be: “For older adults 65 years and older, what is the effect of a vaccination protocol on immunization rates, pre and post use of the vaccination protocol”.

Review of Literature

This literature review will introduce the problem of under-immunization in geriatric patients. The research findings will be described using the Iowa Model of Evidence-Based Practice. Literature depicting the gap between the phenomenon of interest and the current state will be offered. A discussion and appraisal of the results of the research evidence to date that supports development and implementation of the anticipated project will be provided. Literature that identifies interventions and processes to improve outcomes will be explained.

Approach to the Literature 

The Iowa Model of Evidence-Based Practice (EBP) was used to assess the literature on under-immunization in geriatric patients. The EBP provides a pragmatic approach to research. To model the EBP, a three-part search was conducted. The results from the search are explained in the following sections.

Part One. The goal for the first part of the research was to assess if under-immunization is a clinical issue for geriatric patients. Findings verify this statement. High, D’Aquila, Fuldner, Gerding, Halter, Haynes, and Schmader (2010) noted immune systems in older adults do not operate with as much efficiency as with younger generations and are the ones that require vaccinations because of their increased vulnerability to disease. The CDC (2012) reported 45,000 adults pass from diseases that could have been prevented through vaccinations, and mostly from the flu. For instance, in 2008, there were approximately 44,000 cases of pneumonia and a 10% death rate, comprising mostly of adults over the age of 35. Talbot, Zhu, Chen, Williams, Thompson, and Griffin (2013) confirmed out of the approximately 300,000 cases of flu that resulted in hospital stays for 2011 through 2012 were primarily over 49 years of age. According to Weston, Friedland, Wu, and Howe (2012), the increased vulnerability also meant increased vulnerability to death once a preventable disease has been contracted, and also makes them carriers that can pass diseases such as Pertussis to infants, toddlers, and early school-aged children. These statistics confirm that the geriatric population are most vulnerable, and are under-immunized.

Part Two. In the second part, the research on vaccinations was reviewed to discover if certain changes in practice would increase immunization rates. The findings of the research suggest that certain adaptations of protocols and practices do increase immunization uptakes. The CDC (2012) recommended a set of guidelines to help keep the number of immunizations high for senior citizens: accurate record-keeping, having multiple vaccine handy, clear communications to patients, and utilizing a standing order protocol, and offering all relevant vaccines at once as part of these elements. Kempe, Hurley, Stokley, Daley, Crane, Beaty, and Steiner (2008) discovered that a lack of a systematic approach to fulfill immunizations contribute to low vaccination uptakes for geriatric patients, highlighting the need for a systematic approach for immunization in older adults. Lau, Hu, Majumdar, Storie, Rees, and Johnson (2012) utilizing a standing order protocol increased immunization uptake numbers. Shenson, Adams, Bolen, Wooten, Clough, Giles, and Anderson (2012) found that screening for immunizations increased uptakes for vaccines in Caucasians and minorities. Assaad, El-Masri, Porhomayon, and El-Solh (2012) reported their multidimensional program produced high rates of immunizations, which included sending reminders to patients and evaluation feedback. 

Part Three. An analysis was conducted for the third part to this research to learn if changing offering practices within primary care settings had a positive influence on immunization uptakes. Koch et al. (2012) found a positive influence on immunization uptakes when immunizations were offered during wellness visits to the primary care office. Community outreach programs, Lau et al. (2012), can also be credited to increasing vaccination rates. De Wals, Boulianne, Sevin, Quakki, Deceuninck, and Guay (2009) and Shenson et al. (2012) concurred that immunization rates were improved when screenings were conducted within primary care settings.

Gap Between Phenomenon of Interest and Current State

Part one of the review of the literature revealed that existing rates of immunizations are sub-par when compared with CDC expectations to raise immunization rates in older adults. The primary care setting used for this study is along the lines of the research findings. This research project will attempt to raise the levels of immunizations for the proposed primary care setting.

Discussion of the Findings

This literature review was performed in three parts, each with a different goal. It was found that the problem of under-immunization exists for older adults and that it contributes to a host of health problems associated with preventable diseases, such as hospital stays and even premature death. Certain practices were found to have positive effects on immunization rates. These studies aggregately point towards the timely relevance of this study and suggested ideas to implement standards of practice to help improve vaccinating of senior citizens within this primary care setting.  

References

Annunziata, K., Rak, A., Buono, H. D., DiBonaventura, M., & Krishnarajah, G. (2012). Vaccination rates among the general adult population and high-risk groups in the United States. PLOS One, 7(11), 1. http://dx.doi.org/10.1371/journal.pone.0050553

Assaad, U., El-Masri, I., Porhomayon, J., & El-Solh, A. A. (2012). Pneumonia immunization in older adults: Review of vaccine effectiveness and strategies. Clinical Interventions in Aging, 7, 453-461. http://dx.doi.org/10.2147/CIA.S29675

Centers for Disease Control and Prevention. (2013). Recommended adult immunization schedule-United States-201. Retrieved from http://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html

Clarkson Keller, V., Siktberg, L., & Hodson-Carlton, K. (2008). Overcoming obstacles to vaccination. American Nurse Today, 3(10), 23-29. 

De Wals, P., Boulianne, N., Sevin, E., Quakki, M., Deceuninck, G., & Guay, M. (2009). Uptake of pneumococcal conjugate vaccine: Methodological issues in measurement and impact of publicly funded programs. Canadian Journal of Public Health, 100(6), 413-416. Retrieved from http://search.proquest.com/docview/232009412?accountid=35812

High, K. P., D’Aquila, R. T., Fuldner, R. A., Gerding, D. N., Halter, J. B., Haynes, L., & Schmader, K. E. (2010). Workshop on immunizations in older adults: Identifying future research agendas. Journal of the American Geriatrics Society, 58(4), 765-776. doi: http://dx.doi.org/10.1111/j.1532-5415.2010.02772.x

Lau, D., Hu, J., Majumdar, S. R., Storie, D. A., Rees, S. E., & Johnson, J. A. (2012). Interventions to improve influenza and pneumococcal vaccination rates among community dwelling adults: A systematic review and meta-analysis. Annals of Family Medicine, 10(6), 538-546. doi: http://dx.doi.org/10.1370/afm.1405

Kempe, A., Hurley, L., Stokley, S., Daley, M. F., Crane, L. A., Beaty, B. L., & Steiner, J. F. (2008). Pneumococcal vaccination in general internal medicine practice: Current practice and future possibilities. Journal of General Internal Medicine, 23(12), 2010-2013. doi: http://dx.doi.org/10.1007/s11606-008-0800-0

Koch, J. A. (2012). Strategies to overcome barriers to pneumococcal vaccination in older adults: An integrative review. Journal of Gerontological Nursing, 38(2), 31-39. doi: http://dx.doi.org/10.3928/00989134-20110831-03.

Shenson, D., Adams, M., Bolen, J., Wooten, K., Clough, J., Giles, W., & Anderson, L. (2012). Developing an integrated strategy to reduce ethnic and racial disparities in the delivery of clinical preventive services for older Americans. American Journal of Public Health, 102(8), E44-E50. Retrieved from http://search.proquest.com/docview/1039278608?accountid=35812

Talbot, H. K., Zhu, Y., Chen, Q., Williams, J. V., Thompson, M. G., & Griffin, M. R. (2013). Effectiveness of influenza vaccine for preventing laboratory-confirmed influenza hospitalizations in adults, 2011-2012 influenza season. Clinical Infectious Diseases, 56(12), 1774-1777. doi: http://dx.doi.org/10.1093/cid/cit124

Weston, W. M., Friedland, L. R., Wu, X., & Howe, B. (2012). Vaccination of adults 65 years of age and older with tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (boostrix): Results of two randomized trials. Vaccine, 30(9), 1721-1728. doi: http://dx.doi.org/10.1016/j.vaccine.2011.12.055.