Providers' Beliefs, Attitudes, and Behaviors before Implementing a Computerized Pneumococcal Vaccination Reminder

Providers’ Beliefs, Attitudes, and Behaviorsbefore Implementing a ComputerizedPneumococcal Vaccination ReminderJudith W. Dexheimer, MS, Ian Jones, MD, Qingxia Chen, PhD, Thomas R. Talbot, MD, MPH,Donna Mason, MS, Dominik Aronsky, MD, PhD

AbstractBackground: The emergency department (ED) has been recommended as a suitable setting for offeringpneumococcal vaccination; however, implementations of ED vaccination programs remain scarce.

Objectives: To understand beliefs, attitudes, and behaviors of ED providers before implementing acomputerized reminder system.

Methods: An anonymous, five-point Likert-scale, 46-item survey was administered to emergency physi-cians and nurses at an academic medical center. The survey included aspects of ordering patterns, imple-mentation strategies, barriers, and factors considered important for an ED-based vaccination initiative aswell as aspects of implementing a computerized vaccine-reminder system.

Results: Among 160 eligible ED providers, the survey was returned by 64 of 67 physicians (96%), and all 93nurses (100%). The vaccine was considered to be cost effective by 71% of physicians, but only 2% recom-mended it to their patients. Although 98% of physicians accessed the computerized problem list before ex-amining the patient, only 28% reviewed the patient’s health-maintenance section. Physicians and nursespreferred a computerized vaccination-reminder system in 93% and 82%, respectively. Physicians’ pre-ferred implementation approach included a nurse standing order, combined with physician notification;nurses, however, favored a physician order. Factors for improving vaccination rates included improvedcomputerized documentation, whereas increasing the number of ED staff was less important. Relevantimplementation barriers for physicians were not remembering to offer vaccination, time constraints, andinsufficient time to counsel patients. The ED was believed to be an appropriate setting in which to offervaccination.

Conclusions: Emergency department staff had favorable attitudes toward an ED-based pneumococcalvaccination program; however, considerable barriers inherent to the ED setting may challenge such aprogram. Applying information technology may overcome some barriers and facilitate an ED-basedvaccination initiative.

ACADEMIC EMERGENCY MEDICINE 2006; 13:1312–1318 ª 2006 by the Society for Academic EmergencyMedicine

Keywords: pneumococcal vaccines, health care surveys, attitude of health personnel, immunizationprograms, emergency medicine

Pneumococcal infections are a considerable causeof morbidity and mortality, including 3,000 casesof meningitis, 50,000 cases of bacteremia, 500,000

From the Departments of Biomedical Informatics (JWD, DA),

Emergency Medicine (IJ, DM, DA), Biostatistics (QC), Preventive

Medicine (TRT), and Internal Medicine (TRT), Vanderbilt Univer-

sity Medical Center, Nashville, TN.

Ms. Dexheimer was supported by National Library of Medicine

T15 007450-03.

Received May 9, 2006; revision received July 21, 2006; accepted

July 21, 2006.

Contact for correspondence and reprints: Dominik Aronsky,

MD, PhD; e-mail: [email protected].

ISSN 1069-6563

PII ISSN 1069-65635831312

cases of pneumonia, and 40,000 deaths annually.1 Pneu-mococcal vaccination is safe, cost-effective, and reducesthe rates of invasive infections.2–7 High-risk patients aredefined by the Centers for Disease Control and Preven-tion (CDC) as patients older than 65 years of age and aspatients younger than 65 years of age who have achronic illness.1 Despite widespread recommendations,pneumococcal vaccination rates for high-risk individualsare 46% to 59%8–11 and remain far below the 90% vacci-nation goal of Healthy People 2010.8,12

Interventions to increase pneumococcal vaccinationinclude educational initiatives, provider feedback, orga-nizational change, financial incentives, and reminders.13

Different provider-reminder implementation approaches

ª 2006 by the Society for Academic Emergency Medicine

doi: 10.1197/j.aem.2006.07.029

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such as paper-based,14–17 computer-generated,18,19 orfully computerized20,21 strategies have been successfulin increasing vaccination rates in various settings. To fur-ther increase vaccination rates, the CDC and the Centersfor Medicare and Medicaid Services have promoted theimplementation of standing orders22,23 that have beeneffective in various settings.17,21,24,25 However, the im-plementation of standing orders may not be feasible ininstitutions that mandate a physician order.26

The emergency department (ED) setting is a challengingenvironment for the delivery of vaccinations that areunrelated to the patient’s primary reason for visit. Unlikeprimary health care providers, ED clinicians provide epi-sodic care in a multitasking, communication-intensive set-ting in which patient records frequently lack pertinent andquickly available information that would support a deter-mination of a patient’s vaccination eligibility. As a resultof additional challenges such as overcrowding,27,28 nurseshortages,29 and lack of hospital beds,30 the ED settingmay not be perceived as an optimal one in which to offerpneumococcal vaccination. From 1992–2002, an estimated266,000 pneumococcal vaccinations were given in EDsnationally.31 However, many patients at high risk for pneu-mococcal disease frequently seek care in the ED, repre-senting a unique opportunity to offer the vaccine.32 Theexisting opportunities33,34 and the feasibility35–38 of anED-based vaccination program have been demonstrated,and the American College of Emergency Physiciansendorses ED-based vaccination initiatives.35 However,experiences in the ED setting remain scare, and there isvery limited information about ED providers’ attitudes,beliefs, behaviors, and perceived barriers to offeringpneumococcal vaccination in the ED.32

With the increased implementation of clinical-infor-mation systems, it is conceivable that information tech-nology in the ED may provide the infrastructure toovercome certain logistical barriers and facilitate recom-mended vaccination initiatives. The goal of this study wasto understand beliefs, attitudes, and behaviors of EDhealth care providers before implementing a computer-ized reminder system in our ED.

METHODS

Study Design and PopulationWe designed an anonymous, self-administered survey(available as an online Data Supplement at http://www.aemj.org/cgi/content/full/j.aem.2006.07.029/DC1) to under-stand the attitudes and behaviors of emergency-medicineclinicians. The adult ED at Vanderbilt University MedicalCenter in Nashville, Tennessee, is an academic, urban,Level 1 trauma center with more than 50,000 visits annu-ally. All emergency-medicine attending and resident phy-sicians and full-time nurses were eligible. The ED did nothave a pneumococcal vaccination program, and ED-basedadministration of pneumococcal vaccine for eligible pa-tients was less than 1%. The survey design was approvedby the Vanderbilt University Medical Center InstitutionalReview Board.

Survey Content and AdministrationThe survey was administered during a two-month period(December 2005 to January 2006) before the implementa-

tion of a computerized vaccination-reminder systemin the ED. The survey’s readability was 12th-grade level,as measured by the Flesch-Kincaid index. The studysurvey was designed to elicit emergency physicians’and nurses’ attitudes and behaviors regarding pneumo-coccal vaccination in the ED. The survey was partitionedinto sections and included aspects from previous pneu-mococcal surveys and articles.17,32,37,39,40 The surveyincluded sections on participant demographics, vaccinerecommendation and ordering practices, use of the com-puterized patient record, beliefs on vaccination impor-tance, successful implementation strategies, methods toincrease vaccination rates, factors to consider whenoffering the vaccine, and perceived barriers to adminis-tering the vaccine. Participant demographics and charac-teristics included age, gender, and years in practice sincecertification for attending physicians or level of trainingfor resident physicians. Participants were queried fortheir influenza-vaccination status for the current andprevious flu seasons, because the provider’s own vacci-nation status has been linked to recommendation of vac-cinations to patients.39 To assess participants’ vaccinerecommendation and ordering practices, we collectedthe perceived frequency of recommending and orderingof influenza and pneumococcal vaccination in the ED. Toassess the use of the ED information-technology infra-structure for querying and verifying the patient’s vaccina-tion status, the survey inquired about frequency, location,and timing of workstation use during a patient’s ED en-counter. We collected providers’ opinions on ED patientsbeing up-to-date with the recommended immunizationsschedule for tetanus, influenza, and pneumococcal vacci-nations. We queried providers for preferred implementa-tion strategies for an ED-based vaccination initiative.The final sections asked participants to rate differentapproaches for increasing vaccinations in an ED settingand to rate perceived barriers that may prevent providersfrom offering vaccines to ED patients.

Answers were measured on a five-point Likert scaleranged as one of the following, as appropriate: 1,‘‘Strongly Agree;’’ 2, ‘‘Agree;’’ 3, ‘‘Neutral;’’ 4, ‘‘Disagree;’’or 5, ‘‘Strongly Disagree;’’ or 1, ‘‘Always;’’ 2, ‘‘Usually;’’ 3,‘‘Sometimes;’’ 4, ‘‘Rarely;’’ or 5, ‘‘Never.’’ Space for free-text comments was provided after each section. To helpensure clarity, the survey was pilot tested with threeboard-certified physicians and one resident (from thedepartments of internal medicine and pediatrics).

The survey packet included a cover page; the 46-itemsurvey, which was color-printed on two pages; a nonmon-etary incentive; a handwritten note by the investigators;and an opaque, uniquely numbered, sealable envelope.To indicate that a participant had responded, he or shewas instructed to return the survey in the numbered en-velope. An initial distribution in December 2005 wasfollowed by contacting participants during one of theirshifts during the following month. Before data entry, thesurvey was separated from the envelope, allowing fortracking of nonresponding participants while keepingresponses anonymous. One investigator entered all sur-vey data into a Microsoft Access (Microsoft Corporation,Redmond, WA) database. To examine the accuracy ofdata entry, a randomly sampled 30% of surveys werere-entered by a second investigator and showed high

1314 Dexheimer et al. � ED PNEUMOCOCCAL VACCINATION SURVEY

agreement (weighted kappa for composite agreementwith equal-spacing weights, k = 0.998; 95% bootstrappedconfidence intervals [CI] = 0.994 to 1.0).

Data AnalysisExploratory analysis was conducted to assess the phy-sicians’ and nurses’ beliefs and perceived behaviorsregarding vaccinations, computer use during a patient’sED encounter, barriers to vaccination, successful re-minder-system strategies, and factors influencing vaccinat-ing patients. Descriptive statistics were generated withfrequencies and percentages for binary variables, andmedians and interquartile ranges (IQRs) were gener-ated for continuous or five-point variables. Five-pointvariables were compared between the physician andnurse respondents by using the Mann-Whitney test.Spearman correlation coefficients (r) with their 95% boot-strapped CIs using 1,000 bootstraps were reported forthe associations between five-point survey questions.Responses to influenza and pneumococcal vaccinationswere compared by using a Wilcoxon signed rank test.A probability value of less than 0.05 was considered to bestatistically significant.

RESULTS

DemographicsEmergency physicians returned 64 (96%) of the 67 distrib-uted surveys, and all 93 surveys given to nurses werereturned (100%). Participants’ demographics are shownin Table 1. The median age of physicians was 33 years(IQR = 10), and the median age of nurses was 41 (IQR =18) years. In the 2004–2005 influenza season, 91% ofphysicians (2005–2006 season: 92%) and 61% of nurses(2005–2006 season: 68%) reported receiving vaccination.

Vaccination-ordering PatternsTable 2 displays the median Likert-score answer andIQRs for the survey questions for physicians and nurses.Comparing physicians’ and nurses’ responses with ‘‘rec-ommending patients receive vaccinations outside of theED,’’ nurses were more likely to recommend influenzaand pneumococcal vaccinations than were physicians(p = 0.005 and p = 0.003, respectively). Physicians’ re-sponses to ‘‘recommending influenza vaccination’’ werepositively associated with their responses to ‘‘recommend-ing pneumococcal vaccination’’ (r = 0.74, 95% CI = 0.60 to0.83, p < 0.0001); however, physicians were more likelyto recommend influenza vaccination than pneumococcalvaccination (p < 0.0001). Similar findings were observedfor nurses’ responses (r = 0.68, 95% CI = 0.52 to 0.79,p < 0.0001).

When physicians agreed that it was important forpatients to be up-to-date with recommended vaccina-tions, they tended to recommend influenza (r = 0.32,95% CI = 0.05 to 0.53, p = 0.010) and pneumococcal vac-cination (r = 0.31, 95% CI = 0.06 to 0.53, p = 0.014), butthere was no significant association between the beliefin the importance of being up-to-date and ordering theinfluenza vaccination (r = 0.22, 95% CI = �0.01 to 0.42,p = 0.81). Nurses tended to recommend influenza (r = 0.30,95% CI = 0.09 to 0.49, p = 0.004) and pneumococcal vac-cine (r = 0.35, 95% CI = 0.13 to 0.53, p < 0.001); however,

they did not tend to remind physicians to order influenzavaccination (r = 0.14, 95% CI = �0.08 to 0.31, p = 0.197)when they believed that it was important for the patientsto be up-to-date with vaccination.

Physicians who were more likely to recommend thatpatients receive the pneumococcal vaccination agreed onthe cost-effectiveness (r = 0.36, 95% CI = 0.17 to 0.55, p =0.004) and the importance (r = 0.35, 95% CI = 0.15 to 0.56,p = 0.004) of the vaccine. These results were similar fornurses (cost-effectiveness: r = 0.35, 95% CI = 0.17 to 0.53,p < 0.001; importance: r = 0.36, 95% CI = 0.17 to 0.55,p < 0.001).

If nurses themselves were up-to-date with influenzavaccination, they were more likely to recommend pneu-mococcal (p = 0.02) or tended to recommend influenzavaccination (p = 0.07). However, physicians’ influenza-vaccination status was not correlated with them recom-mending the influenza or pneumococcal vaccine to patients(p = 0.89 and p = 0.90, respectively).

Use of Information TechnologyThe computerized medical record was usually viewed be-fore a visit by both physicians (median = 2, IQR = 1) andnurses (median = 2, IQR = 2). When in the patient’sroom, physicians sometimes (median = 3, IQR = 1) ac-cessed the medical record, whereas nurses usually viewedthe record (median = 2, IQR = 1). Physicians almost alwaysviewed the problem list (median = 1, IQR = 1); however,they accessed the health-maintenance section only some-times (median = 3, IQR = 2) and the immunization sectioneven less frequently (median = 4, IQR = 1). Nurses reportedsimilar usage of the problem list (median = 1, IQR = 1),health-maintenance section (median = 2, IQR = 1), andimmunization sections (median = 3, IQR = 2).

Implementation StrategiesPhysicians and nurses had differing opinions on anoptimal implementation strategy for an ED-based vacci-nation program. Physicians agreed with a nurse standingorder to implement a vaccination program, althoughnurses remained neutral to a nurse standing order (p =0.001). Physicians were neutral with implementing a phy-sician-only order, although nurses agreed with this im-plementation method (p < 0.001). Both physicians andnurses agreed that a successful strategy for implementing

Table 1Participant Demographics

IQR

Attending physicians (n = 37)Age, mean (yr) 40 13Gender, % (female) 27

Resident physicians (n = 27)Age, mean (yr) 31 5Gender, % (female) 65PGY-1 (%) 33PGY-2 (%) 33PGY-3 (%) 30Fellow (%) 4

Nurses (n = 93)Age, mean (yr) 41 18Gender, % (female) 84

IQR = interquartile range.

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Table 2Survey Results

Physicians (n = 64) Nurses (n = 93)

Variable Median* IQR Median* IQR

Recommending patients to receive vaccine outside the EDInfluenza 3 1 3 2Pneumococcal 4 2 3 1

Ordering vaccine during the patient’s ED visitInfluenza 5 1 5 1Pneumococcal 5 1 5 1

Use of information systemView patient information on computer before patient exam 2 1 2 2View patient information on computer in the exam room 3 1 2 1View patient’s problem list 1 1 1 1View patient’s health-maintenance section 3 2 2 1View patient’s immunizations section 4 1 3 2

In the ED population, importance of being up-to-date with immunizationTetanus, without an injury present 2 1 2 1Influenza 2 1 2 1Pneumococcal 2 1 2 1

Believe that pneumococcal vaccination isCost-effective for ED patients 2 2 2 1Important for ED patients 2 2 2 2

Sucessful ED strategies for implementing a vaccine-reminder systemNurse standing order 2 2 3 2Nurse standing order combined with physician notification 2 2 2 1Physician order 3 2 2 2

Methods to increase vaccination rates in the EDPaper-based reminder 3 2 3 1Computerized reminder 2 1 2 1Improved documentation in the electronic medical record 2 0 2 2Feedback on physicians’ vaccination rates 3 2 3 2Patient education 3 1 2 1More ED staff 3 1 2 1Physician-education conferences 3 1 2 1

Important factors to consider when offering vaccination to ED patientsVaccine effectiveness 2 1 2 1Patient’s risk for illness 2 1 1 1Vaccination adverse effects 2 1 2 1Antimicrobial resistance 2 1 2 1Recommendation from experts 2 1 2 1Patient’s request or interest for vaccine 2 1 2 1Determining patient’s vaccine status directly from patient 2 1 2 1Determining patient’s vaccine status in the electronic medical record 2 1 2 1

Barriers to offering vaccination to ED patientsRemembering to offer vaccination 1 1 2 1Difficulty in identifying high-risk patients 2 1 2 1Insufficient time to counsel 2 1 2 1Too busy with other tasks 2 1 2 2ED is inappropriate setting 4 1 3 2Cost or reimbursement 3 2 3 1Inadequate ED personnel 3 1 3 2Medicolegal liabilities 3 1 3 1

IQR = interquartile range.

* Median score on five-point Likert scale.

a pneumococcal vaccination-reminder system wouldinclude a combination of a nurse order with physiciannotification before administration (p = 0.243).

FactorsWhen asked about important factors to consider whenoffering the vaccination to ED patients, physicians andnurses agreed that all the mentioned factors were rele-vant. The strongest factor for nurses to consider wasthe patient’s risk for illness (nurses: 1, IQR = 1).

BarriersPhysicians and nurses agreed that remembering to offerthe vaccination to eligible patients (physicians: median = 1,IQR = 1; nurses: median = 2, IQR = 1), being too busy withother tasks (physicians: median = 2, IQR = 1; nurses: me-dian = 2, IQR = 2), having insufficient time to counsel pa-tients (median = 2, IQR = 1 for both), and difficulty inidentifying high-risk patients (median = 2, IQR = 1 forboth) were major barriers to offering vaccines to EDpatients.

1316 Dexheimer et al. � ED PNEUMOCOCCAL VACCINATION SURVEY

DISCUSSION

Offering pneumococcal vaccination in the adult ED mayhelp to boost overall vaccination rates. However, in astudy testing the feasibility of an ED-based vaccinationprogram, only 51% of 128 emergency physicians indi-cated a willingness to provide pneumococcal vaccinationto their patients, and 93% indicated that they had neverordered or given the vaccine in the ED.32 Common rea-sons for failing to offer preventive care included clinicianbeliefs that the ED was an inappropriate place for pre-ventive-care measures or that time or personnel werelacking as well as concerns about adverse reactions. Incontrast, another study found that 89% of eligible pa-tients were willing to receive the pneumococcal vaccina-tion while in the ED.41 Referring patients outside the EDfor pneumococcal vaccination may be conceived as a po-tential solution to overcome existing barriers but was notan effective measure for increasing vaccination rates.42

The results of the survey indicate that physicians in ourED are willing to vaccinate patients during the ED visitbut may not have enough time, may be too busy, ormay not remember to offer the vaccination during thevisit. A nurse order combined with physician notificationbefore administration was the most preferred implemen-tation approach by both physicians and nurses. Despiterecommendations that standing orders be used, ED staffpreferred a combined approach that would share re-sponsibilities in the pneumococcal vaccination process.These findings are critical to assist in the developmentof an ED-based vaccination program, because provideracceptance of the tool is a primary determinant of theintervention’s success.

LIMITATIONS

Our survey is limited because we targeted physicians andnurses from one academic center, which may differ fromvaccination practices and beliefs in other ED settings.Although the survey was performed as a readiness-assessment study before implementation of a computer-ized reminder system in an ED that has access to variousinformation systems, we believe that nurses’ and physi-cians’ reported attitudes of pneumococcal vaccinationpractices are similar to those in other ED settings. Fur-ther, our study was limited to associations among self-reported beliefs, attitudes, and behaviors of clinicians.Subjective report might represent overconfidence in thebehaviors and beliefs of clinicians, but this can only beremedied by using objective data collection. The missingpercentage of each survey question is at most 5% forboth physicians and nurses; the complete case analysiswas implemented in the statistical analysis.43 The singleimputation, however, was also conducted (data notshown) by imputing the median of nonmissing values forcontinuous variables and the most frequent category forcategorical variables, and the conclusions remain thesame. This survey is an exploratory study, and no multiplecomparisons were adjusted in the analysis. We were notable to examine associations with pneumococcal vaccineadministration as an outcome, because administration ofthe vaccine in our ED is extremely rare, reflecting the

national trend of low ED-based pneumococcal vaccina-tion practices.31

CONCLUSIONS

In summary, physicians and nurses did not differ signifi-cantly in many of their beliefs and practices regardingpneumococcal vaccination. Overall, ED staff had mostlyfavorable beliefs and attitudes toward vaccinating ED pa-tients and believed that it is important and cost-effective.However, various barriers encountered in and character-istics of the ED setting appear to hinder ED staff fromproviding the recommended preventive-care measureduring an ED encounter. Applying information technol-ogy to overcome existing barriers may facilitate moreefficient ED-based vaccination initiatives.

The authors thank Pam Chunn for helping in the consent, surveyadministration, and survey collection process.

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