Tdap Education and Adminstration Program for Postpartum Mothers

State: MO Type: Model Practice Year: 2010

Pertussis, or whooping cough, has reemerged in adolescents and adults due to the waning immunity of childhood vaccines, subsequently increasing the risk of transmission to susceptible populations, particularly infants. Pertussis in infants can lead to severe complications, increased hospitalizations, and death. The pertussis booster, Tdap, was licensed in 2005 and recommended for use on adolescents and adults ages 11-64 to prevent pertussis and extend immunity. Decreasing pertussis incidence would decrease the risk of exposure and illness in susceptible infants and the general population; however, many adults, including new parents, are not receiving education from providers and therefore are not getting the Tdap vaccine. Goal: Increase Tdap vaccination rates among postpartum women. The use of Tdap vaccine is high priority among public health agencies and should be a high priority in healthcare facilities, especially for new mothers in the immediate postpartum period. A Tdap Education and Administration Program integrated in healthcare facilities would prevent pertussis among adults and adolescents and thus protect the health and safety of infants and the population at large. A recommended program is to provide Tdap education to health care providers and patients and support administration of Tdap vaccine to household contacts of infants, specifically women of childbearing age and new mothers in the immediate postpartum period. Tdap vaccination rate increased; prior to September 2008 the immuization rate was 0%; from September 2008 to December 2008 the rate was 27%; from September 2009 to December 2009 the rate increased to 35%. Nursing staff report a “very positive” response to the program among patients and staff 100% of patients receive education on pertussis and are screened for and offered Tdap Posters and brochures are available on the unit 100% of OB and nursery staff are educated on pertussis and Tdap OB and nursery staff are also vaccinated with Tdap vaccine
Despite high vaccination coverage among infants, pertussis continues to circulate in communities and cause infections. Though pertussis is preventable through vaccination, immunity wanes after five to 10 years causing adolescent and adult populations to be vulnerable to pertussis. Decreasing pertussis incidence among adolescents and adults, especially household contacts, could decrease the risk of exposure and illness to susceptible infants. The risk for severe pertussis and complications is highest among infants during the first six months of life and remains elevated until infants have received one to two doses of pediatric DTaP. Infants that are not fully protected from pertussis are at the highest risk for complications including pneumonia and hospitalizations. Infants under 12 months of age make up 19% of cases and 92% of pertussis deaths in the US from 2000–2004. Though there has been high vaccination for the primary series of infant immunizations, pertussis incidence in the infant population has increased from 34.2 cases per 100,000 in the 1980s to 103.5 cases per 100,000 in 2003 (Wendelboe et al., 2007). Since the pertussis vaccination became available in the 1940s, incidence decreased by 80%. However, since the 1980s, pertussis has been slowing increasing, especially among adolescent and adult populations due to waning immunity of childhood vaccines. Additionally, adolescents and adults with pertussis frequently are misdiagnosed leading to multiple medical visits, prolonged infectious periods, and increased potential of transmission to infants and the population. According to the CDC (2006), attack rates among household contacts exposed to pertussis with no immunity can be up to 80-90%. In a study from 1999–2002, 57% of pertussis exposures in infants was unknown; however, 32% of cases were identified as the mother, father, sibling, or grandparent (CDC, 2006). Studies reported by the Texas Children’s Hospital (2008) revealed that greater than 75% of infants get pertussis from infected family members. Results of multiple studies support the need for high rates of Tdap vaccination coverage among adult and adolescent populations in order to protect infants.Pertussis cases continue to be reported in the Independence community and surrounding areas, despite vaccination. Cases are seen in all ages with varying circumstances. Cases have been reported in infants too young for vaccination with a household contact that has had a prolonged cough. Ongoing outbreaks have been reported among adolescents in the local middle school due to their waning immunity. Adults have been diagnosed several weeks after having a cough, been misdiagnosed, and now potentially exposed numerous people and children. Many adolescents and adults do not believe they are at risk for pertussis because they were vaccinated as children. This practice provides the opportunity for education so new parents understand that they are susceptible to pertussis and that by vaccinating themselves, they are protecting their new susceptible infants. This practice addresses the issue by providing education to all postpartum women, as well as the OB staff. New families are educated on pertussis infection, transmission, risk factors, high risk groups, and vaccination. Every new mother will be screened for Tdap vaccine after delivery, and if eligible, vaccination will be provided before they leave the hospital. Pertussis in infants can lead to severe complications, increased hospitalizations, and death. Many women of child bearing age and new mothers are not receiving education from providers regarding Tdap vaccine. Tdap vaccine could be provided to these populations to extend immunity and therefore protect infants. Tdap was licensed in 2005 and recommended for use in adolescents and adults ages 11-64 to prevent pertussis which would decrease exposure to the infant population and decrease healthcare costs (CDC, 2006). Tdap has been recommended for conta
Agency Community RolesThe health department identified the problem and proposed development of new policy. The Independence Health Department took the lead in the review of CDC recommendations and current literature to support a policy change for the routine administration of Tdap vaccine to postpartum mothers at the local hospital. The health department partnered with the local university for access to the library in order to obtain current literature and evidence based strategies from peer reviewed nursing and public health journals. The health department also partnered with the Association of Professionals in Infection Control and Epidemiology (APIC) to survey metropolitan hospitals for their practices and policies related to Tdap. The health department compiled all of the information into a concise format and presented it to OB/GYN physicians, nursing and support staff, pharmacy and other policy makers at the hospital. After the policy change was implemented, the health department provided educational materials for patients and nursing staff. The health department has worked to collect data from the hospital on number of births and number of Tdap doses given for purposes of evaluation. The health department also monitors pertussis incidence in the community and state wide. The local hospital welcomed the health department into the quarterly OB meeting, coordinated the presentation and ensured adequate time was available to present and for questions. The hospital physicians and nursing staff were ultimately responsible for the final decision of whether to implement the proposed practice change into policy. Since they were in agreement, they wrote the new standing ordered and ensured appropriate hospital officials were aware of the change. The nursing staff is responsible for providing the education to each patient, screening patients, and administering vaccine. The hospital pharmacy staff provides the data on doses of Tdap given to the health department and the OB Director provides data on number of deliveries for a given time period. Costs and ExpendituresThe Independence Health Department took the lead in the policy change to routinely offer Tdap vaccination to postpartum women. The health department reviewed and compiled CDC recommendations and literature to support a policy change for the routine administration of Tdap vaccine to postpartum mothers at the local hospital. Current literature was reviewed for evidence based strategies with the support of the local univeristy library. In June 2008, the health department presented this information to OB/GYN physicians, nursing and support staff, pharmacy, infection control, and other policy makers at the hospital. Subsequently, in September 2008, a policy change occurred to include routine education and administration of Tdap vaccine to postpartum mothers as a part of standing orders. Public health staff time is provided through the City's General Revenue. Communicable disease investigations and prevention activities are a part of City Charter and therefore fully supported by the City. Vaccine is provided by the local hospital and is reimbursed through their routine reimbursement protocols. ImplementationThe first task by public health was to research CDC recommendations and current evidence based literature on pertussis in healthcare settings and in infants, as well as the routine postpartum administration of Tdap. Because of the ongoing relationship with the local university, access was provided to the library and pertinent nursing and public health journals. Next, through the literature as well as pertussis incidence in the community, the health department identified infants as a vulnerable population. Studies and outcomes of similar programs implemented in acute care facilities were reviewed. Other hospitals in the region were surveyed by the health department for their current practices related to routine Tdap administration and/or pertussis prevention education on OB units. The health department then contacted the Infection Control Practitioner at the hospital and requested a meeting with her and the OB Director. At that initial meeting, research findings and public health concerns were addressed. The health department then requested to be included on the agenda for the next OB staff meeting. After that brief meeting and gathering all of the above information, the health department developed a one page, concise fact sheet for review by the meeting attendees. In attendance were the OB physicians, OB nursing staff, pharmacy, Infection Control, and other hospital policy makers. The health department presented the findings at their quarterly OB meeting and answered multiple questions. Support was gained from the OB physicians and staff and Tdap administration became a part of standing orders. After the approval, the health department ensured education of the nursing staff. Nurses were provided with verbal education as well as a poster and booth at the employee health fair. The booth provided them information on symptoms of pertussis, severity and impact on infants, who should get vaccinated, screening process for all patients, how to educate patients, and how to administer Tdap vaccine. The health department also provided brochures for the hospital to distribute. The health department follows up with the hospital at least quarterly to assess educational needs, address needs for educational materials, and to obtain birth and Tdap doses administered data. In the spring of 2008, discussions began between public health and the hospital regarding their current practices related to Tdap administration. When it was identified that the hospital does not provide this service, the public health department led the research and asked for time to present the issue to the OB staff. Since the next meeting was to be held in June 2008, this allowed for 2 months of time for research and compilation of data. The policy change was effective September 2008. Education of nursing staff occurred during July and August 2008 prior to the policy going into effect. This allowed ample time to educate all staff.
Increase Tdap immunization rates among postpartum women. Educate physicians, OB nursing staff, pharmacy and hospital decision makers on the identified problem and the risk of pertussis to infants, CDC recommendations, and the proposed use of Tdap vaccine.Survey other metropolitan hospitals for their polices and protocols for Tdap administration by April 2008. Research/literature review completed and compiled into a concise document by May 2008. Attend meeting of the OB physicians, OB nursing staff, pharmacy, infection control and other hospital policy makers by June 2008 (present findings and recommendations at meeting). Ensure implementation of policy change by September 2008 Ensure nursing staff education by September 2008 Collect data on births and Tdap doses administered quarterly. Data for evaluation is collected from the OB department and the pharmacy. The OB department reports the total number of births quarterly. They pharmacy reports the total number of doses of Tdap administered by the OB department. The health department collects data on the number of pertussis cases reported and investigates for the source of infection. Data on births and Tdap doses administered is collected quarterly throughout the calendar year. Data on pertussis cases is available daily, but reviewed for trends monthly.Data is shared with the hospital, OB physicians and staff, and other local hospitals and health departments though participation in APIC (Association of Professional in Infection Control and Epidemiology). Lessons learned include appreciating the value of already strong working relationships in order to get a goal accomplished. Coming to the OB meeting as a public health representative, simply there to improve the health and safety of patients and their families, was seen by the hospital staff as non-threatening and encouraging, and as a true voice for public health.Another lesson learned and continuing challenge is getting accurate birth data. The data the OB department can provide is simply the number of births, not the number of women eligible for Tdap. There data does not account for those that have already been vaccinated, have contraindications, etc. Therefore, compliance rates are actually greater than reported. Short term outcome: Policy change to include Tdap education and administration as a part of standing OB orders Short term outcome: increased knowledge of Tdap vaccine among patients, families, OB physicians, and nursing staff. Short term outcome: increased knowledge of pertussis infection among patients, families, OB physicians, and nursing staff. Short term outcome: Increase in Tdap vaccination rates and education among patients Intermediate term outcome: Strengthened relationship between the local health department and the OB physicians and nursing staff. Intermediate outcome: Increase Tdap education and immunization rates among OB staff Long term outcome: Decrease in pertussis incidence in the community All outcomes were intended.
Commitment by the hospital is ensured because, after being presented the facts by public health, they agreed with the proposed policy change and made Tdap administration a routine order for all patients. The hospital committed to this policy change; this is not a trial or pilot project. Communicable disease prevention is a core function of the health department and will remain our commitment. This policy change has been incorporated into the postpartum standing orders. Key stakeholders attending the OB meeting made the decision that this was a worthwhile policy change and therefore committed to it as a routine order for all patients. Financial costs to public health and the hospital would be minimal. Public health is committed to disease prevention, community education and partnership building with the hospital and will maintain those responsibilities.