Influenza and pneumococcal vaccination in the emergency department

Influenza and Pneumococcal Vaccination in the Emergency Department:

Is It Feasible?

KEITH WRENN. MD, MARIE ZELDIN, RN, OTIS MILLER. BA

Objective: To assess the numbers of high-risk adult patients presenting to the emergency department (ED) who have not been vaccinated against itlfluenza or pneumococcal disease and whether emergency physicians are willing or able to routinely provide vaccination. Design: A survey of patients in the ED considered to be at high risk for morbidity and mortality from influenza or pneumococcal disease; an anonymous, mail-back survey of emergency physicians. Setting: The ED of a university-affiliated hospital with an annual census of 50,000 patient visits. Participants: A convenience sample of adult patients visiting tile ED for any complaint who fulfilled the American Thoracic Society and Centers h/r Disease ( 'ontrnl and Prevention requirements as a high- risk patient requiring vaccination with influenza or pneumococcal vaccine. The physicians surveyed were identified from the membership role of the state chapter of the American College of Emergency

Physicians. Measurements: 1 ) Influenza and pneumococcal vaccination rates fur high-risk patients presenting to an ED during influenza season; 2) reasons for lack of immunization; 3) patient willingness to be vaccinated in the ED; 4) vaccination practice patterns for ED physicians; and 5 ) reasons why ED physicians are unwilling to give these vaccines. Results: 212 high-risk patients were surveyed. 57% and 75% of these patients reported not having received the influenza vaccine and the pneumococcal vaccine, respectively. The main reasons for not being immunized included not being informed they needed it, a prior adverse reaction, and procrastination. Of the unvaccinated patients, 54% were willing to be vaccinated in the ED. Of the surveyed ED physicians, 89% and 93% never or rarely gave influenza and pneumococcal vaccines, respectively. 51% of the ED physicians were willing to give the vaccine. Unwillingness stemmed mainly from: 1 ) the perception that ED physicians are not primary care providers, 2) inadequate time or personnel; and 3) concerns about adverse reactions or medicolegal liability. Only 5% of the physicians reported organized case-finding mechanisms in their EDs. Conclusion: Significant numbers of high-risk patients who are tmim- munized against influenza and pneumococcal pneumonia present to the ED. There is hesitancy among ED physicians about assuming the primary care task of providing such immunizations. Any attempt to institute a large-scale vaccination program in an ED setting needs to be carefully planned in a way to involve primary care providers and to decrease ED physician concerns and reluctance. Key words: emergency services; influenza; pneumococcus; vaccination.

J GEN INTERN MED 1994;9:425-429.

THE INFLUENZA AND PNEUMOCOCCAL POLYSACCHARIDE VAC-

CINES are r e c o m m e n d e d for r o u t i n e use in ce r ta in high- risk g roups a m o n g w h o m c o n s i d e r a b l e e x c e s s mor t a l i t y occurs every year. 1 This includes all pat ients wi th chronic lung o r ca rd iovascu la r disease, d iabetes , rena l failure,

Received from the Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.

Address correspondence and reprint requests to Dr. Wrenn: De- partment of Emergency Medicine, Vanderbilt University Hospital, 703 Oxford House, Nashville, TN 37232-4700.

h e m o g l o b i n o p a t h y , o r i m m u n o s u p p r e s s i o n . Addi t ion- ally, all p e r sons ove r the age of 65 years, a m o n g w h o m most of the excess morbid i ty and morta l i ty occurs, should r ece ive these vaccines . 2-4

It was a na t ional o b j e c t i v e to vacc ina te at least 60% of high-r isk g roups by the yea r 1990. ~ Desp i te w i d e p romu lga t i on o f vacc ine r e c o m m e n d a t i o n s , this goal still remains unfulfil led. 6-16 It is c u r r e n t l y r e c o m m e n d e d by

the Centers for Disease Con t ro l and P reven t ion ( C D C ) that ce r ta in hea l th ca re se t t ings shou ld be t a rge t ed as si tes for ident i fy ing and admin i s t e r ing these vaccines , inc luding ou tpa t i e n t c l in ics and phys ic ians ' o l~ces , nurs- ing h o m e s and o t h e r res iden t ia l l ong- t e rm ca re facilit ies, acute ca re hospi ta ls , and faci l i t ies p rov id ing ep i sod i c o r acute care ( e . g , e m e r g e n c y d e p a r t m e n t s [EDs] and walk- in cl inics) . 2

This s tudy was u n d e r t a k e n no t on ly to assess the adequacy of p r i m a r y hea l th ca re de l ive ry of inf luenza

and p n e u m o c o c c a l vacc ines to high-r isk g roups present ing to EDs, bu t also to assess the wi l l ingness of ED physic ians to rou t i ne ly p r o v i d e these vaccines .

MATERIALS AND METHODS

From January 1 to March 31, 1993, a c o n v e n i e n c e sample of all adu l t pa t i en t s c o n s i d e r e d to fall in to a g r o u p at high risk for i nc r ea sed m o r b i d i t y or mor ta l i t y f rom influenza o r p n e u m o c o c c a l d isease and w h o c o n s e n t e d to an in t e rv i ew w e r e s u r v e y e d w h i l e in the ED for any complain t . Pa t ien ts w e r e c o n s i d e r e d to be at h igh risk if they me t any of the c r i t e r ia set for th by the Advisory C o m m i t t e e on I m m u n i z a t i o n Prac t i ces 2, ~ o r the Amer- ican Thorac ic Society. ~ Con t r a ind ica t ions to vacc ina t ion w e r e no t speci f ica l ly sought , a l though pa t i en t s w h o refused vacc ina t ion w e r e asked w h e t h e r they had had a p r io r react ion . The su rvey was c o n c l u d e d by a r e sea rch nurse o r a me d i c a l s t u d e n t d e d i c a t e d to the study. To e l imina te the poss ib i l i ty o f s e l ec t ion bias, i n t e rv iews oc- c u r r e d on the same day each w e e k and on the same shift each day, w h i c h w e r e d e c i d e d p r i o r to s ta r t ing the s tudy. I tems f rom the su rvey ques t i onna i r e i n c l u d e d age, gender, race, r isk factors , i n su rance status, w h e t h e r the pa- t ient had a p r ima ry ca re p rov ide r , the type o f p r ima ry ca re p rov ide r , w h e t h e r t he pa t i en t had r e c e i v e d the influenza vaccine wi thin the p reced ing six months, whe the r

the pa t i en t had eve r r e c e i v e d the p n e u m o c o c c a l vaccine, the reasons for no t r ece iv ing the vacc ine , and w h e t h e r the pa t i en t w o u l d be wi l l ing to r e ce ive the

425

426 Wrenn et al., ED VACCINATION

vaccine in the ED. All unvaccinated patients were re- ferred to a pr imary care setting for vaccination because vaccines were not available in the ED at the t ime of the study.

In addition, a survey was mailed to all 258 physicians belonging to the Tennessee Chapter of the Amer- ican College of Emergency Physicians (ACEP). This survey included quest ions about how often the respondent gives influenza or pneumococca l vaccine in the ED, whether an organized case-finding mechanism for ad- ministering such vaccines exists in their EDs, whe the r they would be will ing to rout inely give these vaccines, why they would not be willing, and demographic data

TABLE 1

Demographic Data for the High-risk Patients

No No Influenza Pneumococcal

Total Vaccine Vaccine (n = 212) (n = 121) (n - 60)

Gender Male Female

Race White Black Asian Hispanic

Risk Age >65 years Diabetes Chronic lung disease Chronic cardiovascu-

lar disease Malignancy Immunosuppression Renal disease Other Hemoglobinopathy

Insurance Medicare + private Private Medicaid Medicare + Medicaid Medicare None

Primary care provider Internal medicine Subspecialty clinic None Family practice Gynecology Surgery

Age range 20-29 years 30-39 years 40 49 years 50-59 years 60-69 years 70 79 years 80-89 years 90-99 years

85 (40%) 47 (55%) 127 (60%) 74 (58%)

67 93

(79%) (73%)

122 (58%) 58 (48%) 91 (75%) 85 (40%) 63 (74%) 59 (69%)

2 (1.5%) 0 (0%) 1 (50%) 1 (0.5%) 0 (0%) 1 (100%)

45 (21%) 26 (58%) 34 (76%) 42 (20%) 24 (57%) 33 (79%) 34 (16%) 19 (56%) 26 (76%)

33 (t6%) 20 (61%) 25 (76%) 25 (12%) 17 (68%) 20 (80%) 16 (8%) 6 (38%) 11 (69%) 8 (4%) 5 (63%) 6 (75%) 6 (2%) 3 (50%) 4 (67%) 2 (1%) 1 (50%) 1 (50%)

49 (24%) 27 (55%) 34 (69%) 47 (23%) 31 (66%) 38 (81%) 44 (22%) 27 (61%) 38 (86%) 36 (18%) 18 (50%) 27 (75%) 15 (7%) 7 (47%) 11 (73%) 13 (6%) 11 (85%) 13 (100%)

142 (68%) 76 (54%) 106 (75%) 31 (15%) 15 (48%) 21 (68%) 20 (9%) 17 (85%) 19 (95%)

9 (4%) 8 (89%) 9 (100%) 4 (2%) 3 (75%) 3 (75%) 4 (2%) 2 (50Olo) 2 (50%)

17 (8%) 12 (71%) 14 (82%) 30 (14%) 20 (67%) 24 (80%) 28 (13%) 18 (64%) 24 (86%) 19 (9%) 9 (47%) 15 (79%) 42 (20%) 18 (43%) 28 (67%) 42 (20%) 22 (52%) 29 (69°6) 25 (12%) 17 (68%) 18 (72%)

9 (4%) 5 (56%) 8 (89%)

about the annum census of the ED and the type of hospital with which it is associated.

This study was approved by the Commit tee for the Protect ion of Human Sub jec t s -Hea l th Sciences of the Institutional Review Board. Correlat ions were ascer- tained using Fisher's exact test or odds ratios. Compar- isons of populat ions we re done using the chi-square test.

R E S U L T S

Demographic data for the 212 high-risk patients surveyed are included in Table 1. This number of patients represents almost 18 patients for each survey period of eight hours. A total of five eligible patients refused to be interviewed. Other eligible pat ients who were not interviewed either were too sick or were unable to be interviewed because of al tered mental status or a lan- guage barrier. The average total number of high-risk patients seen in the ED for the eight-hour shift during which interviews occur red was 24. The mean age of the survey group was 59 years (SD 20, range 2 0 - 9 8 ) .

Among the surveyed patients, 121 (57%) had not received the influenza vaccine within the preceding six months and 160 ( 7 5 % ) repor ted never having received the pneumococcal vaccine. Of those patients 65 years of age or more, 56% had not rece ived the influenza vaccine and 73% had not received the pneumococcal vaccine. Of those less than 65 years of age, 60% had not received the influenza vaccine and 80% had not received the pneumoeocca l vaccine. The reasons unvaccinated patients had not received the vaccine are listed in Table 2.

Of the patients who had not received the influenza vaccine, 56 ( 4 6 % ) were willing to be vaccinated in the ED. Of the patients who had not received the pneumococcal vaccine, 84 ( 5 3 % ) w e r e willing to be vaccinated in the ED. Overall 54% of all the unvaccinated patients were willing to be vaccinated with one or the other vaccine in the ED. Those patients who had not been told about the vaccines or who had not gotten around to being vaccinated represented 97% of the patients willing to be vaccinated in the ED.

Demographic data about the ACEP physicians surveyed appear in Table 3. Fifty percen t (128 ) of the surveyed physicians responded from at least 35 different ED settings. When the survey respondents are compared with the total ACEP membersh ip according to their practice settings (urban, suburban, and rural), there is no significant difference ( p = O. 105). Sixty-two respondents (48%) were from ED settings associated with the training of resident physicians.

Eighty percent of the physicians repor ted "never" giving the influenza vaccine in their practices, while 9% reported giving the vaccine "rarely" (less than once per year), 9% "occasionally" (more than once per month), and 2% "often" (more than once per week). For the pneumococcal vaccine, 71% repor ted never giving it,

JOURNAL OF GENERAL INTERNAL MEDICINE, Volume 9 (August). 1994 427

TABLE 2

The Unvaccinated Patients' Reasons for Not Being Vaccinated

Reason

No No Influenza Pneumococcal Vaccine Vaccine

(n = 121) (n = 160)

Not told they needed vaccination 73 116 Prior vaccination made them ill 24 22 Had not yet gotten around to it 17 16 Unspecified 7 6 Expense 0 0

23% gave it "rarely" (usually before emergency sple- nectomy), 5% gave it "occasionally," and 1% gave it "often."

Only six physicians (5%) reported an organized case-finding mechanism in their EDs. The reported case- finding mechanisms included: 1 ) the triage nurse asked everyone at risk (3 EDs); and 2) other health care providers (physicians, nurses, and patient care technicians) asked everyone at risk (4 EDs).

Sixt3,-seven (52%) ED physicians were willing to routinely give these vaccines to patients. The reasons given by physicians who were reluctant to give these vaccines in the ED are included in Table 4. Most of these reasons were voiced by physicians unwilling to give vaccines, but ten physicians who said they were willing to give these vaccines in the ED also expressed reasons they were hesitant. There was no statistically significant correlation between physician responses and the annual census of the ED, the type of ED, or the university af- filiation (p > 0.05 for all variables).

D I S C U S S I O N

Influenza and pneumococcal vaccine administra- tions are, to some extent, markers of the adequacy of primary care preventive health delivery. Patients who use EDs are often in high-risk groups or do not have primary care providers. It would seem then that the ED would be an ideal place to bolster the acknowledged failure of this aspect of preventive care in this country. Successful hospital-based vaccination programs have been described that supplement the major providers of vac- c ina t i on -ou tpa t i en t clinics and private o f f i c e s . 7" 17, 18 Three studies have shown the feasibility of an ED-based program.8, m. 20 In one study, however, only 34% of el-

• 91 igible patients in one ED were vaccinated.- There are three major components to a successful

ED-based immunization policy• First, to be time- and cost-effective, there should be adequate numbers of un- immunized high-risk patients. Second, ED physicians need to be willing to administer the vaccines. A third hurdle involves devising a case-finding mechanism for unvaccinated high-risk patients.

In the case of adequate numbers of unvaccinated high-risk patients, this study shows that influenza and

pneumococcal vaccine rates fall far below the objectives stated by the CDC. In previous studies spanning the last two decades, the influenza vaccination rates for high- risk patients have varied from 20% to 48% and the pneumococcal vaccine rates from 7% to 37%.6-14

The reasons for failure of vaccination fall into sev- eral groups: 1) failure to disseminate guidelines and rationale to all primary care physicians; 2) failure of physicians to put their knowledge into practice; 3) lack of access of patients to a primary care provider; 4) procrastination or reluctance on the part of patients; and 5) i n a d e q u a t e r e i m b u r s e m e n t ra tes for vaccines.l~, 16.22.23 This failure has occurred despite con- siderable evidence that the vaccines are cost-effective and safe. 1

In this study looking at a sample of patients from an urban ED with an annum census of almost 50,000 patient visits per year, 57% of the high-risk adult patients had not received influenza vaccinations within the prior six months and 75% reported never having received the pneumococcal vaccine• This occurred despite the fact that 80% of these patients were able to identify a primary care provider. The sampling period, January through

TABLE 3 Demograhic Data for the Emergency Department (ED)

Physicians Surveyed

Survey Respondents

(n = 128)

Annual ED census (thousands of visits)

O- 10 4 (3%) 11 20 14 (11%) 2 1 - 3 0 32 (26%) 3 1 - 4 0 26 (20%0) 4 1 - 5 0 24 (19%) 5 1 - 6 0 17 (14%) 61 70 8 (6%)

>70 1 (1%)

Total ACEP* ED setting Membership

Urban 66 (58%) 104 (46%) Suburban 30 (26%) 82 (36%) Rural 18 (16%) 39 (17o/0)

*ACEP = American College of Emergency Physicians.

TABLE 4 Reasons the Emergency Department (ED) Physicians (n = 77) Were

Unwilling to Provide lnfluenza/Pneumococcal Vaccine Routinely

ED physicians are not primary care providers Inadequate time or personnel Concerns about adverse reactions/medicolegal liability Concern about cost of vaccines Competition with non-ED medical staff Unable to document prior immunization No structured protocol for vaccination

50 (65%) 39 (51o/o) 22 (29%) 13 (17%) 2 (3%) 2 (3°/0) 1 (1o/0)

*Total of percentages > 100 because many respondents gave more than one reason.

428 Wrenn et aL, ED VACCINATION

March, was p r o b a b l y the highest - r isk p e r i o d for inf luenza morb id i t y and morta l i ty . These resul ts are s imilar to t h o s e o f p r e v i o u s l y p u b l i s h e d s u r v e y s o f ED patients.8, tg. 20 It w o u l d s eem then that adequa te n u m b e r s

of unvacc ina t ed high-r isk pa t i en t s are seen in ED settings, so that a r ou t i ne vacc ina t ion po l i cy might be bo th cost-effect ive and t ime-effect ive. The benef i ts of vaccina t ion in the ED inc lude no t on ly e x p a n d i n g the numbers of vacc ina ted high-r isk pa t i en t s bu t also p r e v e n t i o n of subsequen t ED visits and hospi ta l iza t ions f rom these po ten t ia l ly p r e v e n t a b l e i l lnesses.

The CDC has r e c o m m e n d e d that EDs shou ld be among the t a rge t ed se t t ings p rov id ing influenza vaccine. 2 Despi te this r e c o m m e n d a t i o n , it is c lear that many

e m e r g e n c y phys ic ians d o no t c o n s i d e r the ED a p r o p e r set t ing for the p rov i s ion of this p r even t i ve p r imary care. They also w o r r y that t he re is i nadequa te t ime o r personnel for case f inding and vacc ine adminis t ra t ion . Fur-

the rmore , t he re is s ignif icant c o n c e r n abou t adverse re- ac t ions and m e d i c o l e g a l l iabil i ty. Finally, ED vacc ina t ion is l ikely to be m o r e e x p e n s i v e than vacc ina t ion in a pr imary care setting. Most EDs are not present ly equ ipped

wi th case-f inding m e c h a n i s m s for inf luenza and pneu- m o c o c c a l vacc ina t ion and this p r o b l e m w o u l d n e e d to be careful ly w o r k e d out. T h e r e is, however , a p r e c e d e n t to case f inding in the ED. It is the s tandard of ca re in most EDs to ask high-r isk pa t i en t s (i.e., those wi th t r auma or l ace ra t ions ) abou t t e tanus immuniza t ion , even t hough te tanus is a ra re disease. A l ikely m e c h a n i s m for vaccinat ion case f inding w o u l d involve using tr iage p e r s o n n e l as the initial ques t ioner , w i th b a c k u p by phys ic ians and nurses in the ED as a fail-safe ins t rument . As par t o f this case-f inding process , it w o u l d be impor t an t to ensu re that patients wi th contra indicat ions to vaccine (e.g., p r ior al lergy o r f eve r ) no t be vacc ina ted . Per iod ic r ev i ew of the efficacy of such a p r o g r a m w o u l d n e e d to be done , pe rhaps by a hosp i ta l ' s o r an ED's infec t ion con t ro l p ro- cess.

A specif ic p r o b l e m that conf ron t s ED phys ic ians is the poss ib i l i ty that pa t i en t s may be unaware o r may have fo rgo t ten that they w e r e vacc ina t ed prev ious ly . This may be t rue espec ia l ly for the p n e u m o c o c c a l vaccine, w h i c h may have b e e n g iven r emote ly . In a s tudy of ch i ldren , pa ren t s p r o v i d e d a c c u r a t e i m m u n i z a t i o n h is tor ies on ly about 65% of the t ime. 24 Physic ians may also be p o o r

at r e m e m b e r i n g the admin i s t r a t ion of vacc ines for spe- cific pat ients . 2~ Al though s o m e au thors be l i eve r e p e a t vacc ina t ion w i th e i the r of these agents ( e spec ia l ly the p n e u m o c o c c a l v a c c i n e ) m a y resul t in an inc reased in- c idence of adverse affects, the ma jo r i ty of adverse re- ac t ions are local and u n c o m m o n , and mos t e x p e r t s feel that r evacc ina t ion is b e t t e r than no vacc ina t ion in high- risk groups w h e n vacc ina t ion status is uncer ta in . 25-28

A m e t h o d of r e p o r t i n g such ED vacc ina t ions to primary care p rov ide r s is impor tan t . Pr imary ca re p r o v i d e r s in an area se rved by an ED mus t also accep t the c o n c e p t of ED vaccinat ion. In one s tudy, 52% of p r iva te physi-

clans refused ED vacc ina t ions for the i r pat ients . 2 t In fact, two g roups of phys ic ians m a d e b lanke t r eques t s that thei r pa t ien ts no t be va c c ina t e d in the ED b e c a u s e they rou t ine ly gave the vaccine . In teres t ingly , howeve r , 61% of those g roups ' pa t i en t s had no t be vacc ina t ed w h e n they w e r e seen in the ED. 21

The issue of e c o n o m i c c o m p e t i t i o n w i th p r iva te p rac t i t i one r s shou ld no t be a large p r o b l e m b e c a u s e these vacc ines d o no t r e p r e s e n t p rof i t ab le i t e m s ) 6.21

W h e t h e r ED vacc ina t ion w o u l d de l e t e r ious ly f r agment heal th ca re de l ive ry is unknown, bu t if the sys tem is no t working, the re shou ld no t bc bar r ie r s to the r e c e i p t of vaccines, z9 "Each e n c o u n t e r w i t h a hea l th ca re p rov ide r , inc luding an e m e r g e n c y d e p a r t m e n t visi t o r hospi tal i - zation, is an o p p o r t u n i t y to s c r e e n immun iz a t i o n status and, if indicated, admin i s t e r n e e d e d vaccines. ' '3° Al- though this quo te appl ies to ped ia t r i c immuniza t ion pract ices , the re is no reason it shou ld no t app ly to adul ts as well , pa r t i cu la r ly adul t s at h igh risk for p r even t ab l e

i l lnesses wi th s ignif icant m o r b i d i t y and morta l i ty . If unvacc ina ted pa t ien ts a re no t vacc ina t ed in the ED, bu t are refer red , it is l ikely that many wil l r ema in unvacc ina ted . In par t icular , pa t i en t s w i th i nadequa t e access to care, many of w h o m use EDs for hea l th ca re del ivery, are l ikely to r ema in unvacc ina ted .

If such ini t iat ives a re to succeed , na t ional organi- zat ions such as the ACEP, t he Socie ty for A c a d e m i c Emergency Medic ine , and the Amer i can Col lege of Phy- sicians as wel l as federa l agenc ies such as the CDC need to be ac t ive in educa t i ona l o u t r e a c h to phys ic ians and in he lp ing to f ind effect ive ways to s u p p l e m e n t p r ima ry care p reven t ive hea l th de l i ve ry to pa t i en t s in the ED in a t imely and i nexpens ive manner . T h e r e n e e d to be c lear gu ide l ines and c lear s t a t e me n t s abou t the advisabi l i ty of vacc ine admin i s t ra t ion o r o t h e r p r i m a r y ca re p roces se s in the ED. W i t h o u t such t o p - d o w n suppor t , e i the r primary care ini t ia t ives in EDs wi l l fail o r c o m p l i a n c e wil l be spo t ty at best . 23 In a r e c e n t s tudy involv ing meas les vacc ina t ion in ped i a t r i c EDs du r ing an ep idemic , 59% of e l ig ible ch i ld ren w e r e no t vacc ina ted . 3~

There are po ten t i a l l imi ta t ions to the resul ts of this study. It is poss ib le that pa t i en t s w e r e w r o n g abou t thei r vaccinat ion status. It is unc l e a r w h e t h e r any bias w o u l d be toward under- or o v e r r e p o r t i n g vaccinat ion , however, and our resul ts do no t differ s ignif icant ly f rom

those of p r io r studies. In t e rms of the phys ic ian survey, it is poss ible that the s amp le of phys ic ians w h o r e t u r n e d their ques t ionnai res was no t r ep re sen t a t i ve of all ED physicians. Al though t h e r e was on ly a 50% re sponse rate, the w ide range of ED p rac t i ce s and the s imilar i ty in p rac t ice set t ings b e t w e e n the su rveyed phys ic ians and the total ACEP m e m b e r s h i p make this unlikely. Finally, the results of our surveys may no t be r ep resen ta t ive of pat ients in o the r ins t i tu t ions o r phys ic ians in o t h e r areas of the country . Tennessee ranked th i r t y - second of all the

states in the ad jus ted ra te of p n e u m o c o c c a l vacc ine use in e lder ly Medicare bencf ic iar ics , t~' It is l ikely that EDs

JOURNAL OF GENERAL INTERNAL MEDICINE, Volume 9 (August), 1994 429

with different pa t i en t m i x e s wi l l have dif ferent ra tes of pat ient vaccinat ion. Some EDs dea l ing w i t h la rger numbers of indigent , u n i n s u r e d pa t i en t s w i t h o u t regu la r primary care p rov ide r s are l ikely to have even h ighe r ra tes of unvacc ina ted pat ients . W h e t h e r n e w m a n a g e d ca re plans will affect vacc ina t ion ra tes is unknown , hu t 80% of the unvacc ina t ed pa t i en t s in this s tudy c o u l d ident i fy a pr imary care p rov ider .

CONCLUSIONS

A major i ty of pa t i en t s w h o p r e s e n t to the ED and are cons ide r ed to be in a h igh-r isk g r o u p for inf luenza or pneumococca l illness have not been vaccinated against these diseases. T h e r e are m a n y reasons w h y vacc ina t ion has not occu r r ed , bu t a ma jo r i t y of these u n v a c c i n a t e d pat ients are wi l l ing to be vacc ina t ed in the ED. Emer- gency d e p a r t m e n t phys ic ians are s o m e w h a t re luc tan t , however , to b e c o m e par t of this p r o c e s s o f p r ima ry ca re prevent ive heal th provis ion . The i r c o n c e r n s need to be dealt wi th before an ED vacc ina t ion p o l i c y can be suc- cessfully under taken .

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Influenza and pneumococcal vaccination in the emergency department