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Welcome again. I'm Doctor Corey Kershaw in the division of Pulmonary and Critical Care Medicine at the University of Texas Southwestern Medical Center, and I have the pleasure of speaking to you about hospitalized patients and vaccinations. Um, this is really a wonderful opportunity, um, where you have a combination of both the captive audience in terms of having the patient right there, um, often for several days, so there's lots of opportunities to vaccinate, but unfortunately, These really are missed opportunities which I'll talk about in some detail here. Uh, again, just to reiterate, these are our learning objectives from, uh, from before we review. I won't. Do you the dishonor of reading those. Uh, these are my disclosures. And let's talk about why the inpatient matters. You know, it's possible for a lot of us that we consider vaccinations to be under the purview of the outpatient physicians, not something in the hospital. And in fact, that is, that is simply not true. Um, in fact, you can see the, the frequent missed opportunities here, um, with some statistics on the left. You know, if you have patients who are admitted for pneumonia. Only 1.9% of those patients are given a flu vaccination by the inpatient team when they're already there for pneumonia. COVID vaccination rates are very poor during hospitalization on 2%, only 2%, and the problem here is that the stakes are very high. These are vulnerable patients with preventable diseases. So just, just, you know, one concept, the one-year readmission rate for patients. Um, that are critically ill with a lung disease, not vaccinated during the hospital stays, 29%, 1 3rd of those patients are gonna come back in a year, um, if you look at the patients that aren't vaccinated, and, um, the outcomes can be very poor. This, you know, the 30-day mortality for patients who have a vaccine-preventable disease, and this is, these are patients over the age of 50, is 4 times higher than patients, um, who are vaccinated. Uh, the one-year mortality is 2.8 times higher with matched controls, and patients who survive a vaccine preventable illness have significant morbidity. 41% of those patients lose independence. We know that they have longer stays and worse outcomes. Um. Uh, you know, just as an example here of one thing we can do to help, if you look at patients that are eligible to receive the pneumococcal vaccine and you, the only, um, way the physician is prompted is just by, for example, an EHR reminder, not active, um, reminders of. Massive reminders, the uptake is 31%. If you do something like EHR standing orders, we can increase that uptake of pneumococcal vaccine administration to 51%. So, I'm gonna come back to this concept throughout this session, not only to talk about the implications of missing vaccination opportunities, but importantly how we correct that with um overcoming the barriers, which I'll talk about in some detail here. So let's look at a case. This is Mr. Carter. Uh, Mr. Carter is 64. He lives in a rural community and has diabetes and high BP. He's been admitted twice in the last year under a different hospitalist, and there has not been any consistent outpatient follow-up. So, already a couple of problems there. When you have multiple doctors taking care of the patient, they may not be communicating with each other. They may not know the patient as well from the previous hospitalization, so this, this could be a missed opportunity here as far as a communication problem. Uh, Mr. Carter has not had a flu vaccination this season. Um, he's never had a pneumococcal vaccination, at least, at least not that's been recorded. In his record, he's not had a COVID-19 vaccination booster, and he's a vulnerable patient. He lives in a high social vulnerability area, so this is already someone who is gonna be at increased risk for vaccine preventable diseases and subsequent complications. Six months ago, he was admitted to a medicine service for a COPD and heart failure exacerbation. Um, he was treated for the acute illness, of course, but no one on the team reviewed his vaccination status or wrote an order for a vaccine. Discharged by the team with no vaccinations order. He comes back six months later. Now he's got influenza A, severe influenza A, and a bacterial pneumonia, uh, is a super infection. He's hypoxemic, he's hyperglycemic, diabetes is now out of control in the setting of critical illness, and he has to admit, be admitted to a step-down unit for 9 days under a different medicine team. And again, this is potentially a preventable admission because he now has two vaccine preventable diseases that we could have um averted if he had been vaccinated during the first opportunity 6 months ago. So we have an audience polling question. Um, what would have most changed Mr. Carter, Mr. Carter's outcome at his first admission? Choice A, the admitting physician reviewing vaccine status as part of the admission workup. Uh, uh, Choice B, physicians set standing orders letting the team vaccinate without a separate order each time. Choice C, the internist judging him eligible despite acute illness rather than deferring, and choice D, the discharging physician documenting and handing off what was still due. Please lock in your responses via the polling application. OK. So, why did this happen? As I said before, you know, there's statistics that show that less than 2% of adults that get admitted with pneumonia will actually get the flu vaccine, so extremely low vaccination rates for a vulnerable patient. Um, and we have several days of contact, but what's missing perhaps is that the physician is not owning the decision. We're focused on one thing and not thinking about other things. Um, you know, 5 to 6 days, someone in the hospital, that's an opportunity to have a vaccine discussion at least once. You should see this quote here from the 2019 chess meeting. So, what's the issue? What, what are the missed opportunities and let's look at what some of those, uh, factors might be. Number one, acute focus by the team. We're focused on what's in front of our face. The patient is in the hospital, sick with the COPD and heart failure exacination. That's what I'm focused on. I'm treating. You know, with diuretics, I'm focused on giving inhalers, um, and oxygen therapy, but not thinking about, you know, preventive medicine at the same time. Therefore, the vaccine status never gets reviewed. Uh, no one's owning the decision. Certainly the physician who's taking care of the patient who should be the owner is not taking responsibility. And without that attending physician setting, setting some standing order already in their, uh, electronic medical record and then identifying who's going to act, you know, it's gonna be the hospital is taking care of the patient, resident to ensure it's, um, followed through on, the nurse to administer the vac administer the vaccine. If we defer to the outpatient setting, are we communicating with the primary care physician that Uh, vaccine was not done and it needs to be followed up on. Therefore, no order gets written despite multiple layers of responsibility that could be taken that were not. Um, this concept that the patient might be too sick for, um, for the vaccine. I think this is quite common. The patient's sick from COPD, they're sick from their heart failure. I can't give somebody a pneumococcal vaccine then. And in fact, that actually may not be true. The only really true precaution you have to take is if the patient has moderate to severe illness during the hospitalization. Um, otherwise, it's quite, it's quite safe to give a vaccine and in that patient who might be too sick, there are opportunities to follow up on it as the outpatient if we communicate properly with the outpatient physician. And let's say we decide to do that. Um, we're gonna hand off and, um, have the vaccine go to the outpatient arena, but there actually is no handoff. The discharging physician omits the vaccine status and the documentation that the primary care physician gets, and there's no direct communication with the primary care physician that vaccines are due. The cycle continues, the patient's back in the hospital six months later with a vaccine preventable disease. So let's talk about these barriers one by one. You know, the hospitalists could say, look, I'm focused on the acute problem. This is just not, you know, in my mindset. It's not on my checklist. Um, so I'm not gonna do that. I'm just not gonna think about that. And because of that, we rarely review the immunization status and so there's no prompt to act. And so the vulnerability here is, is that if the attending physician is not making Uh, the vaccine review, part of the admission on day one, it may, um, you know, we're missing the opportunity there. The eligibility is not visible to everyone else because we didn't review it in the beginning and the patient goes day after day after day in the hospital despite being a perfect candidate to receive a vaccine, they never get it. Um, so what's the, what's the move here, you know, own it at the very first, um, encounter. Write an admission, make it part of a standing order set in your admission order set to review vaccines, find out what the patient is eligible for based on their age and conditions, and Uh, that we actually act on them. It's not just there for viewing, but we actually do something about it once we have identified the patient is eligible based on age and condition. Barrier number 2, no one's owning this, so responsibility is diffused throughout the team, and no one is taking that primary responsibility. I'm assuming someone else is gonna do that, so I assume.