Assessed by:,RN/LPNDate:
Pneumococcal Vaccine (Screen and administer year around)Vaccine indicatedif any of the following apply:
Patient is high-risk if either of the following:
-65 years of age or older.
-Resident of nursing home or chronic care facility regardless of age
OR
Patient is 18-64 and has any of the following high-risk conditions:-Serious long-term health problem with chronic heart or lung-disease (not including asthma), diabetes mellitus, or kidney disease including nephrotic syndrome
-Compromised immunity such as: Hodgkin’s disease, leukemia, lymphoma, multiple myeloma, generalized malignancy, HIV/AIDS, organ or bone marrow transplant, treatment with long-term corticosteroids, cancer drugs, or radiation therapy
-Alcoholism, cirrhosis, or chronic liver disease
-Sickle cell anemia or prior splenectomy
-Cerebrospinal fluid leaks
OR
Patient uncertain about prior vaccination status or history unreliable and meets any of the above criteria.Vaccine not indicatedif none of the above.
STOP ASSESSMENT!
/ Influenza Vaccine(Screen year around. Administer per vaccine availability. If vaccine unavailable, provide education re high-risk status and need to receive the following October.)Vaccine indicated(if any of the following apply):
Patient is:
-50 years of age or older (higher-risk)
-Resident of nursing home or chronic care facility regardless of age (high-risk)
OR
Patient is 18-64 and has any of the following high-risk conditions:-Serious long-term health problem with chronic heart or lung disease (including asthma), diabetes mellitus, kidney disease, or anemia and other blood disorders.
-Compromised immunity such as: Hodgkin’s disease, leukemia, lymphoma, multiple myeloma, generalized malignancy, HIV/AIDS, organ or bone marrow transplant, treatment with long-term corticosteroids, cancer drugs, or radiation therapy
-Women who will be pregnant during the influenza season.
-Conditions that can cause breathing problems.
OR
Patient uncertain about prior vaccination status or history unreliable and meets any of the above criteria.Vaccine not indicatedif none of the above.
STOP ASSESSMENT!
Vaccination Status or Contraindications (Check all that apply)Pneumococcal vaccine NOT INDICATED if any of the following:
Previously immunized after age 65 (Date: ______)
Previously immunized before age 65,but <5 years ago
(Date: ______)
Pregnant women in first trimester only
Reported allergy to vaccine or any of its components.
Patient refuses. Reason:______
______
NOTE: If pt was immunized prior to age 65, only ONE booster in 5 years is required. / Influenza vaccine NOT INDICATEDif any of the following:
Previously immunized this flu season (Date: ______)
Has had a serious allergic reaction to eggs
Previous serious reaction to influenza vaccine or its components
History of Guillain-Barre syndrome within 6 weeks of receiving influenza vaccine
Patient refuses. Reason:______
______
PPV VIS dated 7/29/97 given / Inactivated Influenza VIS dated 6/30/06 given
Vaccination Order (Check all that apply – Both may be given at the same time, but in different arms)
Administer pneumococcal polysaccharide vaccine 0.5 cc IM on hospital day [two]: ______or prior to discharge. / Administer inactivated influenza vaccine 0.5 cc IM on hospital day [two]: ______(or prior to discharge) per vaccine availability. (Expires June 30 annually)
Physicians: If you wish to cancel this standing order, please do so on the current day's order sheet with the patient contraindication for the vaccine(s).
Influenza and Pneumococcal Vaccination Guidelines and References
Berry BB, Ehlert DA, Battiola RJ, Sedmak G. Influenza vaccination is safe and immunogenic when administered to hospitalized patients. Vaccine. 2001:19:3493-3498.
Bratzler DW, Houck PM, Jiang H, et al. Failure to vaccinate Medicare inpatients: a missed opportunity. Arch Intern Med. 2002;162:2349-2356.
Centers for Disease Control and Prevention (CDC). Facilitating influenza and pneumococcal vaccination through standing orders programs. MMWR . January 31, 2003;52(4):68-69.
Centers for Disease Control and Prevention (CDC). General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP) and the AmericanAcademy of Family Physicians (AAFP). MMWR Recommendations and Reports. February 8, 2002;51(RR-2):1-36.
Centers for Disease Control and Prevention (CDC). Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients: recommendations of CDC, the Infectious Diseases Society of America, and the American Society of Blood and Marrow Transplantation. MMWRRecommendations and Reports. October 20, 2000;49(RR-10):1-128.
Centers for Disease Control and Prevention (CDC). Guidelines for vaccinating pregnant women; from recommendations of the Advisory Committee on Immunization Practices (ACIP). October 1998 (updated July 2005). Available at: Accessed August 17, 2005.
Centers for Disease Control and Prevention (CDC). Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recommendations and Reports. May 28, 2004;53(RR-6):1-39.
Centers for Disease Control and Prevention (CDC). Prevention and control of pneumococcal disease: recommendations of the Advisory Committee on ImmunizationPractices (ACIP). MMWR Recommendations and Reports. April 04, 1997;46(RR-8):1-24.
Centers for Disease Control and Prevention (CDC). Use of standing orders programs to increase adult vaccination rates: recommendations of the Advisory Committee on Immunization Practices. MMWR Recommendations and Reports. March 24, 2000;49(RR-1):15-26.
Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare and Medicaid programs; conditions of participation: immunization standards for hospitals, long-term care facilities, and home health agencies. Federal Register. October 2, 2002;67(191):61808-61814. Available at: Accessed August 18, 2005.
Fedson DS, Houck P, Bratzler D. Hospital-based influenza and pneumococcal vaccination: Sutton’s Law applied to prevention. Infect Control and Hosp Epidemiol. 2000;21:692-699.
Nichol KL, MacDonald R, Hauge M. Side effects associated with pneumococcal vaccination. Am J Infect Control. 1997;25:223-228.
Poland G, Shefer A, McCauley M, et al. Standards for adult immunization practices. Am J Prev Med. 2003;25(2):144-150.
Vaccine Information Statements (VIS) and Other Patient Education Information
National Immunization Program Vaccine Information Statements:
National Immunization Program:
Immunization Action Coalition:
New York City Department of Health and Mental Hygiene:
This material was adapted by the New York City Department of Health and Mental Hygienefrom FMQAI, the Medicare Quality Improvement Organization for Florida, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services.. Updated 8/15/2006.