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It’s Not Too Late for You AND Your Patients to Get a Flu Vaccine

Getting a flu vaccine is on many “to do” lists in the fall, but for those who still haven’t checked it off their list, it’s not too late to get vaccinated. Many people don’t realize that flu activity usually peaks in the United States in January or February, and flu viruses can circulate as late as May. As long as there’s flu around, it isn’t too late to get vaccinated.

Getting a yearly flu vaccine is the first and most important step in protecting against the flu, and CDC recommends influenza vaccination for everyone age 6 months and older. We urge you and all health care professionals to get vaccinated yourselves and offer flu vaccine at every opportunity to every patient—except infants younger than 6 months and the very few people for whom flu vaccination is contraindicated.

Studies show that your recommendation makes the difference in your patients’ decision to get a flu vaccine. You should continue to emphasize the importance of flu vaccination for your patients. And, if you don’t already do so, consider offering flu vaccines to patients in your own practice, even if yours is a sub-specialty practice and you don’t see yourself as a vaccine provider. Even if you don’t offer flu vaccines, you can still recommend and emphasize the importance of flu vaccination as a way to keep your patients—and their families—protected throughout the season.

As promising as it is sounds that flu vaccination rates are increasing among children and healthcare personnel, vaccination rates are stagnant for many groups at increased risk of serious complications from influenza, including adults 65 years and adults 19-64 years old who have certain medical conditions. These medical conditions include asthma, diabetes (type 1 and 2), and heart disease.   Pregnant women are also at high risk of severe illness. Vaccination rates increased 2 years ago in response to the 2009 pandemic but have remained stagnant since.  Vaccination is especially important for people with chronic health conditions including asthma, other chronic lung disease, diabetes, immunosuppression, chronic heart, and kidney disease. Even if these conditions are well-managed, people who have them are at higher risk of serious complications from influenza. Yet during the last flu season (2010-2011), only 47 percent of people with high-risk conditions were vaccinated.

While people 65 years and older are at high risk, the vaccination rate in this age group has dropped over the past few seasons. Vaccination coverage in 2010-2011 was three percentage points lower than in 2009-2010 and seven percentage points lower than in 2008-2009. The decreasing trend may have resulted from this age group not being included in the initial groups prioritized to receive the first available doses of the 2009 H1N1 pandemic flu vaccine. This may have resulted in the misperception that people 65 years and older are no longer considered a high priority for seasonal influenza vaccination.

Results from a recent survey of pregnant women reinforce the value of flu vaccine recommendations and offering vaccine by health care providers. Women whose providers offered the vaccine were five times more likely to get vaccinated than patients who reported that their providers did not offer or recommend vaccination. Many women who didn’t receive an offer visited a health care provider at least once, which means that an opportunity for vaccination was missed.

Keep in mind that many of your chronically ill or older patients will visit you at least once during flu season. Although many will have seen advertisements for influenza vaccination, they may not recognize their need to get vaccinated.   A strong recommendation from you can make a big difference in your patient making the decision to get vaccinated.  And while we’re on the subject of everyone needing a flu vaccine, have you been vaccinated yet? And what about your staff? Vaccination of health care personnel is important for patient safety, as well as for your own protection. It also allows you to be an example to your staff and patients by indicating “I got vaccinated. You should, too.” Being a good example can be helpful, especially if you’re talking to a patient who thinks the vaccine can cause the flu, who is concerned about side effects, or who doesn’t understand that people need to get a flu vaccine every year because immunity wanes over time.

During the 2010-2011 flu season, only 63.5 percent of health care personnel were vaccinated—well below the Healthy People 2020 target of 90 percent. We would like to see that number increase substantially this year.

CDC has resources that can help you in your efforts to get your patients vaccinated. You can obtain patient education handouts and posters for your office, copies of the vaccine information statements (VIS), and updated information for you and your staff at and You can also get a variety of other tools, including those that you can add to your Web page, e-cards for a variety of audiences e-cards, and the “flu vaccine finder” widget, where you or your patients can enter an address or ZIP Code and get a map and list of the flu vaccine providers near you.

If there’s anything else you need to help you promote the flu vaccine, contact us at 800-CDC-INFO or We’re here to support your efforts in recommending yearly flu vaccination for your staff and patients.

Abigail Shefer, MD, FACP, is currently Associate Director for Science in the Immunization Services Division (ISD) of the National Center for Immunization and Respiratory Diseases (NCIRD) at the Centers for Disease Control and Prevention (CDC).Abby′s most recent experience has been as Chief, Health Services Research and Evaluation Branch (HSREB) in ISD which she lead from 2000-2005. She has been a medical epidemiologist in the National Immunization Program for the last 14 years. Before moving to Atlanta, she completed a 2 year fellowship with CDC as an EIS officer (Epidemic Intelligence Service officer) while stationed at the Communicable Disease Branch at the California State Health Dept in Berkeley. Abigail completed a medical residency at the University of Wisconsin Hospital and Clinics, Madison, WI and is board certified in Internal Medicine.

Abby′s areas of interest and research have included 1) evaluating strategies to improve and promote adult immunization; 2) improving coverage of low income children through coordination of the national WIC immunization initiative; 3) conducting systematic reviews on cost and cost-effectiveness of population based interventions to improve coverage for both routine and high risk vaccination, and 4) integrating immunization–related quality improvement activities at the practice level.

To request an interview, call CDC′s Division of Media Relations at (404) 639-3286, or e-mail us at

*This blog post was originally published at Safe Healthcare*

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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