Compliance with CDC guidelines for prevention of tetanus, diphtheria and pertussis among patients receiving tetanus boosters in the Emergency Department

Background: Pertussis is the least well-controlled vaccine-preventable disease in the United States. Increasing incidence of pertussis has led the CDC to recommend administration of Tdap vaccine to adults less than age 65 years rather than Td.

Methods: Patients who received tetanus boosters in the ED from September 1, 2009 through August 31, 2010 were identified through an inpatient pharmacy database. Nursing documentation was used to determine which vaccine was given. If missing, physician orders were used to determine the vaccine given. Records were stratified by month and randomly sampled proportional to monthly totals. The study was powered to detect a compliance with the CDC guidelines of 95% (95% CI: 91-99%).

Results: Charts were reviewed for 231 (11%) of the 2085 tetanus vaccinations administered, and 11 were excluded for missing data. Compliance with CDC guidelines based on physician order was 75.0% (95% CI: 69.1-80.9%). Compliance based on actual vaccine type given was 84.5% (95% CI: 79.6-89.3%). There were 31 patients in which the physician order differed from the booster dispensed. Of these, 26 (83.9%) were changed such that the correct booster was dispensed. Patients with non-compliance were more likely to be 45+ years of age (OR = 3.3, 95% CI: 1.5-7.0).

Conclusion: Compliance with CDC guidelines for Tdap versus Td is short of CDC recommendations. In patients for whom the physician order and vaccine administered differed, the correct booster per CDC guidelines was more likely given. Physician education and notifications though the electronic order entry system could improve compliance with guidelines.