Gap between vaccines ordered and shots given remains after use of clinical decision support tool

Is vaccinating hospitalized children against influenza a common practice prior to discharge? It would seem to be a no brainer—but it’s not. One study found that, among children admitted to a hospital with influenza, there was at least one or more missed vaccination opportunities prior to admission.

Moreover, flu vaccination rates for kids in the U.S. as a whole are dismal, with only 63% receiving the jab in the 2018-2019 flu season, and hospitalized kids fare worse, coming up short of that national average.

“The Centers for Disease Control and Prevention Advisory Committee on Immunization Practices recommends vaccination during hospitalization in addition to routine health care visits,” Evan W. Orenstein, MD, from the Department of Pediatrics, Emory University School of Medicine, in Atlanta, and colleagues wrote in JAMA Network Open. “However, influenza vaccination status is ascertained less often at acute-care visits and is often not considered a high priority.”

Orenstein and colleagues decided to tackle this dilemma with a clinical decision support (CDS) strategy to identify the number of hospitalized children eligible for the flu vaccine and have the vaccine administered before discharge. They tested the plan with a quality improvement study conducted at three hospitals in a tertiary pediatric health system.

“The study used a sequential crossover design from control to intervention and compared hospitalizations in the intervention group (2019-2020 season with the use of an intervention order set) with concurrent controls (2019-2020 season without use of an intervention order set) and historical controls (2018- 2019 season with use of an order set that underwent intervention during the 2019-2020 season),” the study authors wrote.

There were nearly 18,000 hospitalizations (n=17,740) during the study period. Fifty percent of the patients were Black and 43% were White. The mean age was 8 years old, and most of the patients had public health insurance. In the 2019-2020 influenza season, 10,997 patients were eligible for the vaccine with 5,449 in the intervention group and 5,548 in the concurrent controls. The historic control group was comprised of 6,743 eligible hospitalizations.

While the CDS increased vaccine orders, administration of the vaccine was not on par.

  • In the intervention group, the flu vaccine was ordered for 4,199 hospitalization (77%) and administered during 1,676 hospitalizations (31%).
  • “In the concurrent control group the vaccine was ordered for 1,488 hospitalizations (27%; P<0.001 versus the intervention group) and administered during 1.051 hosptializations (19%; P<0.001 versus the intervention group).
  • “Looking at the historic controls the vaccine was ordered for 1,024 hospitalizations (15%; P<0.001 versus both the intervention and concurrent control groups) and administered during 912 hospitalizations (14%; P<0.001 versus both the intervention and concurrent control groups).”

The CDS intervention consisted of a default-checked influenza ordered that was timed for noon, the day after admission, and included “just-in-time education regarding influenza vaccine appropriateness for specific populations (e.g., patients receiving corticosteroids, patients with asthma exacerbations, patients with egg allergy, patients with cancer, and other immunocompromised patients), as well as links to the state immunization registry, Centers for Disease Control and Prevention guidance, and supporting literature,” Orenstein and colleagues wrote. “The order group would dynamically appear if the patient met the following criteria: (1) aged 6 months or older, (2) no influenza vaccine in our local EHR system or the state immunization registry for the current influenza season, (3) no history of anaphylaxis to any influenza vaccine in the local EHR system, and (4) no documentation by nursing staff indicating that the patient has already received influenza vaccine, has had an anaphylactic reaction, or parental refusal.”

Staff were also provided a communication tip sheet linked to the order that focused three elements:

  1. The benefits of introducing vaccines.
  2. How to respond to common issues families raised.
  3. Vaccine facts, including adverse effects and time to protection.

“The CDS system was associated with a marked increase in the frequency of influenza vaccine orders for eligible children but with a smaller increase in actual administrations of the vaccine,” Orenstein and colleagues wrote. “This gap between orders and administrations may be due to vaccine refusal or other unknown barriers. Although the effect size was smaller, the influenza vaccination rate among the concurrent controls was significantly higher than among the historical controls. This difference may be due to the presumptive strategy script in the nursing admission questionnaire and communication tip sheet, which were implemented systemwide in September 2019, unlike the influenza vaccine order group, which was implemented in a stepwise fashion. It may also be due to contamination, in which the CDS led physicians to think of influenza vaccine more often even without a patient-specific EHR prompt.”

The aim of the current study was to reduce clinician burden by automating eligibility screening; integrating the CDS early in the workflow to increase flexibility for administration; and avoided interruptive alerts for nursing and clinician staff.

“The CDS system also did not depend on operational resources to disseminate reports or provide ongoing education, “the study authors noted. “Additional benefits may be gained by combining an automated CDS approach with other evidence-based implementation science and behavioral economics interventions, such as audit and feedback, text messages to patients and families, explicit markers of vaccine intention, note template changes, and patient and family education. Nonetheless, scaling up these interventions would benefit from study designs that identify each bundle element to minimize the resource requirements for new sites to implement similar changes.”

While the CDS did improve influenza uptake in this study, the gap between orders and actual adminstration remains, the study authors acknowledged. “Additional work to understand persistent reasons for low uptake and the potential effect of combining CDS with other behavioral economic and implementation science interventions would likely reduce the burden of influenza in a vulnerable population and provide lessons to improve vaccine coverage for other diseases, such as Covid-19,” they concluded.

Limitations of the study include its single-center design and the use of one EHR from Epic Systems. The reasons for low vaccine uptake were not evaluated.

  1. Despite current guidelines that children be vaccinated against the flu during hospitalization or acute-care visits, this is not often done, nor is it a priority.

  2. This study looks at a clinical decision support strategy that aims to increase the number of hospitalized kids being administered a flu vaccine prior to discharge.

Candace Hoffmann, Managing Editor, BreakingMED™

Orenstein reported being the co-founder of and having equity in Phrase Health, a clinical decision support analytics company, outside the submitted work.

Cat ID: 44

Topic ID: 85,44,728,791,730,125,30,44,561,653,151,924