Abstract
BACKGROUND: The American Academy of Pediatrics recommends annual influenza vaccination for all children 6 months and older, yet only 59% of children nationally received the vaccine during the 2014–2016 influenza seasons. Of these, only 4% received the vaccine in a hospital setting. The goal of this quality improvement (QI) initiative was to increase influenza vaccination status at discharge at least twofold in children admitted to our hospital during the 2017–2018 influenza season compared with the 2016–2017 season.
METHODS: The QI initiative was conducted in the inpatient units at a tertiary care children’s hospital. Interventions included electronic medical record triggers, provider education, and peer comparison. The primary outcome measure was the percentage of children discharged from the hospital with at least 1 dose of the influenza vaccine received either at the hospital or before admission. Queries about the influenza vaccination status of children were used as a process measure. Length of stay was used as a balancing measure.
RESULTS: The percentage of hospitalized children discharged with at least 1 dose of the vaccine increased 4.7-fold during the QI initiative (46%) compared with baseline (10%). There was a fourfold increase in parental query about the influenza vaccination status of their children (68%) during the QI initiative compared with the baseline period (16%). No significant difference occurred in the median length of stay among patients admitted during the QI initiative versus the baseline period.
CONCLUSIONS: We increased influenza vaccination status among children admitted to our hospital using electronic medical record triggers, provider education, and peer comparison.
The American Academy of Pediatrics recommends annual influenza vaccination for all children 6 months of age and older.1 Despite these recommendations, influenza vaccination in children 6 months to 17 years of age nationally has been stagnant at 59% since the 2013 influenza season.2 Among influenza-related pediatric deaths, ∼80% occurred in children who were unvaccinated during the 2017–2018 influenza season.3 Thus, increased vaccination coverage of children has the potential to significantly decrease influenza-related illness and deaths.
The hospital setting is underused as a venue to vaccinate children. During the 2013 through 2017 influenza seasons, 83% of children were vaccinated in primary care clinics, whereas only 4% of children received their vaccine at a hospital.4 Our goal for this quality improvement (QI) initiative was to increase the percentage of children discharged from the hospital with at least 1 dose of the influenza vaccine (received at either the hospital or before admission) twofold during the 2017–2018 influenza season compared with the 2016–2017 season.
Methods
Setting and Context
This initiative was conducted from October 1, 2017 to April 28, 2018 in the inpatient units at a 350-bed, tertiary care, freestanding children’s hospital with ∼16 000 annual admissions. The baseline period for comparison was from October 1, 2016 to April 28, 2017.
Stakeholders for this QI initiative included pediatric hospitalists, surgeons, pediatric medical residents, pharmacists, nurses, and advanced practice nurses (APNs). The intervention group consisted of children 6 months and older admitted to the medical and surgical units (excluding the ICUs and patients admitted to surgical subspecialty units). The electronic medical record (EMR) triggers and reminder alerts were available to the surgical subspecialty residents and APNs, but we were unable to do education and peer feedback with them because of their lack of availability for ongoing teaching. Patients admitted to the surgical subspecialties were therefore excluded from the initiative but served as an internal control to gauge the efficacy of the QI initiative to increase vaccine administration.
Inpatient medicine teams were composed of a pediatric hospitalist or subspecialty attending, a senior pediatric resident, and 2 to 3 pediatric (or rotating emergency medicine) interns or APNs. General surgery teams consisted of a pediatric surgery attending, a pediatric surgical fellow, surgery residents, and pediatric surgery APNs. Surgical APNs were enthusiastic champions of this initiative, and this was significant because, historically, influenza vaccination rates among children in the surgical service have been low, and we sought to increase vaccination in this group.
Interventions
A multidisciplinary team that included 2 pediatric hospitalists, a pediatric resident, and 2 pharmacists led the QI effort. Key drivers identified by discussions and meetings with stakeholders were as follows: increasing awareness of influenza vaccination guidelines; instituting a cultural change in the hospital regarding vaccination by encouraging physician, nursing, and parental buy-in; and ensuring adequate vaccine supply (Fig 1).
Key drivers. AAP, American Academy of Pediatrics.
Provider and Parental Education
Educational interventions consisted of didactic education at hospitalist division meetings, resident conferences, and nursing staff meetings to provide information about the American Academy of Pediatrics guidelines regarding influenza vaccination. We sent a quiz about the influenza vaccine (with answers provided at the end of the quiz) to all providers during the first 2 weeks of the initiative to serve as an educational tool. The study team leader met with residents at each inpatient unit at the start of their 4-week inpatient rotation and provided education about influenza vaccination. Information was disseminated by e-mail to reach providers unable to attend the meetings and by pocket cards and posters placed at key locations in the hospital.
Ongoing provider education, reinforcement, and encouragement were provided by the study team leader who walked through the inpatient units 2 to 3 times a week, meeting with residents and nurses to answer any questions regarding influenza vaccination. Parents were provided with an influenza information sheet created in conjunction with the hospital’s family resource center.
EMR Triggers
EMR queries (Fig 2) were added to the history and physical examination and discharge instruction templates. They were designed to obtain information about the influenza vaccination status and to remind providers to order the influenza vaccine for their patients.
EMR trigger questions. A, History and physical template. B, Discharge instructions. DC, Discharge; SCM, Sunshine Clinical Manager.
Peer Comparison
We shared unit-specific influenza vaccination data with each inpatient unit and medical providers. Each unit could compare vaccination percentages with those of their peer units in the hospital. The results were displayed as posters placed at key locations and e-mailed to medical providers.
Study of the Interventions
Data Elements
We obtained the following data from the EMR: influenza vaccination status before admission, parental refusal of vaccination (from EMR queries or any information documented in a text box associated with immunization queries), influenza vaccine administration, patient demographics, discharge service, admission and discharge diagnoses, and length of stay. In our experience, medical providers have been more cognizant of the importance of influenza vaccination in children admitted with asthma or other respiratory diagnoses compared with those admitted with nonrespiratory diagnoses. We made an effort during our educational meetings to stress the importance of vaccinating all children regardless of their admission diagnosis. In an effort to measure the success of this teaching, we did a subgroup analysis of influenza vaccine administration in children with respiratory and nonrespiratory diagnoses. Accordingly, we categorized discharge diagnoses of patients as respiratory versus nonrespiratory. Respiratory diagnoses were defined as any disease process affecting the respiratory tract (eg, asthma, bronchiolitis, viral respiratory tract infection, cystic fibrosis, croup etc).
Measures
The primary outcome measure was the percentage of children discharged from the hospital with at least 1 dose of the influenza vaccine received at either the hospital or before admission. This is based on a measure recommended by the National Quality Forum and determines the overall vaccination status of patients at the time of discharge.5 We also calculated vaccine administration at the hospital among children who were unvaccinated, defined as those who had not received at least 1 dose of the vaccine before admission during the current influenza season. Queries to parents about the influenza vaccination status of their children were used as a process measure. The primary outcome measure was influenced by both vaccination receipt before admission and by parental refusal of the vaccine. We measured both these variables by querying parents about the vaccination status of their children either at the time of admission or later during the hospitalization for parents who were unavailable at the time of admission. We also obtained data on parental refusal. Length of stay during the QI intervention period compared with the baseline period was used as a balancing measure because of concern among medical providers that influenza vaccination may cause fever and therefore delay discharge.
Data Analysis
Primary outcome and process measures, as well as parental refusal, were plotted over time in a statistical control p-chart by using established rules for identifying special cause variation.6,7 The proportion of children who had already received at least 1 dose of the vaccine was plotted over time as a run chart. Characteristics of patients hospitalized during the baseline period were compared with those of patients hospitalized during the QI intervention. Categorical variables were analyzed by using the χ2 test and Fisher’s exact test, and continuous variables were analyzed by using the Wilcoxon rank test. Data were analyzed by using SAS version 9.4 (SAS Institute, Inc, Cary, NC).
Ethical Considerations
The Washington University in St Louis Institutional Review Board determined that this QI initiative was exempt from human subjects review.
Results
A total of 6089 children 6 months and older were admitted to the medical and surgical units during the baseline period, and 6206 were admitted during the QI initiative.
Our primary outcome measure revealed a 4.7-fold increase in the percentage of hospitalized children discharged with at least 1 dose of the vaccine received at either the hospital or before admission during the QI initiative (46%) compared with baseline (10%). Analysis of the primary outcome over time (Fig 3) during the QI initiative revealed an increase in vaccination coverage of children at discharge, which was sustained over much of the influenza season, with a decline in March that corresponded to the decrease in influenza activity at our institution.8,9
Children who received at least 1 dose of the influenza vaccine at discharge (either at the hospital or before admission): statistical process control p-chart. The numerator is the number of children who received at least 1 dose of the influenza vaccine at either the hospital or before admission. The denominator is all children 6 months and older admitted to the medical and surgical units. LCL, lower control limit; UCL, upper control limit.
Vaccine administration in the hospital among children who were unvaccinated (those who had not received at least 1 dose of the vaccine before admission) increased 5.5-fold from 3.8% at baseline (215 of 5686) to 21% (858 of 4168) during the QI initiative.
Vaccine administration in the hospital depends on first identifying (via queries to parents) children who need to be vaccinated. A fourfold increase in queries about the influenza vaccination status (68%) was seen during the QI initiative compared with the baseline period (16%). A significant increase in queries occurred in response to both the educational efforts of the QI initiative and the introduction of EMR triggers (Fig 4A). More than 70% of parents were queried shortly after the introduction of EMR triggers. This high level was sustained until the end of the influenza season, when the decline in queries corresponded to a decline in influenza activity at our hospital.8,9
A, Queries about the influenza vaccine (process control p-chart). The numerator is the number of children queried, and the denominator is all children 6 months and older admitted to the medical and surgical units. B, Vaccination before admission. The numerator is the number of children who received at least 1 dose of the vaccine before admission, and the denominator is the number of children whose parents were queried about the influenza vaccination status. C, Parental refusal (process control p-chart). The numerator is the number of children whose parents declined or deferred vaccination at the hospital, and the denominator is the number of children whose parents were queried about the influenza vaccination status. LCL, lower control limit; UCL, upper control limit.
Queries revealed a steady increase in the number of children who had already been vaccinated before admission from October to April of both the baseline period and the QI initiative (Fig 4B). Queries also identified families who either refused the vaccine (0.6% at baseline versus 17% during the QI initiative) or preferred that vaccination be administered at the primary care office (0% at baseline versus 2% during the QI initiative). Analysis of parental refusal or deferment over time revealed that the rates held steady between 15% and 23% through most of the QI initiative (Fig 4C). Although the EMR tools directed providers to determine if children <9 years old had received 2 doses, this information was elicited in only 15% of children.
We made a concerted effort to increase vaccination in patients with nonrespiratory diagnoses because this was a population that had been undervaccinated previously in our institution. This effort was successful as evidenced by an 8.5-fold increase in vaccine administration in children admitted with a nonrespiratory diagnosis (2% at baseline versus 17% during QI initiative; P < .0001). Vaccine administration increased as well in patients with a respiratory diagnosis (9% at baseline versus 31% during QI initiative; P < .0001; Fig 5).
Service- and diagnosis-specific influenza vaccine administration in children who were unvaccinated. The numerator is the number of children who received an influenza vaccine at the hospital. The denominator is children 6 months and older in medical and surgical units who had not had at least 1 dose of the vaccine before admission.
Another population that had been undervaccinated previously in our institution was children admitted under surgical services. Our efforts to increase vaccination in this group were facilitated by the active engagement and support of the general surgery APNs. The greatest impact of the QI initiative was indeed seen among patients admitted to the general surgery service, with a 70-fold increase in vaccination from 0.2% at baseline period to 14% during the QI initiative. Vaccine administration was highest in children admitted under the general medicine service (27%), which was significantly higher than vaccine administration in children admitted to the medicine subspecialty service (18%) (Fig 5). Vaccine administration among children admitted under the surgical subspecialty service (internal control) revealed no significant increase during the QI initiative (0.5% at baseline versus 0.8% during the QI initiative; P = .2).
Peer comparison of unit-specific influenza vaccination was shared with all units throughout the initiative. Supplemental Fig 6 is an example of the information shared each month and presents the summary for the whole influenza season. There was a significant increase in vaccine administration in all units, even in units that had low vaccination rates previously, such as the 12th floor unit (patients admitted primarily to neurology service), 10th floor unit (patients admitted primarily to surgical and surgical speciality services), etc.
There were no significant differences in baseline patient characteristics, such as sex, ethnicity, median age of patients, or number of patients admitted with a diagnosis of influenza, between the baseline period and the QI initiative (Supplemental Table 1).
Balancing Measure
There was no significant difference in the median length of stay between patients admitted during the QI initiative and those admitted during the baseline period (47 vs 47 hours; P = .3; Supplemental Table 1).
Discussion
Our QI initiative successfully increased the proportion of children discharged from the hospital with at least 1 dose of the vaccine 4.7-fold from a baseline of 10% to 46% during the 2017–2018 influenza season. During the 2017–2018 influenza season, vaccination had been estimated to prevent 41% of expected influenza-related hospitalizations and 39% of influenza-related mortalities in children aged 6 months to 4 years.10 Thus, increasing influenza vaccination in children is an important public health measure.
If families are not asked about influenza vaccination, the children are unlikely to be vaccinated. Thus, a critical aspect of the QI initiative was to increase queries about the influenza vaccination status of the children admitted, and we were successful in increasing queries through education and EMR trigger tools. EMR-based tools have been shown to be effective in increasing vaccination rates in children. Pollack et al11 increased rates of influenza vaccination from 2.1% in the preintervention period to 8% using a nurse-driven EMR screening program. Introduction of the EMR trigger tool increased queries about the patients’ influenza vaccination status significantly to ∼70% during much of the QI initiative, which was sustained through most of the season.
EMR queries and triggers, however, were not effective without concomitant provider education and feedback, as was illustrated by the lack of an increase in vaccine administration among patients admitted to surgical subspecialty services. EMR triggers and reminder alerts were available to the surgical subspecialty providers, but they did not receive education and peer comparison feedback. Active provider engagement is important for achieving high levels of vaccine administration. Active buy-in by the surgery APNs to the QI initiative accounted for the significant increase in vaccine administration among patients admitted to the general surgery service.
Flannery et al12 found that 53% of pediatric deaths from 2010 to 2014 occurred in children with ≥1 high-risk medical condition, and only 31% of these children were vaccinated against influenza. Vaccine administration was significantly higher in children discharged from the medicine service compared with the medicine subspecialty service. Children admitted to medicine subspecialty services often have chronic medical condition(s), placing them at higher risk for influenza-related complications and death. It is important to increase our efforts in vaccinating these children during the next influenza season.
Peer comparison leverages the innate competitive nature of medical providers to improve patient care. Peer comparison was 1 of the 2 behavioral interventions that resulted in lower rates of inappropriate antibiotic prescriptions in the outpatient setting in a study by Meeker et al.13 We were unable to quantify the impact of peer comparison on vaccine administration, but we believe that the active engagement of all medical providers in the initiative was largely due to the monthly peer comparison reports. Vaccination in children admitted to the neurology service (12th floor) or surgical service (10th floor) had been low previously, and there was an eightfold increase in vaccination in these units during the QI initiative. Although we have no objective data, we believe that the peer comparison reports that were shared each month with these units contributed greatly to the increase in vaccination in these units. This generated a sense of competition among the providers, as well as between the units, and generated a positive feeling about the QI initiative overall.
The limitation of this study is that this QI initiative was conducted at a single freestanding children’s hospital and may not be generalizable to other institutions. Additionally, data were collected over only 1 influenza season, and we do not know if the increase in vaccination seen during our QI initiative can be sustained through future seasons. It is important to note that during the baseline period, systematic inquiry into the vaccination status of patients who were admitted had not been performed. A major part of the QI initiative was to introduce EMR triggers that would remind providers to query parents about the influenza vaccination status of their child so that we could identify patients who needed vaccination. Thus, a smaller number of children were queried during the baseline period, and our baseline data regarding vaccination status before admission and parental refusal are therefore an underestimate of the actual numbers.
There was a decline in the overall percentage of children discharged with at least 1 dose of the vaccine at the end of the season. This was largely because of the decline in local influenza activity detected in our region. We plan to devise strategies in future seasons to maintain the momentum to vaccinate children through the end of the influenza season.
Conclusions
We increased the proportion of children discharged from the hospital with at least 1 dose of the vaccine 4.7-fold during the 2017–2018 influenza season using EMR queries and triggers, provider education, and peer comparison. Increasing vaccination in children across the nation who are hospitalized could increase overall immunization rates in children. The Centers for Disease Control and Prevention estimates that if influenza vaccination is increased even by 5% across the entire population, another 483 000 illnesses, 232 000 medical visits, and 6950 hospitalizations associated with influenza could be prevented.14 Thus, increasing influenza vaccination in the hospital setting can have a significant impact in overall influenza-related morbidity and mortality.
Acknowledgments
We sincerely thank John Putman, MD, for assistance with provider education; Hongjie Gu for assistance with the statistical analysis; Jason Newland, MD, Peter Zassenhaus, PhD, and Charles Samson, MD, for reviewing the article; Angela Niesen, BS, MPH, for obtaining data from the Health Information Management System; and Judith Williams, RN, BSN, and Janet Provinse, BS, for creating the EMR query and obtaining data from our electronic medical records.
Footnotes
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
References
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