Evaluating Interventions to Increase Influenza Vaccination Rates among Pediatric Inpatients

Children with certain medical conditions are at higher risk of influenza-related complications, yet studies suggest low influenza immunisation rates among paediatric inpatients and gaps in vaccine ordering during hospitalisation. The objectives of the study were to introduce and evaluate the effectiveness of provider and family-directed interventions to increase influenza vaccination ordering among inpatients in Colorado, United States (US).

Despite recommendations from the Advisory Committee on Immunization Practices and the American Academy of Pediatrics for universal influenza vaccination for individuals 6 months of age and older, national immunisation rates were 59% among children during the 2014–2015 season, remaining below national objectives, highlighting a need to provide vaccination at every opportunity.

For this study, the patient population consisted of all inpatients aged 6 months of age and older admitted to a large paediatric tertiary care hospital between September 1 2014 and to October 12 2014 (preintervention period) and October 13 2014 and March 30 2015 (intervention period) without contraindications to the vaccine.

Baseline data demonstrated that influenza vaccination is a high priority for physicians, but lack of time, forgetting to order the vaccine, and provider belief of caregiver misconceptions about vaccination are central reasons for failure to order the vaccine. Additionally, parents understood the seriousness of influenza infection, the safety, and effectiveness of the influenza vaccine and were open to inpatient influenza vaccination.

There were 2 intervention groups (provider reminders and family education) and 1 control group for comparison, using electronic medical record (EMR) prompts alone.

• For the provider reminder group, clinical support staff provided a team-specific vaccination status report (at the patient level) to residents each morning before rounds, sent weekly emails indicating influenza vaccination status for each medical team to residents and attending physicians on the medical teams, and posted visual reminders regarding influenza vaccination ordering in workrooms and computer workstations. Influenza immunisation dashboards were used to generate reports that outline the immunisation rates for inpatients based on data from best practice advisory data by treatment team and unit.
• For the family education group intervention, research assistants provided an education handout to parents/guardians (or inpatients if age-appropriate) on admission, regarding the benefits and safety of influenza vaccination. The handout was originally created for the current project but was also made available on the hospital's website. The handout was available in English and Spanish, the primary languages for most families seen at the institution.

The researchers measured vaccine ordering rates for each group among eligible children and overall vaccination rates. Among 2,552 patients aged older than 6 months hospitalised during the study period, 1,657 were unimmunised. During the intervention period, the provider group ordered 213/409 (52%) influenza vaccines, the family education group ordered 138/460 (30%), and the control group ordered 71/279 (25%) (P < 0.0001). The provider group had higher influenza immunisation status than the control group (61% versus 53%; P = 0.0017).

The researchers indicate that they anticipated even higher vaccine ordering rates, given the nature of the interventions, and explored potential barriers that exist in the inpatient setting identified in provider surveys. They found that reluctance to vaccinate during illness or the perception that vaccination should be a task reserved for the primary medical home were not widely held beliefs. Therefore, the reasons for the observed rates warrant further exploration.

Among a subset of 158 caregivers in the family education group selected to participate in a pre- and during-intervention survey, 149 completed preintervention surveys. After the education intervention, family members were more likely to agree that influenza vaccines work well to prevent against influenza (71% versus 47%; P < 0.0001), realise that influenza vaccination was available to their child while inpatient (87% versus 74%; P = 0.0013), and report being asked about influenza vaccination during their admission (92% versus 86%; P = 0.03).

Family education was not as effective as provider reminders, with a decrease in vaccine orders among this group toward the latter third of the study period. This decrease occurred despite an increased positive attitude toward influenza vaccination, as evidenced by pre- and intervention survey data. One of the reasons for decreased rates in the family education group: Unvaccinated children toward the end of the season may include a higher proportion of vaccine-hesitant families, who may be less likely to be impacted by education materials.

In short, this investigation demonstrated that provider reminders led to an approximately 30% increase in influenza vaccine orders among paediatric inpatients on the medical unit, which was sustained over the season. Provider reminders in the form of emails, data reports, and visual aids were more successful than family education and prompts in the EMR alone. The researchers conclude that such reminders are simple, sustainable, ways to enhance existing features in the EMR, and that they are a useful method of increasing influenza vaccination rates among paediatric inpatients.