Vaccinating in the Emergency Department, a Model to Overcome Influenza Vaccine Hesitancy

Abstract

Introduction: Vaccine hesitancy and delays in vaccine administration time have limited the success of prior influenza vaccination initiatives in the pediatric emergency department (ED). In 2018-2019, season 1, this ED implemented mandatory vaccine screening and offered the vaccine to all eligible patients; however, only 9% of the eligible population received the vaccine. In 2019-2020, season 2, the team sought to improve influenza vaccination rates from 9% to 15% and administer over 2,000 vaccines to eligible ED patients.

Methods: Key drivers included: identifying vaccine hesitancy, providing counseling, reducing administration delays, and developing reminders for vaccine administration. We tested interventions using plan-do-study-act cycles. We included discharged ED patients, age 6 months-18 years old, emergency severity index score 2-5, and no prior vaccine this season. Process measures included percent of patients screened, eligible, accepting the vaccine, and leaving before vaccination. Outcome measures were the percent of eligible patients vaccinated and the total number of vaccines administered. Vaccination time was the balancing measure.

Results: We included 57,804 children in this study. Comparing season 1 to 2, screening rates (84%) and eligibility rates (58%) were similar. Vaccine acceptance rates improved from 13% to 22%, the proportion of patients leaving before vaccination decreased from 32% to 17%, and vaccination rates improved from 9% to 20%. Total vaccines administered increased from 1,309 to 3,180, and vaccination time was 5 minutes faster in season 2.

Conclusions: This ED influenza vaccination process provides a model to overcome vaccine hesitancy and can be adapted and replicated for any vaccine-preventable illness.

Fig. 1.

Timeline depicting 4 critical interventions (EHR enhancements, nursing and provider education, nursing and provider recognition, and pharmacy workflow) and significant changes over time. Stages of the interventions: (P) planning, (D) doing, (S) studying, and (A) acting.

Fig. 2.

Process map summarizing the emergency department (ED) influenza vaccine administration process at the end of season 2. Shading represents the different stages of the project. Stage 1 represents the baseline process, and stages 2A and 2B represent process improvements made to the workflow throughout season 2.

Fig. 3.

Improving influenza vaccination rates by increasing the percent accepting vaccines and decreasing the percent leaving without vaccination over seasons 1 & 2. A, P chart comparing vaccine acceptance rates in eligible patients between seasons 1 and 2. B, P chart comparing the percent of accepting patients leaving before vaccination in seasons 1 and 2. Critical interventions are documented. LCL, lower control limit; UCL, upper control limit.

Fig. 4.

P chart comparing vaccination rates in eligible patients across season 1 (blue diamonds) and season 2 (red triangles). Special cause seen in this figure did not correlate with our interventions and was attributed to seasonal variation: therefore, we did not shift the baseline. LCL, lower control limit; UCL, upper control limit.