An initiative to improve pneumococcal immunization counseling in children with nephrotic syndrome

Abstract

Background: Immunization is essential in preventing life-threatening pneumococcal infections in children with nephrotic syndrome. An additional 23-valent pneumococcal polysaccharide vaccine (PPSV23) series is required for children with nephrotic syndrome. Despite current practice guidelines, many children with nephrotic syndrome do not receive PPSV23.

Methods: Our nephrology clinic conducted a quality improvement project to improve the overall rate of PPSV23 counseling to more than 70% within a 12-month period by applying several targeted interventions to raise providers' awareness, improve communication with primary care providers, and increase provider adherence. Data was collected from the electronic health record (EHR), and monthly performance was tracked via monthly control charts and overall immunization counseling rate charts.

Results: We increased adherence to PPSV23 vaccination counseling from a baseline of 12 to 86%. The first intervention that effectively increased the vaccine counseling rate from 12 to 30% was improving a provider's awareness of the PPSV23 literature and vaccine guidelines. Other interventions included regular performance reviews at division meetings, creating an immunization protocol, posting performance charts on the office bulletin board, and unifying vaccine recommendation templates. Lastly, specific and timely EHR reminders improved the total counseling rate from 52 to 86% and maintained adherence until the completion of the project.

Conclusion: Bridging the knowledge gap in provider awareness and using specific EHR reminders can improve adherence to PPSV23 counseling in children with nephrotic syndrome. Such interventions could be applied to similar groups of immunocompromised patients in whom additional vaccines are indicated. A higher resolution version of the Graphical abstract is available as Supplementary information.

Keywords: Electronic health records; Immunization; Nephrotic syndrome; Pediatrics; Pneumococcal; Quality improvement.

A higher resolution version of the Graphical abstract is available as Supplementary information.

Fig. 1

Key driver diagram. Multiple interventions were planned and implemented in a sequential manner. Green-colored interventions have been implemented. Grey-colored interventions are ideas to be considered in the future. EHR, electronic health record; PCP, primary care physician

Fig. 2

Control chart of monthly vaccination counseling rate. Different interventions led to variable degrees of improvement in PPSV23 monthly counseling rates. The center line was shifted at month 8, when timely EHR-based reminders were initiated. The numerator is the number of eligible patients who received counseling (or vaccination) in each month. The denominator is the total number of eligible patients seen in clinic in that month. CL, center line; LCL, lower control limit; UCL, upper control limit

Fig. 3

Overall cumulative vaccination counseling rate. Several interventions were implemented. The quality improvement project’s specific aim was to reach more than a 70% counseling rate of eligible nephrotic syndrome patients within a 12-month period and this aim was achieved in month 11. The numerator is the cumulative total number of eligible patients who received counseling (or vaccination). The denominator is the cumulative total number of eligible patients actively followed in our clinics