Quality Improvement Initiative to Improve Time and Adherence to Revaccination after Hematopoietic Cell Transplantation: Implementation of a Revaccination Clinic within the Transplantation Program

Abstract

Revaccination after hematopoietic cell transplantation (HCT) is critical to prevent morbidity and mortality from vaccine-preventable illnesses. The global aim of our quality improvement initiative was to enhance timely, correct, and effective revaccination after pediatric HCT. The SMART aim of our project was to decrease median unvaccinated time by 4 months by decreasing the time to vaccine eligibility, time from eligibility to vaccine initiation, and time to completion of the vaccine series. A multidisciplinary group performed a cross-sectional quantitative and qualitative evaluation of revaccination practices at our institution. We identified factors associated with delayed, incorrect, or incomplete revaccination. Several plan-do-study-act interventions were implemented to address these drivers, including revising immune readiness criteria, increasing auditing of primary care administered immunizations, and, importantly, establishing a dedicated revaccination clinic within the HCT clinic at our center. The time to vaccine eligibility decreased from 12.6 months to 10 months (a 20% decrease), and the time to complete the vaccine series decreased from 19.3 months to 15.7 months (a 19% decrease). With a quality improvement initiative, we addressed the many causes of delayed or incomplete revaccination post-HCT and through a team-based approach successfully decreased the time to vaccine start and time to vaccine completion at our center.

Keywords: Immune reconstitution; Immunizations; Pediatrics; Quality improvement.

Figure 1.

Primary and secondary drivers of challenges to effective and timely post-hematopoietic cell transplantation (HCT) vaccine delivery.

Figure 2.. Demonstration of primary outcome metrics over time: (A) Time to meeting eligibility criteria (months), (B) Proportion starting vaccination within two months of eligibility, and (C) Proportion starting vaccination within 13 months of transplantation.

Boxed letters denote implementation of different interventions. [A] revised vaccine readiness criteria in two phases, [B] opening of revaccination clinic within the HCT clinic, [C] bundling of revaccination services with transplant services, [D] auditing of primary care-based vaccinations, [E] implementation of automated services. Arrows denote time of implementation although x-axis represents date of transplant, so interventions are interpreted as impacting patients transplanted at least 8 months prior.

Figure 3.. Time to completion of vaccine series over time.

Boxed letters denote implementation of different interventions. [A] revised vaccine readiness criteria in two phases, [B] opening of revaccination clinic within the HCT clinic, [C] bundling of revaccination services with transplant services, [D] auditing of primary care-based vaccinations, [E] implementation of automated services. Arrows denote time of implementation although x-axis represents date of transplant, so interventions are interpreted as impacting patients transplanted at least 8 months prior.

Figure 4.. Location of vaccine receipt over time. Shading represents location where vaccine was received.

Abbreviations: PMD Primary care office; CHOP Revaccination within CHOP transplant/oncology clinic