Influenza and pneumococcal vaccinations in the emergency department

The Effect of a Quality Improvement Project on Improving Patients' Willingness to Receive an Influenza Vaccination in the Emergency Department

The aim of this project was to increase willingness to receive the influenza vaccine to the optimal rate of ≥ 70%. Low acuity adult patients who visited an Emergency Department (ED) were assessed regarding their willingness to receive the influenza vaccine before and after an educational intervention that included a provider recommendation and an educational handout. A total of seventy-six patients (n = 76) were assessed. Patients' willingness to receive the influenza vaccine rose from 29% pre-intervention to 72% post-intervention without disrupting the clinical flow in a busy ED. Similar vaccine educational strategies can be applied to influenza and other vaccines in EDs  to increase vaccination willingness in patients, including those who use the ED as a primary point of contact for healthcare, decreasing the burden of influenza illness in the community.

Meeting Patients Where They Are: A Nurse-Driven Quality Improvement Project to Provide Influenza Vaccinations in the Emergency Department

INTRODUCTION

Influenza is highly contagious, vaccine-preventable, and may result in significant morbidity and mortality. While vaccination is the primary protection against influenza, vaccination rates remain low. Traditionally, primary care clinics, retail pharmacies, and public health departments offer influenza vaccines. However, offering influenza vaccines in new settings may increase their availability to the public and increase community uptake. This project aimed to add emergency departments as a new influenza vaccine location to increase the number of vaccines distributed during the 2020 to 2021 influenza season.

METHODS

Adult patients discharged from 24 emergency departments were included in this pre- post-intervention project. A nurse-driven order set was established to enhance efficiency. Education materials (scripting, fliers, etc.) were developed to help nurses feel comfortable with vaccine information.

RESULTS

Nurses indicated that education helped increase their belief that influenza vaccination was important. After completing the educational material, a higher number of nurses agreed that it was necessary to encourage others to be vaccinated (P < 0.05). Moreover, emergency department influenza vaccinations increased significantly throughout the 2020 to 2021 influenza season. Nurses across all 24 hospitals administered 2002 vaccines during this season compared to 9 during the previous year's season.

DISCUSSION

The project demonstrated that delivering influenza vaccinations in emergency departments is challenging yet achievable. Educational offerings were valuable resources to increase nurses' knowledge and positive attitudes about providing influenza vaccines to patients. Further studies regarding how vaccinations could be provided in more emergency departments and alternative care sites, such as urgent care and clinics other than primary care providers, are needed.

The Rapid Evaluation of COVID-19 Vaccination in Emergency Departments for Underserved Patients Study

Study objective

Emergency departments (EDs) often serve vulnerable populations who may lack primary care and have suffered disproportionate COVID-19 pandemic effects. Comparing patients having and lacking a regular source of medical care and other ED patient characteristics, we assessed COVID-19 vaccine hesitancy, reasons for not wanting the vaccine, perceived access to vaccine sites, and willingness to get the vaccine as part of ED care.

Methods

This was a cross-sectional survey conducted from December 10, 2020, to March 7, 2021, at 15 safety net US EDs. Primary outcomes were COVID-19 vaccine hesitancy, reasons for vaccine hesitancy, and sites (including EDs) for potential COVID-19 vaccine receipt.

Results

Of 2,575 patients approached, 2,301 (89.4%) participated. Of the 18.4% of respondents who lacked a regular source of medical care, 65% used the ED as their usual source of health care. The overall rate of vaccine hesitancy was 39%; the range among the 15 sites was 28% to 58%. Respondents who lacked a regular source of medical care were more commonly vaccine hesitant than those who had a regular source of medical care (47% versus 38%, 9% difference, 95% confidence interval 4% to 14%). Other characteristics associated with greater vaccine hesitancy were younger age, female sex, Black race, Latinx ethnicity, and not having received an influenza vaccine in the past 5 years. Of the 61% who would accept a COVID-19 vaccine, 21% stated that they lacked a primary physician or clinic at which to receive it; the vast majority (95%) of these respondents would accept the COVID-19 vaccine as part of their care in the ED.

Conclusion

ED patients who lack a regular source of medical care are particularly hesitant regarding COVID-19 vaccination. Most COVID-19 vaccine acceptors would accept it as part of their care in the ED. EDs may play pivotal roles in COVID-19 vaccine messaging and delivery to highly vulnerable populations.

Barriers to Pretransplant Immunization: A Qualitative Interview Study of Pediatric Solid Organ Transplant Stakeholders

OBJECTIVES

To describe the experiences and beliefs of pediatric transplant stakeholders regarding factors that contribute to low pretransplant immunization rates.

STUDY DESIGN

Semistructured interviews were conducted with transplant team members (hepatologists, cardiologists, nephrologists, transplant nurse coordinators, and transplant infectious diseases physicians), primary care physicians, and parents of heart, liver, and kidney transplant recipients at 3 geographically diverse large pediatric transplant centers in the US. Interviews were conducted between July 2017 and February 2020 until thematic saturation was reached within each stakeholder subgroup. Content analysis methodology was used to identify themes.

RESULTS

Stakeholders participated in 30- to 60-minute interviews (16 transplant subspecialists, 3 transplant infectious diseases physicians, 11 transplant nurse coordinators, 12 primary care physicians, and 40 parents). Five central themes emerged: (1) gaps in knowledge about timing and safety of pretransplant immunizations, (2) lack of communication, coordination, and follow-up between team members regarding immunizations, (3) lack of centralized immunization records, (4) subspecialty clinic functioning as the medical home for transplant candidates but unable to provide all needed immunizations, and (5) differences between organ type in prioritization and completion of pretransplant immunization.

CONCLUSIONS

There are multiple factors that contribute to low immunization rates among pediatric transplant candidates. New tools are needed to overcome these barriers and increase immunization rates in transplant candidates.

Attitudes Toward Influenza Vaccination Administration in the Emergency Department Among Health Care Providers: A Cross-Sectional Survey

INTRODUCTION

Influenza is a burdensome and vaccine-preventable infectious disease. Lack of time was reported as a common barrier by Canadians who did not receive their influenza vaccine. Increasing convenient access to vaccination increases uptake, and a potential setting for vaccine administration is the emergency department, where long wait times are common.

METHODS

A cross-sectional survey to gauge health care provider support and perceived barriers and facilitators to delivering influenza vaccine was conducted at 1 emergency and trauma center in Halifax, Nova Scotia. Anonymous questionnaires were completed by a convenience sample of emergency nurses, physicians, and paramedics (n = 82).

RESULTS

In total, 86% (n = 68) of health care providers supported vaccination in the emergency department when sufficient staffing and resources were available. When asked to consider implementation of influenza vaccination in the emergency department based on current staffing and resources, only 59% (n = 48) supported making vaccination available. Most surveyed health care providers preferred screening for vaccination at triage (57%) and supported a nurse-initiated protocol for vaccine administration (74%). After Bonferroni correction, there was no significant association between preference for when to vaccinate and being a nurse or physician (χ²(2) = 6.208, P = 0.05). The highest risk patient groups with the lowest provider endorsement of vaccination were people involved in poultry culling (77%) and pregnant women (83%).

DISCUSSION

Surveyed health care providers were supportive of ED influenza vaccination. However, this study revealed additional barriers that need to be addressed to effectively launch such a program.

Effect of a Computerized Alert on Emergency Department Hepatitis A Vaccination in Homeless Patients During a Large Regional Outbreak

BACKGROUND

While the overall incidence of hepatitis A has declined markedly since the introduction of a vaccine, sporadic cases and outbreaks of the disease continue to occur.

OBJECTIVE

Our aim was to evaluate the effectiveness of an electronic health record (EHR) provider alert as part of an outbreak-control vaccination program implemented in the emergency department (ED).

METHODS

We conducted a retrospective study assessing the impact of a Best Practice Alert (BPA) built into an EHR to prompt providers when a patient was homeless to consider hepatitis A vaccination in the ED. Data were collected over three 6-month time periods: a historical control period, a pre-intervention period, and an intervention period.

RESULTS

There were no vaccinations given in the ED in the historical period, which increased to 465 after the implementation of the BPA. During the implementation period, there were 1,482 visits identified among 1,131 patients that met the inclusion criteria. Of these, there were 1,147 (77.5%) visits where the patient either received the vaccine in the ED, had already received the vaccine, or it was not indicated due to the current medical issue. There were also 333 (22.5%) visits where the BPA was active for potential vaccination eligibility, but did not receive it in the ED.

CONCLUSIONS

We leveraged an informatics tool developed within our EHR to identify high-risk patients and remind providers of the availability of vaccination in the ED. Using these tools enabled providers to increase vaccination efforts within our ED to help control the community-wide outbreak.

Perception of the Risks of Ebola, Enterovirus-E68 and Influenza Among Emergency Department Patients

Introduction

Emerging infectious diseases often create concern and fear among the public. Ebola virus disease (EVD) and enterovirus (EV-68) are uncommon viral illnesses compared to influenza. The objective of this study was to determine risk for these viral diseases and then determine how public perception of influenza severity and risk of infection relate to more publicized but less common emerging infectious diseases such as EVD and EV-68 among a sample of adults seeking care at an emergency department (ED) in the United States.

Methods

We included consenting adults who sought care in two different urban EDs in Seattle, WA in November 2014. Excluded were those who were not fluent in English, in police custody, had decreased level of consciousness, a psychiatric emergency, or required active resuscitation. Patients were approached to participate in an anonymous survey performed on a tablet computer. Information sought included demographics, medical comorbidities, risk factors for EVD and EV-68, and perceptions of disease likelihood, severity and worry for developing EVD, EV-68 or influenza along with subjective estimates of the number of people who have died of each virus over the year in the United States.

Results

A total of 262 (88.5% participation rate) patients participated in the survey. Overall, participants identified that they were more likely to get influenza compared to EVD (p<0.001) or EV-68 (p<0.001), but endorsed worry and concern about getting both EVD and EV-68 despite having little or no risk for these viral diseases. Nearly two-thirds (64%) of participants had at-least one risk factor for an influenza-related complication. Most participants (64%) believed they could get influenza in the next 12 months. Only 52% had received a seasonal influenza vaccine.

Conclusion

Perception of risk for EVD, EV-68 and influenza is discordant with actual risk as well as self-reported use of preventive care. Influenza is a serious public health problem and the ED is an important healthcare location to educate patients.

Pneumococcal vaccination of the elderly during visits to acute care providers: who are vaccinated?

OBJECTIVE

Many elderly remain unvaccinated against invasive pneumococcal disease yet frequently visit acute care providers where they have an opportunity to receive the pneumococcal vaccine. We describe factors associated with pneumococcal vaccination in adults aged 65 years and older during visits to acute care providers.

METHOD

The study included all elderly aged 65 years of age and older enrolled in a health insurance registry in a large Canadian city in 2009. Pneumococcal vaccination status was determined using a vaccination administrative database. Unvaccinated elderly were linked to ambulatory and inpatient care databases to determine acute care visits. Logistic regression was used to determine odds ratios for vaccination during a first visit to an acute care provider in 2009.

RESULTS

Of 53,249 unvaccinated elderly, 23,574 presented to at least one acute care provider in 2009. Acute care visits were significantly associated with receipt of pneumococcal vaccine (11.0% vs. 7.8%, risk adjusted odds ratio [OR]=1.53; 95% confidence interval [CI]=1.44,1.62), particularly ambulatory care visits during influenza season (OR=4.36; 95% CI=2.86,6.66) and inpatient visits with lengths of stay >14 days (OR=7.71, 95% CI=4.41,13.47).

CONCLUSION

Acute care visits were associated with greater pneumococcal vaccine uptake for the elderly during the annual influenza season and long hospital stays.

Comparing Deaths from Influenza H1N1 and Seasonal Influenza A: Main Sociodemographic and Clinical Differences between the Most Prevalent 2009 Viruses

Background. During the 2009 spring epidemic outbreak in Mexico, an important research and policy question faced was related to the differences in clinical profile and population characteristics of those affected by the new H1N1 virus compared with the seasonal virus. Methods and Findings. Data from clinical files from all influenza A deaths in Mexico between April 10 and July 13, 2009 were analyzed to describe differences in clinical and socioeconomic profile between H1N1 and non-H1N1 cases. A total of 324 influenza A mortality cases were studied of which 239 presented rt-PCR confirmation for H1N1 virus and 85 for seasonal influenza A. From the differences of means and multivariate logistic regression, it was found that H1N1 deaths occurred in younger and less educated people, and among those who engage in activities where there is increased contact with other unknown persons (OR 4.52, 95% CI 1.56-13.14). Clinical symptoms were similar except for dyspnea, headache, and chest pain that were less frequently found among H1N1 cases. Conclusions. Findings suggest that age, education, and occupation are factors that may be useful to identify risk for H1N1 among influenza cases, and also that patients with early dyspnea, headache, and chest pain are more likely to be non-H1N1 cases.

Perceptions of participating emergency nurses regarding an ED seasonal influenza vaccination program

INTRODUCTION

Numerous professional organizations have recommended that emergency departments provide influenza vaccine to patients. However, no study has reported on the perceptions of participating emergency nurses regarding ED influenza vaccination programs.

METHODS

We conducted an anonymous Web-based survey to assess the post-participation perceptions of emergency nurses regarding an ED influenza vaccination protocol. The vaccination protocol occurred at an urban, academic emergency department and was designed to be performed by emergency nurses without added staffing resources by using ED Electronic Medical Record technology. Data from the Web-based survey were analyzed using descriptive statistics and χ(2) analysis to assess significant associations of where emergency nurses believed the protocol was time inefficient.

RESULTS

The ED influenza vaccination protocol was in effect from October 1-25, 2009, with 3091 eligible ED visits and 613 patients receiving ED seasonal influenza vaccination. Fifty-eight of 59 participating emergency nurses (98%) responded to the survey. Significant findings were that 59% of responding emergency nurses found the protocol too time consuming and believed it was inappropriate in the ED setting. Responding emergency nurses reported that protocol efficiency could be improved by adding staff, simplifying screening and vaccination documentation requirements, and improving vaccine supply and stocking procedures in the emergency department.

CONCLUSION

A majority of surveyed emergency nurses who had participated in an ED influenza vaccination program reported that the protocol was too time consuming and inappropriate for the ED setting. Surveyed emergency nurses expressed the opinion that such protocols required added staff, simplified patient consent/vaccination documentation requirements, and improved vaccine supply and stocking processes.