While influenza vaccination is important for all children, it is critical that pediatric patients with cancer get a flu shot because their weakened immune systems leave them especially vulnerable to severe infections. A quality improvement project at The Children’s Hospital of Philadelphia used simple strategies and cues for families and clinicians to ensure that these children did not leave outpatient clinics or inpatient units without any protection from the insidious virus.
Influenza hospitalizes and kills more people in the U.S. than any other vaccine-preventable disease. Because strains of influenza virus that circulate can differ from one season to the next, new influenza vaccine is available each September. The Centers for Disease Control and Prevention recommend that all children at least 6 months old should get the flu vaccine each year, as soon as it is available in their community. Healthy children can opt for a nasal spray version of the vaccine, but children who have cancer and are immunocompromised receive the flu shot, which does not contain live virus.
“Historically at CHOP, about 53 to 56 percent of patients with cancer were getting the flu vaccine,” said Jason L. Freedman, MD, MSCE, an attending physician in the Division of Oncology at CHOP. “Some parents fear: My child has cancer, why would I give them a vaccine on top of this? They may not realize that the ramifications of being unvaccinated are much worse. If you’re immunosuppressed and can’t fight the virus, it could be fatal.”
Dr. Freedman and colleagues decided to improve the Division of Oncology’s track record for flu vaccinations by implementing a multifaceted quality improvement initiative. Between September 2012 and March 2013, they focused on five overlapping interventions that took advantage of multiple opportunities during outpatient visits to identify patients who needed an annual flu shot and communicate the importance of early vaccination.
They started by boosting family education. Informational handouts and posters in physician waiting rooms encouraged patients to ask their physicians about flu vaccination. The next critical piece was working with the CHOP health informatics team to generate from the electronic health record a color-coded daily list of outpatients due for vaccination. As patients had their vital signs taken, the triage staff and nurses would ask, “Did you get the flu vaccine?” Patients who still needed flu shots received bright yellow colored wristbands as an alert to clinicians to order the vaccine. The study team provided education for clinicians during staff meetings on how to order the vaccine correctly and document any refusals or contraindications.
“On the inpatient side, we also saw discharge as an opportunity for vaccination,” Dr. Freedman said. “We built in an order for the flu vaccine into their admission order set. So when clinicians are admitting a child for chemo, there is already a prompt to order the flu vaccine for when they go home, which was a huge area of missed opportunity.”
The interventions were implemented in tandem, so while the research team is unable to pinpoint which interventions made the most difference, overall they increased the complete flu immunization rate by 20.1 percent to 64.5 percent. The proportion of patients receiving at least 1 dose of vaccination went up by 22.9 percent to 77.7 percent. In 2013, the oncology team continued to reinforce the process changes that they implemented during the study period, and they were able to sustain those rates, Dr. Freedman said.
“We augmented the opportunity for vaccination,” Dr. Freedman said. “The key to the success of this initiative is it was multifaceted and multidisciplinary. It has become part of our culture in clinic, and everyone has a sense of comradery about catching someone falling through the cracks.”
Other pediatric healthcare institutions could easily adapt this project to their settings with little expense or upkeep, Dr. Freedman pointed out. He also anticipates that similar approaches could be used within future quality improvement efforts to increase vigilance in other areas of pediatric cancer care, such as facilitating adherence to medication.
“This study shows that putting together new process changes, while it requires attention, education, and people who are invested, is feasible, doable, and affordable,” Dr. Freedman said.
The results of this study appeared online Jan. 12 in Pediatrics.