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Small modifications to hospitals' admission protocols and electronic health records (EHR) systems to promote kids' influenza vaccinations markedly boosted immunizations, researchers found in a controlled trial.

In-hospital vaccinations were given to 31% of eligible children targeted by the intervention in the 2019-2020 flu season, compared with 19% among similar children receiving usual care that season, according to Evan Orenstein, MD, of Emory University in Atlanta, and colleagues.

The trial was conducted at three Atlanta-area children's hospitals, in which the overall in-hospital vaccination rate during the previous flu season was 14% (i.e., historical controls), Orenstein's group reported in .

Key features of the intervention included:

• Items related to vaccination eligibility and acceptance added to the EHR's admissions questionnaire that nurses went through with parents
• EHR order group for flu vaccination that automatically appeared the day after admission, for patients deemed eligible and appropriate
• "Just-in-time" education included in the EHR on vaccine appropriateness for certain groups, such as those with cancer or egg allergy
• Information sheet for clinical staff explaining the potential benefits of in-hospital vaccination, providing answers to common questions and concerns from parents, and basic facts about the vaccine

For instance, nurses at admission asked whether the child had already gotten a flu vaccination. Parents who said no or weren't sure were told that the only medical reason not to have one is because of past anaphylactic reactions, and were asked if their child had such a history. If the answer was no but the parent still refused the vaccination, the EHR instructed the admitting nurse to ask the reason and then discuss it with an MD for potential follow-up with the parent. The wording was such that the default was to vaccinate, with parents having to definitively opt out.

One of the program's goals was to obtain initial parental consent and then get the vaccine administered quickly, Orenstein and colleagues noted. Previous in-hospital vaccination efforts typically relied on physicians to remember to ask parents about vaccination. And if they did, administration often was put off until discharge, when it could be skipped or forgotten among the many other required tasks. Delays also gave parents more opportunity to change their minds.

The intervention was rolled out in phases, initially involving general pediatric admissions at one of the three hospitals, then expanding to the other two and including specialty admissions. It imposed relatively little extra burden on staff, the researchers asserted, because it was integrated into the regular routine and allowed substantial flexibility for vaccine administration.

As a result of this stepped implementation, half of the approximately 11,000 nominally eligible patients were subject to the intervention. The other half, who were admitted during the 2019-2020 season to hospitals or services in which it had not yet been adopted, served as concurrent controls. Another 6,743 patients admitted in the 2018-2019 season were historical controls.

But it was not as successful as it could have been, Orenstein and colleagues indicated, despite the "opt-out" structure built into the protocol. Vaccination was ordered for 4,199 children subject to the intervention, of whom just 1,676 actually received it.

"This gap between orders and administrations may be due to vaccine refusal or other unknown barriers," the researchers wrote.

Other takeaways from the study included the success of the phased implementation, in the investigators' view, which allowed "a reduced burden of change management" and provided opportunities to alter program details with early feedback from staff and patients.

"For example, early in our first pilot on the general pediatrics service, several pharmacists noticed that influenza vaccine orders that were not administered within 12 hours of their due time would fall off the medication administration record for nurses, reducing their administration flexibility. We were able to fix this by changing the frequency setting in the EHR prior to the subsequent rollout of the intervention," Orenstein and colleagues wrote.

Some features of the study could limit its applicability elsewhere, the group cautioned. Hospitals' "organizational culture" and "technical infrastructure" vary widely and may influence how such an intervention is received. Also, the researchers didn't examine the reasons why so many vaccine orders didn't result in actual vaccination.

"Additional work to understand persistent reasons for low uptake and the potential effect of combining [clinical decision support] with other behavioral economic and implementation science interventions would likely reduce the burden of influenza in a vulnerable population and provide lessons to improve vaccine coverage for other diseases, such as COVID-19," Orenstein and colleagues concluded.

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