Pediatric urgent care clinicians evaluate ways to fill routine immunization gaps
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Key takeaways:
- Some provider-focused interventions improved immunization screening, but COVID-19 surges confounded the results.
- Having a designated nurse vaccinator doubled administration rates and reduced declinations.
Incorporating immunization screening and adding a designated nurse vaccinator appeared to improve vaccine uptake at a pediatric urgent care clinic in San Francisco, according to a single-center study published in Pediatrics.
As Healio previously reported, the COVID-19 pandemic caused many children to miss doses of routine vaccines. In an effort to improve vaccine uptake, the San Francisco Health Network began allowing its pediatric urgent care clinic to administer vaccines to patients who were overdue.
“We initiated a quality improvement project when performance data became available in March 2021, hypothesizing that a blend of interventions directed at providers would influence decision-making,” David M. Gordon, MD, MPH, codirector of the Children’s Health Center at Zuckerberg San Francisco General Hospital and associate clinical professor of pediatrics at University of California San Francisco, and colleagues wrote. “We aimed to administer all overdue CDC-recommended immunizations for age during 50% of visits by eligible patients.”
Gordon and colleagues implemented four plan-do-study-act cycles with different interventions between June 28, 2021, and Feb. 19, 2023, at their clinic to see which ones increased immunization uptake.
The first cycle added a vaccine menu to the patient medical history notes, which could not be signed until an item was selected. In the second cycle, clinic staff put a sign in the staff room that read, “Vaccines OK?” with yes and no options for nurses to change if immunizations were not doable at the time.
The third cycle updated staff workflow to discuss vaccines in daily team meetings, added a closed-loop messaging system for providers and nurses to communicate about vaccine orders, and moved the vaccine menu to the “history of present illness” section of the note template, which was more visible. In the fourth cycle, the clinic recruited a designated nurse vaccinator to identify patients who needed immunizations and administered them at the clinic.
Over the study period, the urgent care clinic had 2,717 visits from patients who were eligible for vaccines. Providers screened patients for immunization status at 1,303 visits (48%), and patients received all recommended vaccines at 629 of them (23.2%). Patients or their families declined immunizations at 674 visits (51.7% of those screened).
From the first to fourth cycle, average screening rates increased from 44.7% to 67.4%. Vaccine administration rates decreased during cycle two from 26.5% to 16.2%, but they nearly tripled during the fourth cycle to 50.8%. The proportion of declinations fell from 54.8% to 31.4% during the fourth cycle.
The authors noted that the COVID-19 omicron surge occurred during the second cycle, which caused nurse staffing shortages that impacted immunization screening and administration. The surge ended during the third cycle, but vaccine screening and immunization did not improve until the fourth cycle.
Gordon and colleagues cited staffing turnover as a possible reason why previous interventions were not as effective.
“Over half of the attending pediatricians in our pediatric urgent care had no recent experience managing immunizations, residents rotated every 14 days, and nurses were deployed elsewhere throughout the COVID-19 response,” they wrote. “The provider-centered approach may be more effective at pediatric urgent cares with consistent staffing and workload.”
Although the addition of a designated nurse vaccinator appeared to increase immunization uptake significantly, “conclusions from our study should be made cautiously because provider-facing interventions may have acted synergistically with the designated nurse vaccinator program,” Gordon and colleagues wrote.
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