Improving Influenza Vaccination Rates Among Pediatric Hematology and Oncology Inpatients

Ashley Duvall


Pediatr Nurs. 2019;45(3):142-154+ (box o. 

In This Article

Literature Review

The focus of this literature review is on implementation of an efficient influenza vaccine screening and administration process to improve influenza vaccination rates among pediatric hematology and oncology inpatients. The review begins broadly with the evidence supporting influenza vaccinations among high-risk pediatric patients, such as those on the hematology/oncology unit. This discussion is followed by a review of studies using electronic screening tools and automated alerts in the EMR to improve vaccination rates among inpatients. Finally, the review concludes with current evidence regarding specific provider and patient education strategies to sustain desirable influenza vaccination outcomes among the high-risk pediatric inpatient population. The literature was reviewed and evaluated using a rating system for hierarchy of evidence by Melnyk and Fineout-Overholt (2014) and a rating scale for quality of evidence by Newhouse (2006) (see Table 1).

The first step in implementing an influenza vaccine screening and administration process is identifying those in the high-risk pediatric population who have not yet been vaccinated against influenza. High-risk pediatric patients have been identified as those with HIV infection, diabetes mellitus, rheumatic disease, chronic heart disease, chronic lung disease (including asthma), oncologic disorders, metabolic disease, renal disease, immunodeficiency, and more (Aigbogun et al., 2015). Hofstetter and colleagues (2015) report influenza vaccination is critical in immuno-compromised children because there is a higher association with respiratory failure in these children infected by influenza. Several investigators focused attention on the positive impact the EMR poses on improving vaccination rates among identified high-risk pediatric populations (Aigbogun et al., 2015; Fiks et al., 2009; Freedman et al., 2015; Patwardhan, Kelleher, Cunningham, & Spencer, 2011; Teufel et al., 2008).

Additional studies focused on using the EMR to increase immunizations by implementing automated alerts or reminders. Technology-based interventions are highly effective in reducing missed opportunities and improving vaccination rates (Fiks et al., 2009; Gerard et al., 2008; Hofstetter et al., 2015; Patwardhan et al., 2011; Pollack, Kronman, Zhou, & Zerr, 2014). Patwardhan and colleagues (2011) published a retrospective study that focused on implementing an electronic automatic alert reminder to vaccinate patients in the pediatric rheumatology specialty areas. Influenza vaccination rates increased after intervention from 5.9% in 2007 to 25.5% in 2009 (Patwardhan et al., 2011). Fiks and colleagues (2009) assessed the implementation of EMR clinical alerts for influenza vaccine on overall influenza immunization rates in patients ages 5 to 19 years. Influenza vaccination rates improved 3.4% more at intervention sites than at control sites (Fiks et al., 2009). Gerard and colleagues (2008) evaluated the impact of automatic preselected computerized physician order entries (CPOE) generated by an electronic vaccine screening tool. By the third year of the study, 83% of preselected orders were accepted by physicians, and patient vaccination rates increased by 36% (Gerard et al., 2008).

Although automatic reminders and alerts are effective in increasing vaccination rates, several studies support a more multifaceted approach (Aigbogun et al., 2015; Freedman et al., 2015; Hofstetter et al., 2015; Pollack et al., 2014). For example, Freedman and colleagues (2015) conducted a retrospective study on 1,128 patients to determine the impact a multifaceted approach had on the rate of immunization. This multifaceted approach included providing family and provider education, electronically identifying patients due for the vaccine, and having a vaccine order built into the admission order set. Freedman and colleagues (2015) suggested that family and provider education in conjunction with health informatics contributed to an increase in vaccine rate by 20.1% over the 2-year period (Freedman et al., 2015). Pollack and colleagues (2014) compared influenza vaccination rates of pediatric inpatients before and after the introduction of an automated hospital-based screening program to employ the EMR. This retrospective cohort study of 11,194 patients showed the percentage of those screened electronically for influenza vaccines increased drastically from 19.8% to 81.1% between the 2003 and 2012 flu seasons (Pollack et al., 2014).

Pediatric influenza vaccination rates have improved by using an electronic screening tool, automatic notifications and alerts, and provider and family education. Patients who are screened upon admission to the hospital have a higher likelihood of being vaccinated against influenza prior to discharge (Patwardhan et al., 2011; Pollack et al., 2014). Identifying pediatric inpatients who are eligible for influenza vaccination will help reduce missed opportunities (Hofstetter et al., 2015). The literature strongly supports the implementation of an electronic screening tool in combination with automatic notification alerts, family education, and provider education as a multifaceted approach to gain the most significant influenza vaccination results (Aigbogun et al., 2015; Freedman et al., 2015; Hofstetter et al., 2015; Pollack et al., 2014).

Despite these efforts, there is an increasing trend toward vaccine hesitancy by parents and caregivers (Dubé et al., 2013). There is a perceived lack of confidence in vaccines, negatively impacting the success of vaccination programs. Individual decision-making regrading vaccination is complex and involves emotional, cultural, social, spiritual, political, and cognitive factors. The safety and efficacy of vaccination need to be emphasized, and efforts should be made to listen to the public's concerns and understanding their perceptions (Dubé et al., 2013).