Improving Influenza Vaccination Rates Among Pediatric Hematology and Oncology Inpatients

Ashley Duvall


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

In This Article


Description of Project, Setting, and Sample

This quality improvement project took place at a large, academic, pediatric hospital located in a metropolitan area, serving a diverse population. The sample consisted of pediatric inpatients older than 6 months of age, admitted to and discharged from the hematology/oncology unit over 4 weeks. The sample size was determined by the total number of eligible patients to receive influenza vaccines prior to discharge (N=173).

Inclusion and Exclusion Criteria

Inclusion criteria included patients 6 months of age or older admitted to either the hematology or oncology service. Exclusion criteria included patients who had already received the flu vaccine during the current flu season, patients who had a previous serious reaction to influenza vaccine or its components, serious allergic reaction to eggs, history of Guillain-Barré syndrome within 6 weeks of a previous influenza vaccine, bone marrow transplant within the past 6 months, anaphylactic latex allergy, or patient/parent declination. These criteria were documented in the admission database form, which was then pulled from a report and analyzed (as discussed below). The CDC (2017) supports the safety and efficacy of influenza vaccines. Those whose influenza vaccination history was unknown were considered eligible and should have received an influenza vaccine prior to discharge from the hospital because there is no clinical harm in receiving more than one vaccine (CDC, 2017).

Procedures and Timeline

Preparation. This project took place over a total 10-week period. The preparation phase began with weeks 1 and 2 during the month of September. Preparation included the recruitment of another nurse and the unit's nursing educator to serve as influenza vaccine champions to be responsible for helping to train other nurses.

Education. Weeks 3 and 4 during the month of September included the education phase. The project leader trained a nurse champion so she could help the project leader train other nurses. Approximately 70 nurses from the hematology/oncology unit and float pool received training with a step-by-step display of how to complete the flu vaccine screening and administration process (see Table 2). At the end of the training, all nurses were required to have either the project leader or the champion be present and observe them during a mock admission, using a test domain on Cerner (the electronic medical record software). Support and feedback were provided as needed. The project leader used an Excel spreadsheet to keep track of nurses as they completed the training. This spreadsheet was shared with the nurse champion and updated with any newly hired nurses.

Providers on the hematology/oncology service received training from the project leader, and focused more on the influenza vaccine ordering and verification process. The process was demonstrated in a 10-minute presentation at a daily conference where all residents gather for educational purposes (see Table 3). Within a week of the go-live-date, the unit nursing educator sent a reminder email to all staff nurses with written instructions on how to complete the vaccine screening and administration process, including screenshots of the IT changes (see Figures 1 and 2). An "Influenza Vaccine Resource Binder," containing copies of the step-by-step process, summarized nurse and physician roles, and sample copies of the vaccine information sheet (VIS) were provided to the hematology/oncology unit and made easily accessible at the nurses' work station.

Figure 1.

Flu Vaccine Screening Template
Note: Exclusion criteria in question 3 should reflect the most recent recommendations from the Centers for Disease Control and Prevention for contraindications to the influenza vaccine.

Figure 2.

Medication Administration Record (MAR) Influenza Vaccine Order
Notes: The inactivated influenza vaccine order for those children 6 months to 35 months old (0.25 mL) and 36 months or older (0.5 mL) will be "unscheduled" and "on-call." This is to ensure the vaccine order will not appear overdue, and will always be available on the patient's MAR until it is given and documented.

The pharmacy department was made aware of the planned project. The unit-based pharmacist was invited to attend a training session. The pharmacy department chair sent an email and informed the pharmacy staff that influenza vaccines would be ordered as unscheduled to be given on the day of discharge or when most appropriate for the patient. Nursing leadership staff also attended a training session and were used as additional champions on day shift so more nurses could be efficiently educated. This helped bring situational awareness to the QI project.

Implementation. This phase of the project took place during weeks 5 through 8 (October) and began with the go-live date (October 1, 2017) when the influenza vaccine screen was activated and became a mandatory field within the admission database. This go-live date was determined when the hospital received its vaccine supply and gave the approval to start. As a part of the admission assessment, the admitting nurses completed the "flu vaccine screening" pertaining to current vaccine status and determined if the patient met any exclusion criteria (see Figure 1). If the patient met eligibility criteria, an automatic text box would be accessible to take the nurse directly to the paging system from the admission database. The nurse paged the admitting provider, and the vaccine was ordered and verified by the pharmacy department. The order appeared on the medication administration record (MAR) as an unscheduled medication, inactivated influenza vaccine (see Figure 2). The patient's nurse requested the vaccine from the pharmacy department when appropriate to administer, educated the primary family caregiver with the VIS (see Figure 3), administered the vaccine to the patient, and documented education and administration in the EMR. The patient was often discharged immediately after receiving the vaccine and VIS education.

Figure 3.

Flu Vaccine Screening Responses and Vaccine Status Report Sheet

Data Collection

During weeks 9 through 10 (November), a paper survey in the format of a System Usability Scale (SUS) was used to gain feedback from nurses and physicians regarding the overall flu vaccine process. The SUS is a reliable, low-cost usability scale that can be used to assess the overall usability of the flu vaccine screening and administration process within the EMR by addressing effectiveness, efficiency, and satisfaction of the electronic system process (Brooke, 1996). Bangor, Korthum, and Miller (2008), and Sauro and Lewis (2011) have shown SUS is applicable over a wide range of systems and types of technology. Bangor and colleagues (2008) collected numerous data on the use of SUS with a variety of systems and technologies, and have analyzed over 3,500 SUS results that supported the scale's reliability.

Additional data were collected to evaluate responses to the admission database flu vaccine screen and overall influenza vaccination rates on the hematology/oncology unit. Data collection began during the implementation phase so compliance could be closely monitored. The hospital's data analyst queried an electronic report in the form of an Excel spreadsheet. The report included responses to the flu vaccine screening questions and whether the vaccine was administered prior to discharge (see Appendix 1). Any protected health information (PHI) used to run this report was kept internally with the Cerner data analyst. Data were stripped of any patient identifiers before being accessed by the project leader. The influenza vaccination rates were reported on a weekly basis to staff via email and a dashboard posted to the unit to help maintain momentum and awareness (Freedman et al., 2015).

Appendix 1.

Sample Vaccine Information Sheet (VIS)

Data Analysis

SUS yields a single number representing a composite measure of the overall usability of the system being studied. Scores for individual items are not meaningful on their own (Brooke, 1996). To calculate the SUS score, the project leader added the score contributions from each item. Each item's score contribution ranges from 0 to 4. For items 1, 3, 5, 7, and 9, the score contribution is the scale position minus 1. For items 2, 4, 6, 8, and 10, the contribution is 5 minus the scale position. The project leader then multiplied the sum of the scores by 2.5 to obtain the overall value of system usability. SUS scores have a range of 0 to 100.

An analysis between pre- and post-intervention was used to compare influenza vaccination rates during a 4-week period (December 2016 and October 2017). A rate comparison was calculated using the number of those eligible and vaccinated versus total number eligible.

Measures to Protect Human Subject

The hospital's general consent to treatment upon admission includes inpatient vaccinations. This consent is kept in the patient's paper chart located on the unit. During the data collection phase, Cerner's data analyst stripped the electronic report of any PHI before the project leader had access to it. This project was approved by the University of Maryland Baltimore (UMB) Institutional Review Board (IRB) for a Non-Human Subjects Research (NHSR). Separately, it was also approved by the organization's Nursing Research Advisory Council (NRAC) and IRB submission at the organization.

Plans for Sustainability

The incorporation of the text box with automated accessibility to the paging system to notify providers to order influenza vaccines will serve as a permanent change to the EMR. This will help to ensure sustainability of the project. The admission database flu vaccine screening criteria may have to be modified annually to reflect the most current CDC recommendations.