Offering Flu Vax at ED Discharge Boosts Uptake Rates

A Wisconsin pediatric emergency department (ED) implemented a screening protocol that significantly increased flu vaccination rates in a traditionally undervaccinated population, a researcher reported.

Compared with the 2018-2019 flu season, the proportion of children vaccinated increased from 9% to 20% in the 2019-2020 season after Children’s Wisconsin implemented an electronic health record (EHR) infrastructure that allowed nurses to screen, counsel, and refer all children presenting to the ED for flu shots at discharge, reported Shannon Baumer-Mouradian, MD, of the Medical College of Wisconsin in Milwaukee.

Of children vaccinated, about 75% had Medicaid, and half were racial and ethnic minority patients, who have been reported to have lower vaccination rates, Baumer-Mouradian said at the American Academy of Pediatrics (AAP) virtual meeting.

“Many of our children are uninsured or underinsured, and they do use the [ED] as their medical home,” Baumer-Mouradian told MedPage Today. “The ED breaks down barriers families have, whether it’s a lack of transportation to their primary care office or working weird hours and not being able to make it to appointments.”

Just 50% of children are vaccinated for influenza each year. In Wisconsin, vaccination rates are even lower at about 40%, Baumer-Mouradian said.

Health officials are warning of a “twindemic” this fall as the flu season approaches, but many Americans are hesitant to get a flu shot. In general, pediatric immunizations have plunged during the pandemic.

The AAP recommends all children receive a flu shot this year to reduce the chances of simultaneous influenza and COVID-19 outbreaks.

“If there was ever a winter to get a flu vaccine, it is this winter,” said Kenneth Hempstead, MD, of Kaiser Permanente in Roseville, California, who was not involved in the research.

After the program in this study improved immunizations only slightly in the 2018-2019 influenza season, Baumer-Mouradian and colleagues refined the protocol to also identify families who were more vaccine hesitant. In those settings, both a provider and a nurse counseled families in the 2019-2020 season.

“Identifying vaccine hesitancy meant not only did the nurse talk to the family about vaccines, but a trusted second-level provider also came in to spend time with families and encourage vaccines,” Baumer-Mouradian said during the virtual presentation. “I think that second step was an influential piece.”

Many families also reported that the wait time to get the flu shot in the ED was one of the main reasons they elected not to get it, so Baumer-Mouradian and colleagues started storing the vaccines in the ED refrigerators, she said.

The change resulted in a significantly reduced time to discharge for patients, from 20 minutes in the 2018-2019 season to 16 minutes last season. Also, the proportion of patients leaving prior to vaccination decreased from 30% to 10% between seasons, Baumer-Mouradian reported.

“Families didn’t want to wait around for the vaccine having already been in the [ED] for multiple hours in some cases,” Baumer-Mouradian said.

In total, 2,839 children were vaccinated at the hospital, which was a 2.3-fold increase from last year, the authors reported. Before this new protocol was implemented, the vaccine acceptance rate was 13%, but that increased to 22% in the 2019-2020 season, they added.

Equally important to removing barriers to vaccination for families is eliminating friction for providers in the process, Hempstead said. Part of the protocol in this study involved EHR reminders sent to providers to administer the vaccine.

“My guess is what you are seeing here is a reduction of that friction and the barriers,” Hempstead said. “Not having people wait is huge; emphasizing that this will avoid another trip to the pharmacy or doctor’s office.”

The program at Children’s Wisconsin can be adapted to deliver other vaccines, including a COVID-19 vaccine, should one become available, Baumer-Mouradian said.

“We are already in the planning phase and are thinking about how that might roll out,” Baumer-Mouradian said.

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    Elizabeth Hlavinka covers clinical news, features, and investigative pieces for MedPage Today. She also produces episodes for the Anamnesis podcast. Follow


Baumer-Mouradian and co-authors disclosed no relevant relationships with industry.

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