Previsit Planning Improves Pneumococcal Vaccination Rates in Childhood-Onset SLE.

BACKGROUND: Childhood-onset systemic lupus erythematosus (c-SLE) is a complex autoimmune disease that requires systemic immunosuppressive therapy. Infections are the second leading cause of death in these patients, with invasive pneumococcal infections being a major preventable cause of morbidity and mortality. Pneumococcal vaccination is recommended in this population; however, vaccination rates remain low. METHODS: The plan-do-study-act method of quality improvement was applied. We calculated baseline vaccination rates for pneumococcal conjugate and pneumococcal polysaccharide vaccines in patients with c-SLE in the rheumatology clinic from January 2015 to August 2016. We developed an age-based algorithm to simplify the vaccination guidelines. The clinical pharmacist and nurses performed weekly previsit planning to update vaccine records, make targeted recommendations, and ensure vaccine availability. The primary outcome measure was the percentage patients with of c-SLE seen per month who had received age-appropriate pneumococcal vaccination. RESULTS: The percentage of children receiving at least 1 pneumococcal vaccine increased from 24.9% to 92.7% by 12 months. By 18 months, the compliance rate with both pneumococcal vaccines increased from 2.5% to 87.3%, with sustained results. No serious adverse events or disease flares were reported. CONCLUSIONS: By identifying the major barriers to pneumococcal vaccination in our population with c-SLE, we significantly improved vaccination rates while decreasing time burden on providers. We attribute our success to a team-based quality improvement approach and plan to implement alerts in the electronic health record to streamline the process.

Reduction of immunization errors through practitioner education and addition of age-specific alerts in the electronic prescribing system.

PURPOSE: The reduction of immunization errors through the use of age-specific alerts within the electronic medical record (EMR) and mandatory interactive education for prescribers is described. METHODS: A health system-wide initiative was implemented at an academic pediatric hospital to reduce the number of immunization errors. The preimplementation period (January 1-December 31, 2013) involved a baseline review of adverse drug events (ADEs) reported through a voluntary event reporting system to determine the number and types of immunization errors. During the prescribing phase of the medication-use process, 57% (43 of 75) of errors occurred. First, age-based restrictions were implemented within the EMR. This was followed by mandatory immunization education for all prescribers working in the primary care network. Data collection included all reported vaccine errors within the voluntary event reporting system and completion rates of education by physicians, nurse practitioners, and medical residents. RESULTS: During the seven-month postimplementation period (January 1- July 31, 2014), prescribing events decreased from 57% to 25%. Following implementation of age-specific immunization alerts and mandatory prescriber education, the hospital went 175 days without a vaccine ADE. CONCLUSION: The implementation of age-specific alerts within the EMR and mandatory prescriber education decreased the number of immunization errors within a pediatric health system.

Comparison of systematic developmental surveillance with standardized developmental screening in primary care.

Many physicians use surveillance questions to assess development; the American Academy of Pediatrics recommends screening at 9-, 18-, and 24-month health supervision visits (HSVs). There are no studies directly comparing surveillance with screening. The authors directly compared systematic surveillance with standardized screening using a cross-sectional observational study of children with no known delays. Surveillance questions were completed at each HSV. The Ages and Stages Questionnaire (ASQ) was administered following the 9-, 18-, or 24-month HSV. The authors compared detection of delays by surveillance with ASQ screening. Using surveillance, 11/95 subjects were identified as delayed. Using the ASQ, 15/95 subjects scored fail; 28/95 scored monitor. Among the 11 delayed surveillance subjects, 5 scored fail on the ASQ and 5 scored monitor. Ten of the 15 subjects scoring fail on the ASQ were not identified by surveillance. The study's findings support the American Academy of Pediatrics recommendations for periodic formal screening in addition to continued surveillance.

Increasing immunization coverage.

In 1977, the American Academy of Pediatrics issued a statement calling for universal immunization of all children for whom vaccines are not contraindicated. In 1995, the policy statement "Implementation of the Immunization Policy" was published by the American Academy of Pediatrics, followed in 2003 with publication of the first version of this statement, "Increasing Immunization Coverage." Since 2003, there have continued to be improvements in immunization coverage, with progress toward meeting the goals set forth in Healthy People 2010. Data from the 2007 National Immunization Survey showed that 90% of children 19 to 35 months of age have received recommended doses of each of the following vaccines: inactivated poliovirus (IPV), measles-mumps-rubella (MMR), varicella-zoster virus (VZB), hepatitis B virus (HBV), and Haemophilus influenzae type b (Hib). For diphtheria and tetanus and acellular pertussis (DTaP) vaccine, 84.5% have received the recommended 4 doses by 35 months of age. Nevertheless, the Healthy People 2010 goal of at least 80% coverage for the full series (at least 4 doses of DTaP, 3 doses of IPV, 1 dose of MMR, 3 doses of Hib, 3 doses of HBV, and 1 dose of varicella-zoster virus vaccine) has not yet been met, and immunization coverage of adolescents continues to lag behind the goals set forth in Healthy People 2010. Despite these encouraging data, a vast number of new challenges that threaten continued success toward the goal of universal immunization coverage have emerged. These challenges include an increase in new vaccines and new vaccine combinations as well as a significant number of vaccines currently under development; a dramatic increase in the acquisition cost of vaccines, coupled with a lack of adequate payment to practitioners to buy and administer vaccines; unanticipated manufacturing and delivery problems that have caused significant shortages of various vaccine products; and the rise of a public antivaccination movement that uses the Internet as well as standard media outlets to advance a position, wholly unsupported by any scientific evidence, linking vaccines with various childhood conditions, particularly autism. Much remains to be accomplished by physician organizations; vaccine manufacturers; third-party payers; the media; and local, state, and federal governments to ensure dependable vaccine supply and payments that are sufficient to continue to provide immunizations in public and private settings and to promote effective strategies to combat unjustified misstatements by the antivaccination movement. Pediatricians should work individually and collectively at the local, state, and national levels to ensure that all children without a valid contraindication receive all childhood immunizations on time. Pediatricians and pediatric organizations, in conjunction with government agencies such as the Centers for Disease Control and Prevention, must communicate effectively with parents to maximize their understanding of the overall safety and efficacy of vaccines. Most parents and children have not experienced many of the vaccine-preventable diseases, and the general public is not well informed about the risks and sequelae of these conditions. A number of recommendations are included for pediatricians, individually and collectively, to support further progress toward the goal of universal immunization coverage of all children for whom vaccines are not contraindicated.

Performance of rapid streptococcal antigen testing varies by personnel.

Rapid carbohydrate antigen tests are frequently used to diagnose group A streptococcal (GAS) pharyngitis. Despite evidence of modest sensitivity in medical settings, rapid antigen tests are available to the public for self-testing. We sought to determine if the personnel performing a rapid streptococcal antigen test influence the test's performance characteristics. Throat swabs of pediatric patients performed for GAS pharyngitis in a tertiary-care children's hospital network were included during two study periods in 2004 and 2005. The performance characteristics of a rapid carbohydrate antigen test were evaluated in three clinical settings against a nucleic acid probe test method according to the personnel performing the test (laboratory technologist versus nonlaboratory personnel). Between the study periods, nonlaboratory personnel from one site underwent retraining. Subsequently, the performance characteristics of the rapid antigen test were reassessed. The sensitivity of the rapid antigen test varied widely among the different testing sites (56 to 90%). Notably, test sensitivity was consistently greater when the test was performed by laboratory technologists than when it was performed by nonlaboratory personnel (P < 0.0001). Although the rapid antigen test sensitivity significantly improved after nonlaboratory personnel at one testing site were retrained (sensitivity before versus after retraining; P < 0.0001), the sensitivity remained greater in the laboratory technologist cohort (P < 0.0001). These data confirm the important relationship of the operator performing a rapid streptococcal antigen test with the test's accuracy, even in a clinical setting, where operator training is mandated. Therefore, its use outside the medical setting by lay persons cannot be recommended without culture backup.