Using computer decision support to increase maternal postpartum tetanus, diphtheria, and acellular pertussis vaccination.

OBJECTIVE: To evaluate whether use of a computer-based clinical decision-support algorithm that used data stored in the electronic medical record increased administration of tetanus, diphtheria, and acellular pertussis (Tdap) vaccine to postpartum women. METHODS: We performed a before and after cohort study of postpartum women at an urban public teaching hospital. We compared the frequency of Tdap vaccination during the preintervention (October 1, 2008-January 14, 2009) and postintervention (January 15-April 30, 2009) time periods. We intervened by automating electronic presentation of preselected orders to physicians who provided postpartum care. The order was displayed when physicians ordered iron supplementation or patient discharge to a woman who met certain criteria. We evaluated whether patient characteristics were associated with receipt of vaccine. RESULTS: Tetanus, diphtheria, and acellular pertussis vaccination was more likely for postpartum women postintervention compared with preintervention (147 of 248 [59%] compared with zero of 183 [0%]; difference=59%; 95% confidence interval [CI] 53-65%). Among 248 women who delivered during the postintervention period, those who met pharmacologic criteria for decision support rule activation were vaccinated more often than those who did not meet criteria (146 of 232 [63%] compared with one of 16 [6%]; difference=57%; 95% CI 43-70%). Race and ethnicity and cesarean delivery were not associated with vaccine receipt; however, there was a lower likelihood of vaccination among older women (P=.05 by a trend test across age quartiles). CONCLUSION: We implemented a computer-based clinical decision-support algorithm that dramatically increased Tdap vaccination of postpartum women. Deployment of our algorithm in hospitals that have clinical decision support systems should increase rates of this important postpartum preventive intervention. LEVEL OF EVIDENCE: II.

Clinical trial of standing-orders strategies to increase the inpatient influenza vaccination rate.

We compared strategies to increase the rate of influenza vaccination. A written standing-orders policy that enabled nurses to vaccinate patients was compared with augmentation of the standing-orders policy with either electronic opt-out orders for physicians or electronic reminders to nurses. Use of opt-out orders yielded the highest vaccination rate (12% of patients), followed by use of nursing reminders (6%); use of the standing-orders policy alone was ineffective.

Association between antimicrobial resistance among pneumococcal isolates and burden of invasive pneumococcal disease in the community.

Treatment of infections with drug-resistant strains of Streptococcus pneumoniae (pneumococcus) may fail; whether drug resistance is associated with an increase in the number of serious infections in the community is unknown. We evaluated the relationship between the proportion of antimicrobial-resistant S. pneumoniae isolates and the number of cases of invasive pneumococcal disease. Linear regression models included 1996 county-level data from 38 counties participating in the US Centers for Disease Control and Prevention's Active Bacterial Core Surveillance. Separate models evaluated hospitalized children aged <5 years, nonhospitalized children aged <5 years, adults aged 18-64 years, and adults aged >64 years. The proportion of isolates resistant to > or =3 drug classes was associated with invasive disease in both hospitalized (P=.06) and nonhospitalized (P=.001) children. The proportion of multidrug-resistant pneumococcal isolates did not predict invasive cases among adults. The increasing prevalence of multidrug-resistant pneumococci among children may be leading to an increase in invasive disease.