The implementation of the computerized reminder system in the adult ED demonstrated a 10.8% increased pneumococcal vaccination rate among elderly ED patients. Compared to other pneumococcal vaccination initiatives that vaccinated 58% and 84% of eligible ED patients19, 21
, we consider the improvement moderate. However, these studies screened a convenience sample of ED patients, as opposed to the entire ED population, during a relatively short time period. In addition, these studies required a considerable number of additional staff that was dedicated to the initiative, thus had a low level of sustainability. Our method differed as the information technology supported infrastructure facilitated a workflow-embedded and team-oriented approach as well as a more sustainable infrastructure that did not depend on additional resources in the ED.
The overall vaccination declination rate was high when compared with other non-ED studies. Many patients refused vaccination when asked during triage, suggesting an increased need for patient education. Although the nurses were able to check the medical record for vaccination status, patient reporting was taken as the most important source of information for determining eligibility. While most of the patients (79%) reported having a primary care physician, only 50% reported being up-to-date with pneumococcal vaccination. Patients recalling accurately the status and date of their vaccinations is a further limitation of assessing eligibility. This may be addressed through vaccination registries or health information exchange systems that connect primary care physician offices with healthcare institution. To assess accurately vaccination status and eligibility criteria, other studies have involved dedicated healthcare workers that have more dedicated time to focus on vaccination status and eligibility criteria, and have achieved higher rates. This approach, however, is not integrated with the normal ED patient care process, causes additional resources and costs, and is more difficult to implement on an ongoing basis.
Triage may not be the ideal time and location for screening patients for vaccinations. Asking patients about vaccination status when they present in an emergency condition, often combined with pain, is not an ideal situation for the patient or the care providers in the ED. As the ED gets busy the triage nurses are often focused on patient throughput and, unfortunately, may spend less time on non-emergency related aspects of preventive health care. Vaccination screening may be more suitable at the patient’s beside when the most relevant aspects of the patient’s reason to seek care in the ED are addressed and the bedside nurse may have more time. Bedside screening, however, may also require a nurse reminder and may not occur until later during a patient’s ED visit when a physician has already completed all necessary interactions with the order entry system. In this case the physician may not receive the reminder at the time of the first order session or may have to initiate an additional order entry session solely for the purpose of ordering the vaccination. Alternatively, a standing nurse order for pneumococcal vaccination may delegate the preventive care measure to the nursing staff and would not require physician interaction for the large majority of patients.
A possible reason for physician refusal of ordering vaccination could be the design of the prompt in the order entry system or the design of the workflow. While the design of the physician prompt included additional information, it was designed to emulate other reminders in the order-entry system that displayed additional and supporting information without further user interaction. The order vaccination option was pre-selected to make ordering the vaccine as easy and quick as possible. An alternative reminder workflow would prompt first the physician in the order entry system, at which time the physician may not know the patient’s vaccination status.
This would require asking the patient or querying the electronic medical record, and then return to the order entry system to complete the session or initiate an additional session. It remains unclear whether any of the alternative workflows would result in a higher vaccination rate.
As our ED did not have a pneumococcal vaccination policy, the current system represents a feasibility study for the integrated approach. Prior to initiating the implementation of the reminder system, the beliefs and attitudes of the nurses and physicians towards vaccination in an emergency care setting were overall positive32
The informatics approach focused on strong clinical workflow integration by taking advantage of the various clinical information system components. The reminder system utilized the electronic medical record to retrieve vaccination status, the computerized triage application to support the determination of a patient’s eligibility criteria, the provider order entry system to remind physicians to order the vaccine for eligible and consenting patients, the order tracking system to notify the nurses about the vaccine order, and finally the longitudinal electronic medical record which captured the vaccination update documentation and makes the information available for subsequent healthcare episodes including repeat visits in the ED.
For patients younger than 65 years old an automated method to determine eligibility for would ideally have coded co-morbidities electronically available (e.g., abnormal innate immune response or functional or anatomic asplenia). The problem list in our EMR is currently semi-structured making the integration of past medical history information more challenging. Asking the triage nurse to collect this information would not fit easily into the current workflow and investigating a computerized approach may represent a next step. A possible computerized solution would involve parsing of free-text terms on the problem list or the application of natural language processing methods. Furthermore, the date of prior pneumococcal vaccinations is needed in the electronic medical record to evaluate the guideline recommendations. We have developed an approach to identify pneumococcal vaccination from the health maintenance section and free text reports33
; however, determining the date of administration remained a challenge. Reminder systems have been effective in the inpatient setting with similar CPOE adoption issues from providers22
. One of the system’s limitations is that it only targets an elderly population. Previous work and early experiences from our ED suggest that this patient group includes about 49% of eligible patients34
. For two years (2004–2005) prior to the study period there were only three spontaneous vaccination orders for ED patients out of 399 inpatient vaccination orders in the hospital.
The informatics approach evaluated in this study may be expanded to other vaccinations and preventive care procedures, as additional data captured by busy ED clinicians were limited and relevant data were presented at the time of decision making. Studies of vaccine delivery methods suggest that standing orders are the best way to improve vaccination coverage in an office, hospital, or long term care settings35
, although clinician prompts have also been effective at increasing vaccination rates in both the inpatient and outpatient settings36, 22, 37,
. We believe the approach can be successfully applied at other institutions to improve preventive care practices, given that an appropriate information system infrastructure is available.
In summary, we believe this to be the first study targeting pneumococcal vaccination in the ED using fully computerized tools. Our system may be scalable to other vaccinations and preventive care procedures.