title: Quality improvement initiative to increase influenza vaccination in pediatric cancer patients.
abstract: BACKGROUND
  Pediatric patients with cancer face more severe complications of influenza than healthy children. Although Centers for Disease Control and Prevention guidelines recommend yearly vaccination in these patients, in our large academic center, <60% of oncology patients receiving chemotherapy were immunized at baseline. Our objective was to increase this rate through a multifaceted quality improvement initiative.
  
  
  METHODS
  Eligible patients were >6 months old, within 1 year of receiving chemotherapy, >100 days from stem cell transplant, and had ≥ 1 outpatient oncology visit between September 1, 2012, and March 31, 2013. Five interventions were instituted concomitantly: (1) family education: influenza/vaccine handouts were provided to families in clinic waiting rooms; (2) health informatics: daily lists of outpatients due for immunization were generated from the electronic medical record and sent automatically to triage staff and nurses; (3) outpatient clinic: patients due for vaccination were given colored wristbands during triage to alert providers; (4) inpatient: vaccine order was built into admission order set; and (5) provider education: staff education was provided at conferences on screening of patients, vaccine ordering, and documentation of refusals/contraindications.
  
  
  RESULTS
  The complete influenza immunization rate increased by 20.1% to 64.5%, and the proportion of patients receiving ≥ 1 dose of vaccination increased by 22.9% to 77.7%. Similar changes were noted across all cancer types, with highest rates of immunization in leukemia/lymphoma patients (86.8%) and lowest in patients after stem cell transplant (66.7%).
  
  
  CONCLUSIONS
  Technology, education, and multidisciplinary clinical process changes increased influenza vaccination rates. Ongoing efforts are targeting subgroups with lowest rates of immunization.
authors.affiliation: Division of Oncology, and freedmanj@email.chop.edu.
authors.forename: Jason L
authors.initials: JL
authors.lastname: Freedman
authors.affiliation: Division of Oncology, and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Anne F
authors.initials: AF
authors.lastname: Reilly
authors.affiliation: Department of Nursing, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and.
authors.forename: Stephanie C
authors.initials: SC
authors.lastname: Powell
authors.affiliation: Division of Oncology, and Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: L Charles
authors.initials: LC
authors.lastname: Bailey
mesh_terms: D000046:Academic Medical Centers; D000970:Antineoplastic Agents / Q000009:adverse effects / Q000627:therapeutic use; D002648:Child; D003299:Cooperative Behavior; D005260:Female; D018380:Hematopoietic Stem Cell Transplantation; D006801:Humans; D007117:Immunization, Secondary; D007252:Influenza Vaccines / Q000276:immunology* / Q000627:therapeutic use*; D007251:Influenza, Human / Q000150:complications / Q000276:immunology* / Q000517:prevention & control*; D033183:Interdisciplinary Communication; D008297:Male; D009369:Neoplasms / Q000276:immunology* / Q000628:therapy*; D010290:Parents / Q000193:education; D058996:Quality Improvement / Q000458:organization & administration*
chemical_list: D000970:Antineoplastic Agents; D007252:Influenza Vaccines
keywords: immunization; influenza; oncology; pediatrics