Published on in Vaccine Update for Healthcare Providers
In-person school is important for education as well as for the mental health of youngsters and their adult caregivers. As many of my friends have stated quietly, “I love my children, but I didn’t plan to home-school them,” so for families, back to school preparations are often accompanied by great rejoicing.
But this is not so much the case for primary care offices prepping with the fervor of Noah before the Deluge. We know that the number of patients who fell behind on immunizations during the first year of the COVID-19 pandemic was substantial and that this summer — in addition to the usual rush — we need to get those patients back up to date. Adolescents, in particular, will require a special level of effort because of how precipitously their vaccination rates dropped:
- 9- to 12-year-olds: 63.6% decrease between March and May 2020 and 12.2% decrease between June and September 2020 compared with the same periods during 2018 and 2019
- 13- to 17-year-olds: 71.3% decrease between March and May 2020 and 28.1% decrease between June and September 2020 compared with the same periods during 2018 and 2019
- 9- to 12-year-olds: 66.4% decrease between March and May 2020 and 21.3% decrease between June and September 2020 compared with the same periods during 2018 and 2019
- 13- to 17-year-olds: 61.4% decrease between March and May 2020 and 30% decrease between June and September 2020 compared with the same periods during 2018 and 2019
James Clear writes in Atomic Habits, “You do not rise to the level of your goals, you fall to the level of your systems.” With that in mind, this month we are offering eight tips for getting your office systems primed to habitually vaccinate patients. None of these are startling news, and few are quick fixes, but each is worthy of your quality improvement efforts during the back-to-school barrage, the flu vaccination flood and beyond.
1. Get every provider in the office to agree to use the same schedule
It’s just too much to ask the nursing staff to remember which provider wants to start HPV at age 10 and which wants to wait until 12 or who gives MMR at 12 months and who waits until 15 months. Variation holds the door open for error. Have leadership herd the cats to a mutually agreed upon schedule and then print it, laminate it and post it.
See the “Recommended Child and Adolescent Immunization Schedule for ages 18 years or younger, United States, 2021” for guidance during your discussions.
2. Use standing orders
Pre-approved medical protocols, called standing orders, allow certain healthcare professionals (e.g., registered nurses in many states) to administer a vaccine to patients meeting certain criteria (e.g., age, no previous dose) without the immediate supervision or approval of an attending provider at the time of the appointment.
To implement standing orders in your practice, check out these “Standing Orders Templates for Administering Vaccines” offered by the Immunization Action Coalition.
3. Give vaccines at every type of visit
Most often vaccines can be given at acute care visits, but a couple of factors make this harder than people might guess. First, everyone in the office is running as fast as they can, so adding vaccinations to an acute care visit may feel like a stretch. Second, families may perceive that their ill child is suffering too much to add a jab.
Because we don’t get a lot of opportunities to see some of our patients, particularly adolescents, we must take advantage of every opportunity. The CDC’s “Comprehensive Recommendations and Guidelines” includes information about common misperceptions related to vaccine precautions and contraindications, such as mild illness.
To create a plan, tackle this as a team, discussing specific ways you can address it. At first, you may seek to “whittle down” the number of acute care visits that include a missed opportunity to vaccinate. And, if you cannot agree to vaccinate at all acute care visits, agree on a list of acute care scenarios during which you will vaccinate. For example, maybe your team would be comfortable incorporating vaccinations at visits for extremity injuries, concussions, insect bites, contact dermatitis, cellulitis and the like.
4. Give all the vaccines that are due
Set the expectation that every vaccine that is due will be given. Often this is more of an issue with adolescent patients than with infants and toddlers. Emphasize that you’ll give all vaccines today to reduce anguish. You might say something like, “We find that if we only give two shots and schedule the patient to return, they keep thinking about the next shot. So, this approach will cause less anxiety if you just get it over with right now.”
5. Don’t forget the MenACWY booster dose
The 2019 immunization rates for adolescents 13- to 17-years of age indicate that the first dose of MenACWY is administered almost as often as Tdap, but rates of completion for the booster dose of MenACWY are closer to those of the HPV vaccine series. Get your staff in the habit of remembering the Give2MenACWY slogan, “You’re not done if you give just one.”
For more information and resources, check out the website, Give2MenACWY.org, offered as part of a national campaign that aims to improve protection against this devastating disease.
6. Train ancillary staff to do everything they can do
Ancillary staff should know why we are giving each vaccine, so they are as passionate about vaccination as we are. Because they are often the people talking with patients and families, they have opportunities to support the vaccination process in the office. With this in mind, they should be prepared to:
- Identify patients for whom vaccines are indicated.
- Screen for contraindications and precautions.
- Put in an order pending the provider signature or prompt the provider to order the vaccines directly.
- Answer frequently asked vaccination questions succinctly and accurately and point patients or families to reliable resources. For example, you may want to have an accessible list of reliable resources that can be shared with parents or a location on your website that links to resources your team trusts. This will reduce the number of “Google searches” that may or may not lead them to the most accurate information.
Having ancillary staff prepared to do this increases the provider’s time to address novel or technical questions.
7. Prevent pain
Concerns about vaccination pain add to vaccine hesitancy across the lifespan. (Children are not “little adults,” but we adults often show ourselves to be “big babies.”) As such, be sure your team is prepared with some ways to address this aspect of the vaccination process. Various simple, quick, low-cost, evidence-based ways to diminish the experience of pain associated with vaccination are available:
- See the age-specific sections of the Vaccine Education Center’s Parents PACK website for age-appropriate ideas.
- See the “About Kids Health” YouTube channel based on the publication by Taddio A, McMurtry CM, Shah V, et al. Reducing pain during vaccine injections: Clinical practice guideline. CMAJ. 2015;187(13):975-982. doi:10.1503/cmaj.150391.
You can also consider identifying a member of your nursing staff as the “pain-free hero,” so they can identify useful approaches and teach the rest of the team.
8. Use the huddle
Most offices use some form of “huddle,” during which all team members gather at the start of the shift for 10 minutes or so to discuss the day ahead. Vaccinations can become part of this conversation, particularly if someone on the team scans the EHR or state immunization information system to check which vaccines are due for each patient. By taking this approach, vaccination checks will not need to be done during the hustle and bustle of office hours.
Hopefully, these tips have given you some ideas for not only catching up on vaccines missed during the pandemic, but also for incorporating changes that will serve your team and your patients well moving forward.
Do you have tips? Send them to us at firstname.lastname@example.org using the subject line, “Technically Speaking – Tips,” so we can compile and share ideas that have worked for others!
Materials in this section are updated as new information and vaccines become available. The Vaccine Education Center staff regularly reviews materials for accuracy.
You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family's personal health. You should not use it to replace any relationship with a physician or other qualified healthcare professional. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult your physician or, in serious cases, seek immediate assistance from emergency personnel.