Discussion
The 2016–2019 hepatitis A outbreak in Michigan resulted in 920 cases and 738 hospitalisations. Our multihospital health system responded by creating an EMR BPA to identify and increase vaccination rates among vulnerable populations. This led to a remarkable increase in vaccination rate from 3.6 per 100 000 patient visits in the preintervention period to 155 per 100 000 patients visits in the intervention period. Lessons learnt from the implementation of this ED-based vaccination system can help us better identify patients at high risk for other vaccine-preventable diseases, including SARS-CoV-2.
Other countries have addressed hepatitis A outbreaks using an interagency model. In 2010, a hepatitis A outbreak among an Orthodox Jewish community in London led to an aggressive contract tracing and vaccination effort.18 After a 2016 outbreak among men who had sex with men in England, epidemiology, laboratory and health protection teams comprehensively responded with enhanced surveillance and a letter recommending vaccination of at-risk men in outbreak areas. This increased sexually transmitted infection testing, partner notification and the use of the National Health Service web portal to disseminate targeted hygiene advice and disease information to the public.19
Clinical nudging
Our study evaluated how ‘nudging’ health care provider behaviour using electronic prompts can lead to an increase in ED vaccination rates. Nudging—a psychological concept popularised in 2008—refers to the altering of people’s choices through a minimal, cheap environmental intervention without forbidding options or changing economic incentives.20 Nudging has been used in multiple clinical settings to better align health care provider decision-making with established guidelines.21 A December 2021 narrative review found that nudging strategies targeting COVID-19 vaccination orders for patients, such as text message reminders, had a positive result.22 A 2021 systematic review found that clinical nudging interventions that make information more salient are the most successful in improving vaccine uptake.23 This concept also been tested successfully through randomised control trials.24 The findings of these analyses are consistent with our study. When the hepatitis A BPA made a patient’s qualifications for vaccination readily available and noticeable to the health care provider, then the health care provider was more likely to order the vaccine.
Increase in vaccine administration
A similar hepatitis A vaccination initiative was performed with success in a single ED in San Diego, California, in 2017.15 In that electronic health-record-based study, patients were considered at high risk and eligible for vaccination if they were homeless, time at which a BPA would prompt physicians to order the hepatitis A vaccine. That study showed an increase in vaccination rates from 9 vaccines per 1000 visits among homeless patients (preintervention period) to 184 vaccines per 1000 visits among homeless patients (intervention period). Our study expands on this study and demonstrates that these initiatives can be scaled to a large hospital system with multiple EDs and can identify patients using multiple risk factors. During the first 24 months of the hepatitis A outbreak prior to our BPA’s implementation, we administered only 32 (3.6 per 100 000 patient visits) vaccines. During the next 19 months after the BPA was implemented, we administered a total of 1205 (155 per 100 000 patient visits) vaccines.
In a Philadelphia-based study analysing ED hepatitis A vaccination rates, the hepatitis A vaccine was offered to all adult patients (5024 patients) regardless of risk factors on arrival to the ED during a 6-week intervention period.25 If the patient agreed to a vaccine during their clinical visit, an electronic BPA would prompt their physician to order one. During this study period, 669 vaccines were administered (approximately 13 000 per 100 000 patients). In the scenario where vaccines are plentiful and the number of patient visits is fewer, offering a vaccine to every ED patient is doable. However, in scenarios where vaccines are limited or the patient visits are greater—as they were in our hospital system (700 000+)—having the ability to identify those who are most at high risk can be important.
Gap between vaccines eligible and vaccines ordered
The intervention identified 11 016 vaccination-eligible patients visits, but a vaccine was ordered during only 1929 (17%) visits. We suspect that the remaining 83% of patient visits did not have a vaccine ordered because of provider non-compliance with the tool. Reasons for non-compliance include lack of familiarity with vaccination by ED physicians and advanced practice providers, time constraints, patient refusal, acute illness and alert fatigue leading to physicians and advanced practice providers ignoring the prompt.
Gap between vaccines ordered and vaccines administered
Overall, fewer than half of the ordered vaccines were administered to patients. Each month, the order-to-administration gap ranged between 36 vaccines and 125 vaccines. We suspect at least some of the gap was related to patient refusal. If the physician or advanced practice provider put in the order for the vaccine before having the opportunity to return to the patient’s room to discuss the vaccine, the patient—not knowing what the purpose of this vaccine was—would have already refused. Another explanation could be that there were delays in obtaining the vaccine from the pharmacy, and the patient’s ED visit ended before they could be given the vaccine. Within the Epic EMR system, nurses could comment on why a specific medication or vaccine was not given. So, to answer this question more definitely, we would need to return to the records of all patients for whom the vaccine was ordered but not administered and evaluate the nursing comments.
In total, 565 vaccines were ordered and 322 vaccines were administered independent of the BPA. It is plausible that physicians, advanced practice providers or patients who were familiar with the hepatitis A outbreak would proactively offer or ask for the hepatitis A vaccine regardless of risk factors and it would be ordered.
Barriers and suggestions for upholding compliance
Maintaining long-term successful use of this tool requires buy-in from both nurses and physicians. Compliance with completion of the screening questionnaire by nurses remained a consistent 70%–80% during any given month of the study period. Physicians and advanced practice providers were initially more compliant with ordering the vaccine through the BPA, but a few months after the rollout, compliance declined and never improved. In September 2018, 20.2% of eligible vaccines were ordered, but by January 2020, only 13.3% of eligible vaccines were ordered.
Our survey results showed that key barriers to sustaining compliance with the vaccine initiative included (a) lack of time and (b) the perception that the screening tool is too low yield for ED use. Some studies have shown that other major barriers for physicians in ED-based-vaccination initiatives include difficulty with changing workflow to accommodate the vaccination effort and uncertainty about indications for the vaccine.26 One study evaluating nursing perceptions about the influenza vaccination in the ED revealed similar barriers to use including the concern that the extra screening was burdensome and the perception that the ED is not the appropriate place for vaccine administration.27
To address these perceived barriers, we must identify specific workflow obstacles. For example, once alerted by the BPA, physicians and advanced practice providers may not have time to thoroughly evaluate the patient’s chart to confirm candidacy for the vaccine. Additionally, it is possible that over time physicians and advanced practice providers forget the importance of the vaccine, how to advise patients about the vaccine or the medical circumstances under which the patient should receive the vaccine. In teaching hospitals where the resident physician groups change every year, there may be a subset of individuals that were never educated about the BPA and would be far less compliant with its use. This emphasises the need for ED leadership to prioritise educational reminders about the importance of public health initiatives and eligibility criteria for vaccine administration. It is essential to frequently audit and provide feedback to physicians and advanced practice providers on their compliance, as well as address their concerns about barriers to use.
Another method for addressing these barriers is to educate nurses, advanced practice providers, and physicians about the public health importance behind the screening tool. Those individuals who are at high risk for an illness like hepatitis A also happen to be the same individuals who are less likely to have access to primary outpatient care. By identifying those patients in the ED, we may be providing them with the only chance they have to be protected against this illness. These types of interventions have the potential to provide a social good. Various studies have shown that ED-based initiatives aimed at increasing vaccination rates against other vaccine-preventable diseases including influenza and pneumococcus can be successful.28 29 Having a vaccination programme can not only be a good service for vulnerable members of our community but can also be cost-effective for the hospital system by averting the economic burden of the illness itself.30
A suggestion to increase buy-in from nurses would be to implement the screening tool for a prescribed period (eg, ‘5 months’ or ‘1 year’) so that it reasonably matches the incidence of the illness in that community. This may incentivise nurses to complete the screening because they know that they are doing it at a time when it matters most: around the time of the actual outbreak. Time-limited screening could also help to minimise ‘pop-up fatigue’ from the physicians’ and advanced practice providers’ side.