tah lags behind the national average in childhood and teen vaccinations, with rates dropping as kids grow, notably for the HPV vaccine. The COVID-19 pandemic worsened the situation as missed well-child checks and appointments led to lower vaccination rates. Despite creative efforts by local and national pediatricians, CDC research indicates pre-pandemic vaccination rates remain unreached. Not only was accessibility compromised, so was our societies’ confidence in vaccinations and vaccine development.
Not just a primary care concern—this is an opportunity for inpatient impact.
A 2019 Hospital Pediatrics study revealed that approximately half of hospitalized children were behind on vaccinations, with only 13% administered during inpatient stays. These are missed opportunities for us as inpatient providers to catch our patients up on immunizations and engage caregivers. The pandemic's negative impact on completing well-child visits as well as distribution and access to vaccinations, specifically for children living below the Federal Poverty Level, rural areas, and school-age children, raised the imperative for hospitals to step up to bridge the healthcare gap.
At Primary Children’s Hospital, many of our patient's ive in under-resourced communities with limited access to primary care due to insurance and socioeconomic factors which also inequitably hinders vaccination rates. As pediatric hospitalists, we aimed to tackle these disparities by offering vaccines during inpatient stays.by We established an interdisciplinary team of pharmacists, nurses, medical residents, outpatient providers, parent advisors, and hospitalists to strategize effective inpatient vaccination approaches.
Over the course of many months, we identified several key strategies to implement: First, to raise awareness to fellow inpatient providers about the importance of vaccines beyond outpatient settings and that fostering vaccine confidence begins with positive provider-patient relationships. Second, to offer healthcare teams the necessary tools for conducting nonjudgmental discussions regarding vaccination. Lastly, to develop a streamlined process for efficiently identifying and administering vaccines to eligible patients prior to discharge.
Vaccine confidence starts with a positive patient/provider relationship.
An American Academy of Pediatrics (AAP) study shows that having a conversation about vaccines with a trusted provider is the number one way to boost parent confidence in vaccines. These no-judgment conversations are key to compassionately address concerns to improve vaccination rates in Utah and across the country.
Providers, regardless of their clinical setting, can support one another in their conversations regarding vaccinations.
As pediatricians, we need to build vaccine confidence in the guardians of our patients. But we have to start by building confidence in ourselves. It’s our job to know what we’re talking about, so we have to start by learning. We need to know:
- How are vaccines developed and tested?
- What kind of misinformation are patients exposed to?
- What reliable resources are out there for families?
- What materials are in vaccines?
- What are the possible side effects of vaccines?
Having this information readily available as talking points can be helpful as you have this conversation. But you must also set aside expectations of how you want the conversation to go. Put away your own agenda and keep the conversation centered on the patient. Where are they in the learning process? What are their concerns and worries?
It can also be good to have a variety of resources available that are not from the CDC. While the CDC provides reliable information, unfortunately some people now see the agency as polarizing. Patients may have more trust in the AAP or children’s hospitals instead.
Finally, remember you may be their trusted physician, but you might not be their most trusted person. Your job is to just take the time to sit with the family to discuss these issues, to initiate conversations. You may have to continue the conversation at a later appointment when the family has had time to learn more or spend more time thinking about vaccines.
Start the conversation—and maintain a “No Judgment Zone”
If you feel nervous approaching these conversations, there are a number of resources online to help lead a judgement-free discussion.
Our favorite resource is called, “The No Judgement Zone: Building Trust Through Trustworthiness” by Dr. Kimberly Manning of Emory University. This method includes determining where people are currently on vaccinations. Are they a zero—meaning they definitely won’t vaccinate? Or a 10, where they definitely will?
Once you know where they are, you can help them by answering their questions with honesty, respect, and kindness. Keep it patient-centerd, if vaccinations would be or could be relevant to their child’s hospitalization, you can say that.
Even if they are contentious or angry, you can answer with kindness and leave the door open for future vaccination conversations.
In addition to Dr. Manning’s information, we also recommend these resources:
- Talking with Parents about Vaccines for Infants
- Responding to increasing parental vaccine hesitancy
- AAP Immunization Discussion Guides
All of these guides emphasize meeting parents’ concerns with empathy, using simple language to talk about vaccines, and keeping the conversation open, whether or not patients walk away vaccinated.
Know when to walk away
Take the personal out. You can follow every guide in the book, but families may still be resistant to a conversation about vaccines. To maintain your relationship with the family and build trust, you’ll need to know when to stop the conversation and move on.
In general, you should move on when:
- The conversation is not supporting the child’s recovery.
- The conversation is damaging the relationship with the family.
- The family appears stressed about the conversation.
At this point, it’s fine to acknowledge to the family that while we aren’t on the same page about vaccinations, we are on the same team in caring for your child. You can give them resources and leave them to make their own decisions. Families may be more open to conversations about vaccines later in a child’s care.
If you do need to end the conversation, don’t think of it as a failure. Building vaccine confidence is a long-term effort. You can mention to the family that you will bring up vaccines later, as well as loop in their primary care physician on having the conversations.
Establishing a process to identify vaccine eligible patients.
Identifying who is “vaccine-eligible”—children who are missing any number of recommended vaccines for their age and condition—proved challenging in the inpatient setting. Many factors make it difficult to capture vaccine eligibility on admission. Our central Utah database had to first sync with our electronic medical record. Pulling vaccine forecasts for eligibility of the specific vaccines requires a manual process by our pharmacist to look up each patient and notify their medical team. Over time, we were able to establish an appropriate identification and vaccine administration infrastructure.
Now that we have an approach to identify those who are vaccine-eligible, we have to ensure there are vaccines in the hospital and create a process for timely and clear communication with families and between healthcare team members. We also need ways to capture data for study, to ensure we are meeting our goals of increasing inpatient vaccinations and ideally completing the vaccine-eligibility status of each patient. These processes are still underway, and now receiving QI mentorship through Primary Children’s Quality Improvement administrative team.
Community problems require community solutions
To fully address our compromised vaccination rates, we need to work together as a team across the care continuum. While we are addressing these issues as hospitalists, primary care teams are doing so in their outpatient offices every day.
We can partner together to really strengthen our efforts, share resources, and improve communication education about vaccines.
We can even loop in other sub-specialists within the hospital who can address this issue with their patients. This strengthens our healthcare system’s preventative and safety nets.
With our shared purpose and passion, both inpatient and outpatient caregivers can work together to have continuous and meaningful conversations with families about vaccines. By integrating these discussions into our standard practices, we have a greater chance to build vaccine confidence and protect more children from preventable diseases.
Background/scope of problem of vaccine coverage:
- Jan 13 2022: CDC MMWR on vaccine coverage up to 24 months and disparities
- Jan 13, 2022: CDC MMWR on vaccine coverage up to kindergarten and decreasing vaccine coverage
- Jan 6 2022: CDC MMWR on racial disparities and covid-19 vaccine confidence for age 5-17y
- The Utah 2021 coverage report – below national average and our rates have dropped over the last few years
- Sources and Perceived Credibility of Vaccine-Safety Information for Parents
Inpatient hospitalization opportunities:
- Vaccine Administration in Children's Hospitals
- Pediatric Hospitalizations: Are We Missing an Opportunity to Immunize?
- The No Judgement Zone: Building Trust Through Trustworthiness
Provider-focused references on building vaccine confidence:
- Countering Vaccine Hesitancy