Tracking Patient Immunizations Can Improve Post-HSCT Vaccination Rates

Because of the high doses of immunosuppressive chemotherapy and radiation they are administered, patients undergoing allogeneic hematopoietic stem cell transplant (allo-HSCT) can remain immune-impaired for up to 4 years after treatment, leaving them at increased risk of vaccine-preventable infections.

But adopting guideline-driven tracking tools to determine which patients have been assessed for immunization eligibility and which of them have received vaccines, and a provider progress-note template, can improve vaccination rates for these patients, reported authors of a small feasibility study at the Oncology Nursing Society (ONS) 42nd Annual Congress, held May 4–7 in Denver.

“Clinicians respond to simplicity,” noted lead study author Carole Elledge, DNP, RN, AOCN, of Methodist Hospital in San Antonio, Texas.

Among patients undergoing HSCT, influenza-associated pneumonia rates are as high as 35%, Elledge noted. This is more than four times as high as those seen in the general population. Immunization is “elemental” in preventing illnesses among patients undergoing HSCT, Elledge said.

Guidelines released by the US Centers for Disease Control and Prevention, the Infectious Disease Society of America, and the European Group of Blood and Marrow Transplantation all recommend serial re-immunizations after HSCT recovery with seasonal influenza, pneumococcal, and haemophilus-B conjugate vaccines.

But an audit of patient records indicated that only 1 of 15 allo-HSCT recipients in 2014 at Elledge’s institution received initial vaccinations, and that of 51 adults undergoing allo-HSCT that year, five contracted Influenza A within a year of transplantation. There was not a systematic process for post-transplantation vaccination assessment or immunizations in place, she noted.

In order to improve immunization rates among adults undergoing allo-HSCT, the team reviewed the literature and conducted a feasibility study. The literature review revealed that provider confusion can be avoided with simple, standardized cues and standing immunization orders.

To determine whether or not a revised systematic tracking system could improve pneumococcal vaccination rates, the research team in 2016 analyzed vaccination rates before and after implementation of a guidelines-driven tracking tool quality improvement initiative intended to facilitate serial vaccinations for allo-HSCT patients and a revised order set for vaccinations.

The new tracking tool noted patients’ transplantation dates and vaccination histories, providing this information for clinician review before patient visits, Elledge said. An immunizations field was added to providers’ dictation template to facilitate vaccine-eligibility assessments, and clinical staff was educated about guideline recommendations and indications for vaccination following HSCT.

Vaccination patterns were assessed for 61 adult patients (57% women) before implementation of the quality-improvement initiative and 18 patients (44% women) after implementation. Most patients had acute myeloid leukemia (48% of the pre-implementation group and 44% of the post-implementation group), followed by acute lymphoblastic leukemia (21% and 6%).

Prior to implementation, 10% of patients had been assessed and 57% of those deemed eligible for vaccination had received immunization. However, 35% of ineligible patients were also vaccinated. But after implementation, 100% of patients were assessed for vaccination eligibility and 92% of those who were deemed eligible received vaccination. “Importantly, none of the ineligible patients were vaccinated,” Elledge reported.

Nurses are used to vaccination schedules for children, but are sometimes so focused on the acute-care needs of adult cancer patients that they do not consider vaccination needs, she said. Others assume that vaccination is handled at pharmacies or primary care provider offices. “This is becoming part of survivorship care for our patients, especially in the transplantation patient population,” she emphasized.

The failure to successfully incorporate vaccination information into electronic health records systems was “frustrating,” Elledge noted.

The study had several limitations, she pointed out. The patient cohort was heterogeneous and relatively small, Elledge cautioned. The study period was 3 months, so it was not possible to determine if all three vaccines were administered to all patients in the cohort, she added.