Background/Purpose: Streptococcus pneumonia is a leading cause of illness in children worldwide and can lead to death in those with an immunosuppressed status. Given the pathophysiology of systemic lupus and therapies needed to induce and maintain remission, these patients are more susceptible to pneumococcal infections compared to healthy counterparts. As recommended by the CDC/HHS, a simple preventative measure by immunization with the pneumococcal polysaccharide vaccine (PPSV23) is key in risk reduction for this population. The purpose of this QI initiative was multidimensional: first to increase pneumococcal vaccination rates in childhood-onset systemic lupus erythematous (cSLE) patients at our institution and second to examine the effectiveness of various interventions to ensure continued vaccination success.

Methods: Initial undertaking for this QI project was started in summer 2015 with utilization of a plan-do-study-act model. Baseline immunization rates of PPSV23 for eligible patients were assessed through chart review. These included all children ≥ 2 to <18 years old with cSLE (with and without immunosuppression) and were evaluated in rheumatology clinics within 6 months of the initial cycle. Interventions included a presentation to rheumatology providers and nurses, pre-visit planning and placing paper reminders on clinic schedules. Various interventions were analyzed based on chart review and provider feedback, which led to identification of barriers to successful vaccination.

Results: The pre-intervention to post-intervention PPSV23 immunization rates for 111 eligible cSLE patients increased from 4.5% to 47.1% during a 27-week cycle. Out of the patients who did not receive PPSV23, the reason was unknown in 70.2%, declined in 10.8%, and due to lack of follow up in rheumatology clinic during cycle 1 in 18.9%. Of the patients with an unknown status, 52.5% did not receive the vaccination due to lack of vaccination reminder and 47.4% of providers deferred vaccination to the next visit due to lack of time. The reason for a lack of vaccination reminder included changing clinic schedules (i.e. clinic add-ons) in 65.8% and oversight in 34.1%. All providers specified that they needed reminders in the patient’s EMR rather than on paper, as this would also circumvent changing clinic schedules. To date, the total number of cSLE patients at our institution is 548 (aged 2 years to 18 years old). Since initiation of this project, 60.4% of cSLE patients have received the PPSV23 vaccine.

Conclusion: Our study shows that the main barrier to cSLE patient’s receiving PPSV23 vaccination is provider oversight, lack of clinic time, and/or ineffective reminders. To increase vaccination success, a best practice advisory (BPA) alert in each cSLE patient’s EMR is being created. Ongoing work has centered on developing BPA parameters regarding variables such as PPSV23 vaccination status, age, and prior vaccination with the PCV13, a prerequisite to receiving the PPSV23. We hope this work will reduce vaccine preventable illnesses that would otherwise consume provider time, resources and unnecessary health care costs.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/improving-pneumococcal-vaccination-rates-in-childhood-onset-sle-patients-at-a-large-tertiary-care-center-the-path-to-creating-a-more-sustainable-model-of-vaccination-with-the-help-of-emr/