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| Journal of the New Zealand Medical Association,
03-July-2009, Vol 122 No 1298
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Rowena Gilbert, Katharine Wrigley
New Zealand’s low immunisation coverage has caused
concern among health professionals and
planners.1 Nationally, only 76% of children are
up to date with immunisations, with even lower rates among Māori and
Pacific children, and low socioeconomic
groups.2 Lakes DHB, served by Rotorua Hospital,
has the lowest immunisation rate in the country; 63% of two year olds in the
area are up-to-date.3
Missed opportunities are a major factor in
under-immunisation, and opportunistic immunisation is key to improving
coverage.4-6 Hospital admission provides a
valuable opportunity to review children’s immunisation status and provide
catch-up immunisation.7,8 Documentation of
immunisation status and opportunistic immunisation of hospital inpatients were
adopted as Clinical Indicators by Rotorua Children’s Unit in 2007, with
the aim of benchmarking performance and driving improvements in practice.
This audit looks at the immunisation status of paediatric
admissions to Rotorua Hospital over a 6-month period. Three issues are
addressed; immunisation status and factors affecting this, documentation of
immunisation, and action taken in response to the under-immunised child. We then
discuss potential barriers to catch-up immunisation within our service, and make
recommendations for service improvement.
MethodsIn-patient notes were sought for all children aged 3 to
23 months who were admitted to the hospital under paediatric care between 1 May
2007 and 31 October 2007. Demographic information was recorded, as well as
immunisation status from the paediatric clerking. For some children, official
Ministry of Health immunization records had been obtained and filed in the notes
during admission. These were used to confirm the accuracy of information
documented in the admission clerking.
It is possible that some parents brought their Well
Child (Tamariki Ora) Health Book to hospital during admission. While this may
have been an additional source for determining a child’s immunisation
status we were unable to determine this from the inpatient notes, and felt that
contacting parents to obtain this data retrospectively was beyond the scope of
this audit.
Where children had not received all of their
age-appropriate immunisations, the notes were reviewed for any explanation given
for this, and to identify whether any action had been taken, for example advice
to see GP for immunisation, discussion about immunisation or catch up
immunisation on the ward.
The notes were reviewed by four members of the
paediatric team; two SHOs, a senior nurse and an experienced care assistant.
Audit questions
Audit
standards
Results388 children aged 3 months to 2 years were admitted under
paediatric care between 1st May and
31st October 2007. Of these, 369 were included
in our audit. Reasons for exclusion were the unavailability of notes, children
not clerked by paediatrics (boarder children accompanying siblings; children
admitted for routine investigations) or children too old for the study (24
months or older on admission).
Demographic information—From the
audit sample of 369 patients ;
Immunisation
status—Immunisation rates among children admitted by Rotorua
Hospital's Paediatric Department were low, though at a level similar to
community immunisation rates within the
region.3 Only 60% of children who had
immunisation status documented were up to date.
Māori children were less likely to be immunised, but,
in contrast with community statistics,3
immunisation status was not significantly affected by socioeconomic status.
Documentation—Documentation of
immunisation status was missed in 16% of admission clerkings. Furthermore,
Ministry of Health data was only available for 43 patients, although this
improved in October when the ward began to routinely obtain faxed reports from
the Ministry of Health. Twelve (28%) of the Ministry records contradicted
parental reporting of immunisation status.
Reasons for not immunising—Of 119
children who were behind with immunisation, reasons were recorded in 43 (36%).
The most common reason for missing immunisations was illness at the time a
vaccination was due; this was cited in 21 cases. We were unable to determine the
type of illness preventing immunisation. Parental choice or concern about
vaccination safety (11 children) and time constraints (6) were the other main
reasons.
Catch-up immunisation would have been inappropriate in five
cases; two children were palliative care patients and three had
contraindications to vaccines.
Action on immunisation—In 90
patients, 79% of those in whom catch-up vaccination was indicated, no action was
documented. Only 4 children were given catch up immunisations on the ward. A
discussion on immunisation was recorded in 15 cases, and 5 were referred to
their GP.
No-one who was offered the opportunity for catch-up
immunisations declined.
40 of the under-immunised children had at least one previous
admission to the children’s ward, suggesting previous missed opportunities
to vaccinate.
DiscussionThis audit confirms a low rate of immunisation in children
admitted to Rotorua Hospital, and demonstrates a high level of missed
opportunity in relation to catch-up immunisation to the ward. While we believe
this is the first audit of opportunistic immunisation in New Zealand, it is
likely that similar problems exist in other district health boards. We hope that
this audit and discussion will help other district health boards to reflect on
and improve their practice.
16% of children presenting to the children’s unit did
not have their immunisation status documented on admission, despite this being a
key question in paediatric history taking. Furthermore, verification of
immunisation status was rarely possible, since Ministry of Health data was only
available for 43 patients. Parental recall of immunisation status is often
inaccurate,4 and official health records are
essential if catch-up immunisation is to take
place.7-9
It is encouraging that the availability of this data
improved towards the end of the audit period, when the paediatric ward clerk
began routinely obtaining and filing Ministry of Health Records.
Perhaps most concerning was the lack of action when children
were found to be behind with immunisation. Despite catch-up immunisation being
recommended by many bodies, and being adopted as a clinical indicator for the
children’s unit, only 4% of under-immunised children received
immunisations in hospital.
Availability of staff trained in immunisation was a major
barrier to catch-up immunisation. While the Children’s Unit is trying to
address this, it is still common for there to be no immunisation trained nurse
available on the day of discharge.
Lack of a pre-ordered vaccine supply was another potential
obstacle to ward-based immunisation. While vaccines were always available from
hospital pharmacy, they needed a doctor’s prescription before they could
be obtained on the ward, and could not be ordered in advance.
However, since only 19% of patients have any action or
discussion documented, it seems likely that the patient’s immunisation
status is often over-looked. Immunisation status is not routinely referred to
during discharge planning, and in our experience vital information often remains
unread in a patient’s charts.
Some of the barriers to catch-up immunisation may relate to
a lack of knowledge and education among health professionals. In his study of
opportunistic immunisation of hospitalised children in Leeds (UK), Conway noted
a lack of interest in immunisation among health
professionals.8 There may be a need for
increased education among junior doctors and nurses about the importance of
immunisation.
It is also possible that junior doctors do not feel
confident in discussing immunisation with parents. Indeed, a survey of New
Zealand GP’s demonstrated significant knowledge gaps in relation to
immunisation,1 while research in Rotorua found
that a significant proportion of health professionals lack confidence around
immunisation safety.10 It is likely that
hospital healthcare providers have similar educational needs, which must be
addressed if practice is to improve.
Interestingly, the most common reason for incomplete
immunisation was illness at the time the immunisations were due; only 11 parents
cited ‘choice’ or ‘concern’ as an explanation.
Furthermore, none of the families who were offered catch-up immunisation
refused. This correlates well with New Zealand data suggesting that only 5-6% of
families choose not to immunise their
children.11
As doctors, we may overestimate parental concern about
immunisation; a survey of New Zealand GPs found that parental concern was
believed to be the most significant barrier to improving immunisation
rates.12 An appreciation of parental
willingness to immunise should encourage health professionals to respond more
confidently to missed immunisations, with less fear of causing conflict with
parents.
A number of steps have now been taken on the paediatric unit
to try to improve practice, beginning with the prioritisation of immunisation as
a paediatric clinical indicator and the decision to audit this practice. Most
importantly, the ward has now established routine systems for establishing
children’s immunisation status from the Ministry of Health. It has also
increased the availability of vaccine information for parents and professional,
begun training more nurses in immunisation, created systems for vaccine ordering
and cold chain storage, and made arrangements for continuous monitoring of
practice.
RecommendationsSystems for immunisation of hospitalised children have been
developed by Conway8 in Leeds, UK, and by Bell
and colleagues7 in Philadelphia, USA. Both
authors highlight key aspects of a ward-based immunisation programme;
Discussion with Rotorua
paediatricians has identified two ongoing barriers to catch-up immunisation.
These relate to systems for immunisation and staff training.
The unit lacks a routine system for providing catch-up
immunisation; to establish this will require a commitment from all staff to
provide immunisation on day of discharge, education and encouragement from
senior ward medical and nursing staff, and a system to help alert staff to the
under-immunised child. As a visual reminder, we would recommend a coloured stamp
or laminate to highlight the child’s status in the front of the in-patient
record and drug chart.
Secondly, unavailability of staff trained in immunisation is
a major barrier to catch-up immunisation. We recommend that the children's unit
broadens programmes to train nurses in immunisation, and considers including
junior doctors in such programmes. As an interim measure, the ward now displays
a list of immunisation trained nurses at the nurses station.
Leadership and coordination is an essential aspect of
improving immunisation practice.7,8,13 We
recommend the nomination of a person with responsibility for immunisation, whose
role would include education, support and monitoring of progress. The district
health board may want to consider the introduction of an Immunisation
Coordinator to help develop and maintain a strong programme.
Ongoing evaluation and feedback to staff about the successes
and limitations of an in-patient immunisation programme is
vital.12 The Children’s Unit has already
made arrangements to repeat this audit and bench-mark our performance against
other District Health Boards in New Zealand; it is hoped that analysis of this
data will demonstrate a change in practice and promote continuous
improvement.
Competing interests: None known.
Author information: Rowena Gilbert, Senior
House Officer, Paediatrics, Lakes DHB, Rotorua; Katharine Wrigley, Senior House
Officer, Paediatrics, Lakes DHB, Rotorua
Acknowledgements: We thank Lynne Cooper and
Debbie Coates, for their assistance with data collection, and Stephen Bradley
and Belinda Coulter for supervision and feedback.
Correspondence: Katharine Wrigley, 53
Craiglockhart Park, Edinburgh, EH141EU, UK. Email wrigleykate@hotmail.com
References:
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