5-6 million American children undergo anesthesia annually and all of them undergo a history and physical. This is an untapped health-care opportunity in which we, in our roles as pediatric doctors/practitioners, can step out of our traditional OR anesthesia mind-set (silo) and be the point of the spear to dramatically improve public health (yes, you are pediatricians as well as anesthesiologists!). Why is the preop period so ideal as a public health intervention touchpoint? Because general anesthesia and surgery are so fraught with fear and anxiety, it is a “teachable moment,”—that is, an event that “motivates individuals to spontaneously adopt risk-reducing health behaviors” and help overcome resistance to behaviors like smoking cessation.1, 2 Dr Kim Strupp and her colleagues at the Children’s Hospital Colorado wondered if the perioperative period would be an opportunity to increase the abominably low rate of influenza vaccination in children? (and to be completely transparent, I was actively involved in this study from its conception to its eventual submission for publication). Myron Yaster MD
Original article
Rao S, Morrissey T, Ziniel SI, Mandler T, Yaster M, Strupp KM. Influenza Vaccination in Perioperative Settings: A Teachable Moment. Anesthesiology. 2022 Dec 1;137(6):745-747. PMID: 36269853
“The primary prevention and control of the influenza virus is through vaccination and the seasonal influenza vaccination program is one of the most commonly utilized immunization programs in the United States. The influenza vaccine is safe and effective, prevents influenza-related complications, and it is particularly important in children as vaccination among children has been shown to reduce influenza illness in older adults.”3 And yet, pediatric influenza vaccination rates in the United States hover around 50% and are far below the 70% target rate set by the U.S. Department of Health and Human Services (Washington, D.C.).4 Indeed, the actual vaccination rate may be as low as 35%.3 The need to increase pediatric influenza vaccination rates are critically important in order to control flu epidemics. But how?
Strupp et al.5 reasoned that the perioperative period was a “teachable moment” and an untapped health care opportunity which could overcome parental resistance to vaccination.1, 2 “Further, to “sweeten the pot,” vaccination under general anesthesia provides several benefits, including patient comfort, expedited care, and leveraging existing workflows and processes that we also believed would increase vaccination rates”.5 The results were astonishing. How dramatic was the improvement? In the first year of the intervention, influenza vaccination rates increased from 140/year to 930/year. Since the submission of the manuscript the vaccination rates have more than doubled again to over 2,000 vaccinations last year.
How did they do it? Drs. Strupp and colleagues implemented a standardized process to actively offer influenza vaccination to all of their patients undergoing elective general anesthesia. They developed “best practice” workflows with key stakeholders and end users and recognized the need for an organized processes system change, rather than individual change, which confirms other studies on the importance of collaboration and teamwork in process improvement.6, 7 This standardized process substantially increased the number of perioperative vaccinations, particularly among Hispanic children, without increasing postoperative vaccine-related adverse events.
Just think of how powerful this could be if we all offered influenza vaccination in the perioperative period? If you would like more information on how to implement this program in your practice please contact Kim directly (kim.strupp@childrenscolorado.org). Further, a SPA based consortium is being organized for the 2023-2024 flu season. If you would like to participate contact Kim. Finally, going forward this is a model not only for influenza vaccination but also for Covid and perhaps other childhood vaccinations. Let me know what you think and I will post in a reader’s response.
References
1. Shi Y, Warner David O. Surgery as a Teachable Moment for Smoking Cessation. Anesthesiology. 2010;112(1):102-107. doi:10.1097/ALN.0b013e3181c61cf9
2. Shi Y, Warner DO. Pediatric surgery and parental smoking behavior. Anesthesiology. Jul 2011;115(1):12-7. doi:10.1097/ALN.0b013e3182207bde
3. Gates DM, Cohen SA, Orr K, Caffrey AR. Pediatric influenza vaccination rates lower than previous estimates in the United States. Vaccine. Oct 19 2022;40(44):6337-6343. doi:10.1016/j.vaccine.2022.09.053
4. U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion. Healthy People 2030. https://health.gov/healthypeople
5. Rao S, Morrissey T, Ziniel SI, Mandler T, Yaster M, Strupp KM. Influenza Vaccination in Perioperative Settings: A Teachable Moment. Anesthesiology. Dec 1 2022;137(6):745-747. doi:10.1097/aln.0000000000004341
6. Lovely JK, Hickman JA, Johnson MG, Naessens JM, Morgenthaler TI. Impact of a Program to Improve Venous Thromboembolism Prophylaxis on Incidence of Thromboembolism and Bleeding Rates in Hospitalized Patients During Implementation of Programs to Improve Venous Thromboembolism Prophylaxis. Mayo Clin Proc Innov Qual Outcomes. Apr 2020;4(2):159-169. doi:10.1016/j.mayocpiqo.2019.10.006
7. Streiff MB, Lau BD, Hobson DB, et al. The Johns Hopkins Venous Thromboembolism Collaborative: Multidisciplinary team approach to achieve perfect prophylaxis. J Hosp Med. Dec 2016;11 Suppl 2:S8-s14. doi:10.1002/jhm.2657