Pediatric influenza vaccination in the perioperative setting
Myron Yaster MD, Kim Strupp MD, and Lynne G. Maxwell MD
As long time readers of the PAAD know, I’ve always thought of pediatric anesthesiologists as perioperative pediatricians not just perioperative anesthesiologists/physicians. One area in particular that lends itself to this idea is to use the perioperative period as a means of increasing influenza vaccination in children. Although influenza vaccination is recommended for all children 6 months of age and older, American vaccination rates are well below U.S. Department of Health and Human Services (Washington, D.C.) target goals. Indeed, “To increase vaccination rates, the Centers for Disease Control and Prevention (Atlanta, Georgia) and the American Academy of Pediatrics (Itasca, Illinois) recommend influenza vaccination during all healthcare-seeking opportunities including the perioperative period.”1 My former colleagues Drs. Kim Strupp (one of the authors of today’s PAAD), Tyler Morrisey, and I published a successful “standardized process to actively offer influenza vaccination to all our patients undergoing elective general anesthesia.”1 We reasoned that “Because general anesthesia is 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”1,2 and would help overcome resistance to vaccination. 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.”1,3 Indeed, since the inception of this program over 7,000 children have been vaccinated intraoperatively!
In today’s PAAD, Meyer et al.4, in a quality improvement study, repeated this strategy with a twist: “vaccinations were given during in person preoperative clinic visits in a pediatric perioperative surgical home (PSH)” preoperatively, rather than during the surgical procedure. Isn’t time for you to consider doing some variation of this in your practice? Myron Yaster MD
Original article
Meyer AJ, Smith JR, Wright TL, Engler LJ, Bigham MT, Bhalla T. Pediatric influenza vaccination in the perioperative setting: A quality improvement project. Paediatr Anaesth. 2024 Feb;34(2):167-174. doi: 10.1111/pan.14790. Epub 2023 Nov 13. PMID: 37955042.
Meyer et al. report on their quality improvement project conducted at Akron Children’s Hospital, “a large, multi-campus, freestanding academic children's hospital with 443 beds, 1.2 million outpatient visits, and 17 000 surgeries, of which 11 000 receive preoperative evaluation through our Pediatric Surgical Home (PSH) department. The PSH project team was multidisciplinary and included an anesthesiologist, APRN, RN, quality improvement specialist, and an electronic health record (EHR) specialist. Ad hoc input was solicited early in the project from an infectious disease physician and PSH clinic staff. Key improvement tools included a key driver diagram, process mapping, simplified failure modes and effects analysis, and plan-do-study-act (PDSA) cycle testing.”4
Over a 3 year period, the influenza vaccination rates which started at zero, “exceeded vaccination rate goals of 10, 15, and 18%, for the first, second and third influenza seasons, respectively. A total of 695 vaccines have been administered since program inception. Interestingly, during the second season, they recognized the staff’s interest in offering vaccinations was declining due to persistent patient and family hesitancy and rejection. They instituted achievement-based recognition and improved awareness with immunization themed t-shirts. They continued this focus through the third vaccination season by focusing on patient-family communication and education.
These results are similar to those of Rao et al.1 No same day surgical case cancellations were observed as balancing measure”, although they “didn’t have the ability to track case cancellations prior to day of surgery due to vaccine related adverse events.”
Why do this? Meyer et al. explain that they “sought to accomplish two keys aims: (1) increase the rate of eligible patients receiving influenza vaccine during their PSH clinic visit and (2) promote the health and well-being of perioperative patients through providing protection from influenza as part of organizational influenza initiative goals.”4 The pediatric PSH model of care has been described as “a team-based patient-centered model designed to improve the delivery of health care and reduce cost,” and enhance value provided to the patient–family and organization.5 Ferrari further comments a PSH often involves serving as an entry point to perioperative care to manage patient populations according to acuity, comorbidities, and risk factors using evidence-informed clinical care.”5
By using the PSH rather than vaccinating intraoperatively, Meyer et al. avoided some of the concerns that intraoperative vaccination may confuse the diagnosis and treatment of postoperative fevers and may prevent a normal immune response to vaccination which may limit vaccine effectiveness.3 We think either approach is terrific and should become part of your program.
While the authors’ institution, Akron Children’s Hospital, clearly has a robust and well-staffed PSH/preoperative evaluation program, other institutions, including those where many of our readers practice, may not be so fortunate. Even in institutions that have in person preoperative clinic visits, the population served by these clinics may be limited to those with more complex underlying conditions or those who are scheduled for complex surgeries. In addition, many institutions with in person clinics, have decreased their number, continuing practices adopted during the COVID-19 pandemic of increased telehealth preoperative visits, or telephone screening, especially for ASA 1 and 2 patients scheduled for same day surgery. As the authors state, “in organizations without a PSH, preoperative clinic, or with a different process for preoperative preparation, they may not have the capacity and efficiency to accomplish this additional vaccine administration duty.”
We applaud the work of these authors to meet the demand of the AAP and CDC to offer influenza vaccinations are every health-seeking opportunity and to impact hospital policy to allow for liberalization of vaccination policy.
We would challenge the authors and really all of you to go back to the hospital/health-system and move towards offering these vaccinations while the child is under anesthesia to decrease further barriers and hesitancy patients and families.
What do you think? Has your institution adopted policies to allow vaccination in the perioperative period? Send your thoughts to Myron who will post in a Friday reader response.
References
1. Rao S, Morrissey T, Ziniel SI, Mandler T, Yaster M, Strupp KM. Influenza Vaccination in Perioperative Settings: A Teachable Moment. Anesthesiology 2022;137(6):745-747. (In eng). DOI: 10.1097/aln.0000000000004341.
2. Shi Y, Warner DO. Pediatric surgery and parental smoking behavior. Anesthesiology 2011;115(1):12-7. (In eng). DOI: 10.1097/ALN.0b013e3182207bde.
3. Lin C, Vazquez-Colon C, Geng-Ramos G, Challa C. Implications of anesthesia and vaccination. Paediatric anaesthesia 2021;31(5):531-538. (In eng). DOI: 10.1111/pan.14148.
4. Meyer AJ, Smith JR, Wright TL, Engler LJ, Bigham MT, Bhalla T. Pediatric influenza vaccination in the perioperative setting: A quality improvement project. Pediatric Anesthesia 2024;34(2):167-174. DOI: https://doi.org/10.1111/pan.14790.
5. Ferrari LR. How can the Perioperative Surgical Home be applied to pediatric anesthesia practice? Paediatric anaesthesia 2017;27(10):982-983. (In eng). DOI: 10.1111/pan.13222.