Improving Pneumococcal Vaccination in Patients with Childhood Systemic Lupus Erythematosus in a Pediatric Rheumatology Clinic

Purpose/Objectives: Childhood Systemic Lupus Erythematosus (cSLE) is a multisystem disease requiring long-term immunosuppressive therapy. Children with cSLE are at increased risk of invasive pneumococcal disease due to disease characteristics and immunosuppressive therapy. The Centers for Disease Control (CDC) recommends routine vaccination of patients with cSLE with the 13 Valent Pneumococcal Conjugate Vaccine (PCV13) and the 23 Valent Pneumococcal Polysaccharide Vaccine (PPSV23). Visits with patients who have cSLE are complex and pneumococcal vaccination is often forgotten. We found that our patients were significantly under immunized with only 21.4% up to date with pneumococcal vaccination. The aim of the project is to increase the percentage of patients with cSLE seen in our Pediatric Rheumatology clinic who are up to date with pneumococcal vaccination from 21.4% to 85% by July 1st, 2021.

Design/Methods: This was a division-wide quality improvement initiative which utilized the Model for Improvement. Key drivers (Figure 1) were identified after process mapping and were acted upon in various Plan-Do-Study-Act cycles. Pneumococcal vaccination data were collected and updated weekly. The primary outcome measure was the percentage of children seen in our practice over the preceding year who are up to date with recommended pneumococcal vaccination. To drive our outcome, we created a secondary outcome measure that was the percentage of eligible children seen in our clinic each week who received the pneumococcal vaccine. Once the weekly number of eligible diminished due to prior vaccination, we began grouping data into vaccination per 10 consecutive eligible visits. Eligible children were patients with cSLE seen in clinic missing the PCV13 and/or PPSV23 and had not received a pneumococcal vaccine in the preceding 8 weeks. Statistical process control charts were used to view and analyze the secondary outcome measure with Nelson rules being used to identify special cause variation.

Results: Eligible patients receiving vaccines at their clinic visits increased from an average of 12.1% to 59.4% with special cause variation associated with nurses ordering the vaccine when eligible patients were identified (Figure 2). We improved the overall rate of pneumococcal vaccination in our clinic from 21.4% to 61.4%. Rates for PCV13 vaccination improved from 42.7% to 74.3% and PPSV23 from 34.3% to 67.0%. Recent interventions utilizing EHR functionality to identify eligible patients within clinic workflow are promising but have not yet been associated with special cause variation.

Conclusion/Discussion: Using improvement methodology focusing on clinical processes to drive a secondary outcome measure, we were able to drive an improvement in the overall percent of children with cSLE in our rheumatology clinic who were up to date with pneumococcal vaccination. We suspect our increased ability to successfully vaccinate patients when they are seen in our clinic will drive us to our goal of 85% vaccination in our cSLE population.