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5/08 K;IProj/Acc&Pres/CIRC/DateDue.indd

 

’DELIVERY OF PEDIATRIC IMMUNIZATIONS IN PRIMARY CARE I,
By
Catherine H. Nowka ,

A SCHOLARLY PROJECT

Submitted to
Michigan State University
in partial fulﬁllment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing ,

1998

ABSTRACT
DELIVERY OF PEDIATRIC IMMUNIZATIONS IN PRIMARY CARE
By
Catherine H. Nowka

This project explores the delivery of immunizations for children under three years
of age in a primary care setting. King’s General System Framework guides the
development of a comprehensive method for immunization delivery for preschool children.
The goal of the immunization delivery process is to achieve the Healthy People 2000
objective of having 90 percent of two year olds complete the basic immunization series
against ten major preventable childhood illnesses. The purpose of the project was to
develop an algorithm for primary care providers to facilitate decision making about the
process of immunization delivery systems for preschool children in Michigan. The
advanced practice nurse can apply the algorithm in a primary care setting to meet the

immunization needs of preschool children.

Copyright by
Catherine H. Nowka
1998

 

 

I I I‘ll
i l .

ACIQNIOWLEDGMENTS

I would like to acknowledge and thank my scholarly project committee
chairperson, Mary Jo Amdt, RN, EdD who provided the reassuring support needed to
complete this project. I would also like to thank the committee members Cynthia
Gibbons, RN, PhD, and Billie Gamble, RN, MA for their ﬁrrther contributions to this
project. I would also like to thank Patricia Peek, RN, MS, CS, PNP for her enthusiasm
and promotion of advanced practice nurses.

I would like to thank my husband, Jim, and my children James, Renee, and Stephen
for their encouragement in my eﬁ‘orts to complete this project, and their belief that I can
accomplish anything. I would like to thank my extended family for their understanding of
my absence at many recent family gatherings.

I would like to thank my colleagues in primary care at East Jordan Family Health
Center who consistently strive to provide comprehensive, accessible, coordinated care to

the clients in our community, and have energized my efforts to complete this project.

iv

TABLE OF CONTENTS

LIST OF FIGURES ..................................................................................................... vii
Introduction ................................................................................................................ 1
Statement of the Problem ................................................................................. 7
Conceptual Framework and Literature Review ............................................................ 9
Conceptual Deﬁnition ...................................................................................... 9
Applicability and Relevance .............................................................................. 11
Relationships .................................................................................................... 13
Literature Review ............................................................................................ 14
Synthesis of Literature Review in Relation to Project ....................................... 19
Project Development ................................................................................................... 20
Approach ......................................................................................................... 20
Assumptions .................................................................................................... 21
Assessment ...................................................................................................... 22
Education ........................................................................................................ 25
Vaccine Administration .................................................................................... 26
Documentation ................................................................................................ 27
Evaluation of the Algorithm ......................................................................................... 28
Implications for the Advanced Practice Nurse in Primary Care ..................................... 29
Implications for Education ........................................................................................... 30
Implications for Research ............................................................................................ 31
Summary ..................................................................................................................... 3 1
APPENDIX A: Immunization Opportunity Algorithm ................................................ 33
APPENDIX B: Provider Immunization Resources ...................................................... 34
APPENDIX C: Provider Barrier Identiﬁcation Tool ................................................... 36
APPENDIX D: Recommended Childhood Immunization Schedule - l 998 ................... 37

 

APPENDIX E: Recommended Accelerated Immunization Schedule ........................... 39

REFERENCES ........................................................................................................... 40

LIST OF FIGURES

Figure l- Imogene King’s System Framework ............................................................. 10
Figure 2- Potential barriers to the vaccination delivery process ..................................... 12
Figure 3- Assumption component of immunization algorithm ....................................... 21
Figure 4- Assessment component of immunization algorithm ....................................... 24
Figure 5- Education component of immunization algorithm .......................................... 26
Figure 6-Vaccination administration component of iminunization algorithm ................. 27
Figure 7- Documentation component of immunization algorithm .................................. 28
Figure 8-Pediatric immunization opportunity algorithm for primary care providers ....... 32
Figure 9-Provider barrier identiﬁcation tool ................................................................. 35

vii

 

 

INTRODUCTION

Across the United States children receive health care, and in particular
immunizations, in a wide variety of settings. Of particular interest to the nation today is
the delivery of health care services in a primary care setting. \Vrth the many recent
changes in health care, and the move toward managed care environments, many children
are receiving vaccines in busy primary care settings (Bordley, Margolis, & Lannon, 1996).
The Institute of Medicine (1994) deﬁnes primary care as the provision of integrated,
accessible health care services by clinicians, who are accountable for addressing a large
majority of health care needs, developing a sustained partnership with patients, and
participating in the context of family and community. Integration of vaccine delivery in
the primary care setting is of major concern to all primary care providers and clients in the
community. Vaccines are one of the most cost effective and widely used public health
interventions according to the US. Preventive Services Task Force (1996).

Vaccination rates for young children have come under increased public scrutiny
because coverage rates have been surprisingly low. In fact, Michigan ranked lowest in the
nation in 1995 for coverage levels of children ages 19-35 months according to the Centers
for disease Control and Prevention (CDC, 1996). Children are currently immunized in the
United States against ten diseases: diphtheria, pertussis, tetanus, measles, mumps, rubella,
poliomyelitis, Haemophilus inﬂuenza type B, hepatitis B, and varicella (CDC, 1997).
Immunization coverage levels for children ages 19-35 months are commonly based on 4
doses of diphtheria, tetanus, and acellular pertussis vaccine (DTaP), three doses of
poliovirus vaccine (OPV/IPV), one dose of measles-mumps-rubella vaccine (MMR), and
at least three doses of Haemophilus inﬂuenza type B vaccine (Hib). This is commonly

referred to as a 4:3: 1:3 series completion level. Tracking of the Hepatitis B (Hep B) and

 

2

_ and varicella (V ar.) have not kept up with the vaccine schedule changes introduced in
1992 for the Hep B, and the changes in 1996 for varicella. Series completion rates for all
six of the currently recommended vaccines; DTaP, IPV/OPV, MMR, Hib, Hep B, and
Var., have not been measured by the CDC. Comprehensive measurement for preschool
children will be a4:3:l:3:3:1 (4 DTaP, 3 polio, l MMR, 3-4 Hib, 3 Hep B, 1 Var)
vaccination coverage completion rate. It will be the expanded measurement standard as
national coverage levels are gathered in the future.

National immunization coverage levels in 1995 for the 4:3:1 series (4 DTP, 3
polio, l MMR) were 78% for children ages 19-35 months (CDC, 1996). Michigan’s rate
in 1995 was 76% for the 4:3:1 series (CDC, 1996). It is still well 'short of the national
goal for 90% of the nation’s 2 year olds for complete immunization coverage. Coverage
levels of 76% completion for a 4:321 series represent a signiﬁcant number of children in
Michigan left at risk of contracting one or more preventable childhood diseases.

The Childhood Immunization Initiative (CII) was developed in 1993 in the United
States to address the undervaccination of preschool children by setting goals for coverage,
and establishing a vaccination delivery system (CDC, 1994; Osguthorpe & Morgan,

1995). The CII established the goal of increasing vaccination coverage levels among
children under age three to at least 90% series completion by 1996. Vaccination coverage
levels are monitored by the CDC’s National Immunization Survey (NIS). In 1994, the
NIS began to monitor vaccination coverage levels for children ages 19-35 months acroSs
the nation. The NIS utilizes random-digit dialing and telephone interviewing to collect
information, and also makes weighted adjustments to account for households without
telephones (CDC, 1997). .

The CD announced in 1997 that the national goal for 90% series completion for
each of the important vaccines had been accomplished. Nationwide children received 3 or
more DTP (95%), 3 or more polio (91%), one or more of any measles containing vaccine

(91%), and 3 or more Hib (92%) (CDC, 1997). However series completion of 4:3:l:3 for

 

3

children ages 19-35 months for 1996 was 77% (CDC, 1997). No data are available for a
series that also includes Hepatitis B (Hep B) and varicella (Var). Three doses of Hep B
was measured at 82%, and one dose of Var at 18% in 1996 (CDC, 1997). These
represent the highest level of vaccination ever recorded for American preschoolers (CDC,
1997).

Continued achievement of vaccination coverage and disease-elimination goals will
require development of a fully functional vaccine-delivery system (CDC, 1997).

According to the CDC the important components are (1) state and community based
computerized vaccination registries that include all children ﬁom birth, and can identify
children in need of vaccines and recall them for missed vaccinations, (2) ongoing
quality-assurance and information-feedback activities, and (3) continuous education
programs for parents and health-care providers (1997).

The Vaccine for Children Program (VF C) was implemented in 1994 to help
eliminate ﬁnancial barriers to vaccines. Local health departments provide free vaccines to
health care providers that enroll in the program. Children are eligible for VFC vaccines if
they are ages 0-18 who are enrolled in Medicaid, American Indian or Alaskan Native,
uninsured, or under-insured. Vaccines available are : Diphtheria, Tetanus and Pertussis
(DT, DTaP, DTP/Hib, Td), Haemophilus inﬂuenzae type B (Hib, DTP/Hib), polio (e-IPV,
OPV), Hepatitis B (Hep B), Measles, Mumps, Rubella (MMR), and Varicella (Var). In
exchange for ﬂu vaccines from the health department, health care providers must comply
with current vaccination schedules, provide vaccination information materials, provide
state immunization cards, provide vaccines ﬁee of charge and may charge a minimal
administration fee, provide regular reports of all doses administered, practice safe handling
and storage, and share immunization information with the local health department.

The Standards for Pediatric Immunization Practices were deve10ped in 1992 by the
National Vaccine Advisory Committee (NV AC), in cooperation the US. Public Health
Service, and the American Academy of Pediatrics. Eighteen (18) standards for health care

4

providers are outlined to improve vaccination delivery for children. These standards

represent the consensus of a 35 member expert group about the most desirable practices

by health care providers to ensure complete immunization coverage for children. Issues

addressed are access to services, reduction of missed opportunities, education, and

inrrnunization tracking.

The Standards for Pediatric Immunization Practices are a comprehensive approach

to vaccine delivery which present a challenge for many primary care providers to

implement.
1 .
2.

10.

11.

The following is a summary of the standards (NVAC, 1992).
Immunization services are readily available.

There are no barriers or unnecessary prerequisites to the receipt of
vaccines.

Immunization services are available free or for a minimal fee.
Providers utilize all clinical encounters to screen and, when indicated,

immunize children.

. Providers educate parents and guardians about immunizations in general

terms.

Providers question parents or guardians about contraindications and, before
immunizing a child, inform them in speciﬁc terms about the risks and
beneﬁts of the immunizations their child is to. receive.

Providers follow only true contraindications.

Providers administer simultaneously all vaccine doses for which a child is
eligible at the time of each visit.

Providers use accurate and complete recording procedures.

Providers co-sched'ule immunization appointments in conjunction with
appointments for other child health services.

Providers report adverse events following immunization promptly, accurately

and completely.

5

12. Providers operate a tracking system.

13. Providers adhere to appropriate procedures for vaccine management.

14. Providers conduct semi-annual audits to assess immunization coverage levels

and to review immunization records in the patient population they serve.

15. Providers maintain up-to-date, easily retrievable medical protocols at all

locations where vaccines are administered.

16. Providers operate with patient-oriented and community-based approaches.

17. Vaccines are administered by properly trained individuals.

18. Providers receive ongoing education and training on current immunization

recommendations.
The NVAC recognizes that implementing all the standards will be difﬁcult for many
providers, but standards will help providers identify needed changes to improve
vaccination delivery. Health care providers that make a maximum effort to meet all the
standards will provide comprehensive, accessible, coordinated vaccination services to their
clients.

Barriers to immunizations fall into three broad categories (Institute of Medicine,
1994). First are barriers in the health care system. Second are barriers in the provider
settings. Third are personal and cultural barriers that inﬂuence whether individual families
will utilize the immunization delivery system available in their community. Several barriers
eﬂ‘ect each of these broad categories and contribute to the immunization coverage level
obtained in any given community (IOM, 1994).

Barriers in the health care system are multifaceted. Some mral areas do not have
enough health care providers to meet the needs of the communities, or may not have
accessible services in terms of hours of operaiion, or have prolonged waiting periods. One
of the most frustrating barriers for health care providers is a lack of reliable and accessible
immunizations records for children who obtain immunizations from multiple sources in the

same community or diﬁ‘erent communities. In Michigan, a computerized vaccination

6

registry (Michigan Childhood Immunization Registry or MCIR) is in development, but is
still not available for all providers to make easy assessment of immunization status. In
addition to maintaining a child’s irmnunization history, MCIR will generate reminder and
recall notices, and identify due and overdue immunizations.

Several barriers can be identiﬁed at provider settings, which will be unique to that
setting. Items such as inaccessible hours or unavailable supply of vaccines, improper
vaccine handling, and untrained providers are barriers unique to a particular setting. Lieu,
Black, Sorel, Ray, and Shineﬁeld (1996) concluded provider practices play an important
role in underimmunization of children who have insurance coverage for vaccines. The
focus of common provider barriers are missed opportunities. A missed opportunity arises
every time a child comes to the setting and still is not ﬁrlly immunized. A missed
opportunity is deﬁned as a child in need of immunizations seeks health care but receives
either no immunizations or does not receive all the needed immunizations (CDC, 1994).
A missed opportunity can arise if providers can not accurately assess the immunization
record, if not all vaccines are given simultaneously, or if true contraindications are not
followed (Holt et al., 1996; Fairbrother, Friedman, DuMont, & Lobach, 1996).

Personal or cultural barriers also eﬁ‘ect vaccination coverage levels in a practice
(10M, 1994). Some families do not understand the risks and beneﬁts of vaccinations, or
the importance of complete and timely immunization. Other families may completely
object to some or all vaccines, or have concerns about vaccine safety that prevent them
from obtaining vaccines for their children. Some providers set up cultural barriers with
families in the community, such as not speaking the same language as the client, or not
being sensitive to diﬁ‘erences in health beliefs, or religious inﬂuences that can alienate
clients Some of family health beliefs, such as parental objection to vaccines, are very
diﬁcult to alter. The emphasis to ﬁrlly immunize the children who are using the health
care system and are in families that desire complete immunizations should be planned for,

so families are able to obtain the services they seek.

7

Advanced practice nurses (APNs) in primary care are ideal providers to assess,
plan, implement, and evaluate eﬂ‘ective vaccination delivery systems. The issue of
immunization coverage and disease prevention coincide with the APN roles of assessor,
clinician, collaborator, and evaluator. APNs with assessor skills can identify needs for
immunization delivery services that are accessible, comprehensive, affordable, and
convenient for clients. APNs as clinicians are responsible for keeping current with
immunization recormnendations for schedules and practices, and accurate and timely
immunization of the population they serve.

APNs utilize collaborator skills to interact with other health care providers and
community members to ensure immunization coverage for the community. APNs possess
the skills to evaluate immunization delivery systems for clients, groups, and communities,
and can foster accountability of primary care providers to ensure prevention of
communicable diseases. APNs Operating in a managed care environment will be valuable
providers if they are able to maintain consistently high vaccination levels for all their
clients. Vaccine preventable diseases are still present in the United States, and low
vaccination coverage levels put the community at risk for disease.

Statemenmemblem

Vaccines are one of the most effective methods for preventing serious illness and
death, yet immunization coverage levels remain surprisingly low for children under three
years of age. Even with the recent addition of the Vaccine For Children program, which
removesmany of the ﬁnancial barriers to vaccines, coverage rates have remained below
the goal of 90% coverage levels. The challenge of overcoming barriers to immunization
belongs to the whole cormnunity, the health care providers, and the individual families in
need of immunization services. '

As health care moves toward managed care environments, immunization coverage
levels will be one of the markers addressed in measurement of appropriate health care

delivery. In the past, relatively few vaccines were given by primary care providers because

8

of ﬁnancial barriers, so many children received vaccines through local health departments.
Now many of the ﬁnancial barriers are removed, thus encouraging primary providers to
incorporate vaccines delivery on a daily basis to increase the comprehensiveness of
services available for the clients. There is a belief that immunizations act as an incentive to
well child visits, and removing vaccines tied to well visits may decrease attendance at well
visits (Rodewald et al., 1996). Studies of vaccine delivery outside the primary care setting
reveal immunizations obtained elsewhere does not alter the use of well-child visits (Hugart
et al., 1997; Rodewald et al., 1996), however recommendations are still strong to
strengthen vaccine delivery in primary care settings (F airbrother et al., 1996).

Immunizations given in primary care settings tends to link to other preventive
services such as lead screening and anemia screening (Rodewald et al., 1995). The
“immunization gap” is really a “preventive care gap” in primary care services according to
Rodewald et al. (1995). Bordley, Margolis, and Lannon (1996) found many primary care
providers are unaware of the immunization rates in their practices, and conclude
inadequate screening of vaccination coverage is a large barrier contributing to
underirnmunization in their practices.

The problem of develOping an eﬁ‘ective immunization delivery system in the
primary care setting can be addressed and managed by primary care providers. APNs in
the primary care setting need to be aware of the many barriers to complete immunization
coverage for their clients, and also strategies to eliminate these barriers. The APN’s
ability to improve immunization coverage levels will decrease the risk of preventable
communicable diseases in their client population. A planned vaccine delivery system will
help improve immunization delivery outcomes by providing a consistent and organized
approach for providers to implement and evaluate immunization delivery.

Speciﬁcally, the purpose of this project is to develop an algorithm for primary care
providers to facilitate decision making about the process of immunization delivery

systems for preschool children in Michigan. It is recognized that each individual setting

9

may have different barriers to providing vaccinations for their clients. King’s General
System Framework guided the identiﬁcation of personal, interpersonal, and social system
barriers that can inhibit clients and providers in meeting the goal of improving vaccination
coverage levels to 90% series completion of 4:3: 1 :3:3:1 (4 DTaP, 3 polio, 1 MMR, 3-4
Hib, 3 Hep B, 1 Var) for children ages 19-35 months. The Framework also provided a
visual tool to help explain the immunization delivery system in primary care. A decision
tree was constructed for primary care providers to consider choices in vaccine decisions,

to help avoid missed opportunities, and integrate the Standards of Pediatric Immunization

Practices in the delivery of vaccines.
Conceptual Framework

 

The immunization delivery system in primary care for this project is based on
King’s General System Framework. King (1971) based the framework on the four main
concepts that human beings ﬁrnction in social systems through interpersonal relationships
in terms of their perceptions which inﬂuence their life and health. King (1981) explained
the overall assumption for the framework is that the focus of nursing is human beings
interacting with their environment leading to a state of health for individuals, which is an
ability to ﬁrnction in social roles. King (1986) extended the scope of ﬁamework to
include families by adding that nurses set mutual goals with families. King has maintained
for many years that the framework is based on systems theories and views personal,
interpersonal, and social systems as open, dynamic, and interacting.

King (1981) described the personal system as a uniﬁed, complex whole, self who
perceives, thinks, desires, imagines, decides, identiﬁes goals and selects means to achieve
them. King (1981) described the interpersonal system as the process of interaction
between two or more individuals in verbal and nonverbal behaviors that are goal directed.
Social systems are the organized boundary system of social roles, behaviors, and practices,

10

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Barrel. King’s General System’s Framework (1981)

11

developed to maintain values and the mechanisms to regulate the practices and rules
(King, 1981). Social systems encompass the family, school, industry, social
organizationsand the health care delivery systems. Social systems provide a context in
which nurses practice.

King’s model notes the domain of nursing includes promoting, maintaining, and
restoring health (King, 1971, 1981). King deﬁnes health as the dynamic state in the life
cycle of an organism which implies continuous adaptation to stresses in the internal and
external environment through optimum use of one’s resources to achieve maximum
potential for daily living. Nursing is viewed as a process of action, reaction, and
interaction whereby the nurse and client share information about their perception in the
nursing situation. The goal of nursing is to help individuals maintain their health
so they can ﬁmction in their roles.

King developed a transaction model to explain the nursing process, which is
referred to as the Theory of Goal Attainment. The components of the nursing process are
perception, judgement, action, reaction, disturbance, mutual goal setting, exploration of
means to achieve the goal, transaction, and attainment of the goal. In the assessment
phase the nurse and client perceive each other, make mental judgements about each other,
and take some mental action to react to each other, and begin to interact through
cormnunication. In the planning phase the nurse and client interact to set mutual goals
regarding concerns identiﬁed by the nurse and client. The implementation phase of the
process is the transactions which occur to reach goal attainment. The evaluation phase is
the feedback loop to measure if goals are met.

King’s General System Framework can be applied to the process of immunization
delivery. The systems framework is abstract, but helps to explain the context in which

APN and clients interact and receive vaccines. The goal of immunization delivery is to

12

Potential Barriers to lrrmmization Delivery
in Primary Care Settings

’----------------------------‘
irradeqrﬂeftndim
vaccinelackofavaihbiity
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Iackofsymmsbtrackcoreragelewhzbedﬁandmﬁonal
hckdeoadiraﬁonbelmnm ‘
chamircwecineacheduea

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eoriraindieations
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lack of leakage-vaccines. ‘
achedde, records
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Eigutel. Potential barriers to the vaccination delivery process in the primary care setting.
Adapted ﬁom King’s General Systems Framework (King, 1981).

13

provide immunizations according to the recommended immunization schedule to the
children in the service area in the appropriate time frames. APNs apply their knowledge
and assessment skills to meet the goal of vaccine delivery at the apprOpriate ages. The
APN is in an ideal situation to assess and educate the family/caregiver on which vaccines
are recommended, and mutually set goals on how this can be accomplished, and continue
to assess immunization needs for clients in a systematic approach.
Relationships

King’s System Framework can be used to identify personal, interpersonal, and
social system barriers to vaccine delivery in primary care in order to eliminate barriers and
improve vaccination coverage levels. Personal barriers can include personal beliefs or
objections to vaccines, lack of knowledge, missed appointments, lack of transportation, or
true contraindication exists to vaccines. Interpersonal barriers include provider issues
such as missed opportunities to vaccinate, incomplete documentation, scheduling and
access issues, provider lack of knowledge about vaccines, inadequate vaccine handling,
supply, and storage, vaccine administration techniques, lack of tracking and recall system.
Larger community issues include utilizing available resources for information or support,
insurance and ﬁnancial barriers, lack of networks with other organizations supporting
vaccine delivery, lack of comprehensive computer registry to provide vaccine information.

The combination of these potential barriers interact in open systems to inﬂuence
the outcome of immunization status for the child. The goal is to plan a process of
interventions which will increase the satisfaction for the client, so that an ongoing
relationship is obtained in the primary care setting to enable health needs to be assessed,
met, and evaluated. In order for a systems ﬁ'amework to be eﬁ‘ective in an organization,
all members of the team will need to work together to meet the goal of 90% coverage
levels for children in the service population. The setting will need to assess current
coverage levels in order to move toward this coverage goal. Primary care settings that are
able to achieve 90% coverage levels are working in an organized approach to eliminate

------———————

l4

barriers to vaccine delivery in a comprehensive manner that address personal,
interpersonal, and social system issues.
W

The literature oﬁ’ers several aspects of immunization delivery to consider when
attempting to structure nursing interventions that will overcome perceived barriers to
immunizations. A personal barrier to obtaining vaccines is a lack of knowledge about
vaccines or negative attitudes related to obtaining vaccines. A recent study examined the
attitudes of 47 women receiving irmnunization services linked with the Program for
Women, Infants, and Children (WIC). Eight focus group discussions revealed mothers
believed it was the responsibility of parents to get their children immunized, but it was the
responsibility of W1C staﬁ‘ and primary care providers to work together to remind parents
when vaccinations are due (Shefer, Mezoﬂ‘, Caspari, Bolton, & Herrick, 1998). Mothers
felt linking W1C with immunization services was helpful and convenient. Telephone
reminders and education were mentioned as the best ways to encourage to get their child
vaccinated on time.

Provider issues are another focus of research study. Physicians (pediatricians,
family practitioners, and general practitioners) across the nation completed a 15 minute
telephone interview in 1995 about vaccine adverse eﬁ‘ects and potential litigation
(Zimmerman, Schlesselman, Mieczkowski, Medsger, & Raymund, 1998). In this survey,
(N = 1236) 40% of participants were in a 1- or 2-person practice, 33% were in practices
with 3 to 5 physicians, and 27% were in practices with 6 or more physicians. Of those
physicians aware of the Vaccine Injury Compensation Program (VICP)'which was 85%,
only 41% believed that the program aﬂ‘ordeda high degree of liability protection, 22% felt
it gives little protection, and 37% gave an intermediate answer.

The VICP provides no-fault compensation to patients suﬂ‘ering a permanent injury
related to vaccination. Among physicians highly concerned about'vaccine litigation, 22%
were unlikely to recommend a third dose of DTP to a child with a fever of 39.4 degree

15

Centigrade (102.9 degrees Fahrenheit) and no other symptoms after the second dose of
DTP. Most physicians recommended vaccines even if a parent was concerned about
possible adverse effects. The study concluded providérs’ beliefs about adverse events
following vaccination contribute to untimely and incomplete vaccinations for children in
their practices (Zimmemran et al., 1998).

A study of Georgia’s rise in vaccination coverage levels ﬁ'om 1988-1994 was
examined to see if the rise was due to a program of annual measurement (LeBaron et al.,
1997). Clinic vaccination records of 136,004 children were reviewed for clients ages
21-23 months who received vaccines in the public clinics. Series completion rates rose
ﬁom 53% to 89% for 4 DPT23 OPV:1 MMR. In the same time period, other indexes of
undervaccination fell; missed opportunities ﬁ'om 6% to 0%, lost contact for more than 12
months from 14% to 1%, and ﬁrst vaccination more than one month late ﬁ'om 19% to 8%.
Annual measurement of vaccination levels for this age group andfeedback of the coverage
levels to the public providers, increased the immunization rates for public clinics in
Georgia. It is not known if these results could be expected to occur in private ofﬁces.
Very few private providers have participated in omce audits. LeBaron et al. (1997) point
out a perceived resistance to a “record audit by the government” in private settings, lack
of legal mandates, and diverse characteristics of private settings as barriers to obtaining
their vaccination coverage levels.

Practice-speciﬁc immunization rates are one of the few objective measures in
prevention of illness for children utilizing primary care services. Since knowledge of
vaccination rates are essential to determining if improvement is needed, a study was
conducted in 11 diﬁ'erent states to measure vaccination coverage in 15 pediatric oﬁces
(Darden et al., 1996). Immunization rates were calculated by 3 methods for each cities.
The consecutive method measured data from charts of patients seen consecutively in the
oﬁce. The chart method used data ﬁ'om randomly selected charts in the ofﬁce, and the

active method used a combination of the medical record and a telephone call to collect

16

missing information. The result of coverage levels for a 4321 series for children two- and
three years old was that each method had similar results, however the consecutive method
was easier and preferred by practitioners to implement (Darden et al., 1996).

Family functioning has been shown to inﬂuence vaccination rates in two inner-city
health centers (Zimmerman et al., 1996). Families (N = 167) were studied in two health
centers which received ﬁee vaccines from a local health department. A Family Proﬁle
score to measure family concordance, family discordance, active involvement, and
religious inﬂuence was obtained, along with responses to health belief questions about
MMR and DTP injections. This study found that parents of children with late
vaccinations, as compared to parents with timely vaccinations, reported higher scores on
family dysfunction, lower income, and a perceived lower rating by their physician of the
value of vaccines. Vaccine knowledge was not associated with vaccine delay in this study.
Strategies that may increase lmowledge may only have a modest eﬁ‘ect on coverage levels
for inner-city health centers, while maximizing visits while in the setting, sending
reminders, calling about missed appointments, and focusing efforts on families that are
known to be dysfunctional have more eﬂ‘ect on increasing vaccination rates (Zimmerman
et al., 1996).

Lannon et al. (1995) attempted to develop a greater understanding of the factors
that impede poor parents’ utilization of health care services. They conducted a focus
group study for 50 women without health insurance or Medicaid for their children.
Mothers identiﬁed several barriers to receiving immunizations in North Carolina health
departments. The barriers identiﬁed were a lack of ﬂexibility in scheduling, long waiting
times, lack of transportation, chaotic home environments, employment conﬂicts, and lack
of knowledge about vaccine recommendation changes and vaccine safety. Suggestions to
eliminate some of these barriers were more ﬂexible scheduling, assistance with
transportation, improved waiting facilities, and increased health education (Lannon et al.,
1995). '

I?

Missed opportunities for immunizations is another factor associated with
underimrnunization in preschool-aged children. A signiﬁcant increase in irmnunization
rates in primary care was reported by Szilagyi et al. (1996) when an intensive screening
eﬁ‘ort was made to reduce missed opportunities in a primary care ofﬁce. The intervention
was to have oﬁce nurses screen every chart at all visits and attach reminder cards to
charts of eligible children. A second intervention eliminated the need for parental consent
for vaccines which had no eﬁ‘ect on immunization outcomes. When reminder cards were
attached to charts there was a signiﬁcant increase in immunization rates, however
reminder cards were only attached on one third of the vaccine-eligible visits (Szilagyi et
al., 1996). More eﬁ‘ective interventions are needed to incorporate screening all children in
busy primary care oﬁces (Szilagyi et al., 1996).

Christy, McConnochie, Zernik, and Brzoza (1997) found an algorithm-guided
nurse intervention improved the use of immunization opportunities at non-well child care
visits. One problem identiﬁed was the lack of reliable immunization history in 43% of the
subjects (N = 651). Nurses were more likely to assess a child’s vaccination status if the
history was available 21.3%, as compared to 8.2% assessment rate if the history was not
available. Christy et al. report the algorithm had the greatest impact on nurse education
and performance enhancement related to missed opportunities, and the increased attention
to immunizations may have motivated nurses to try to improve their performance. The
children who had regular timely well child care generally were not due for vaccines at
non-well child care visits, and the algorithm was not helpful in those situations. The
eﬁ‘ectiveness of the intervention was limited by the lack of a reliable information system
such as a computerized national or state immrmization registry (Christy et al.).

A recent study compared vaccination practices of pediatricians and family practice
physicians (Szilagyi et al., 1994). Overall, physicians working with populations at higher
risk of undervaccination and more recent graduates ﬁ'om medical school were more

aggressive in their immunization practices and tended to vaccinate at acute illness visits,

18

provided simultaneous vaccinations, and used tracking systems. The authors concluded
education eﬂ‘orts should be focused at solo practice physicians and older physicians who
tended to be less likely to follow the new standards for immunization practices (Szilagyi et
al., 1994). _

Research has been conducted to study the seroconversion rates of administering
vaccines when children have an upper respiratory tract infection. Dennehy, Saracen, and
Peter (1994) found seroconversion to measles, mumps, mbella, and varicella was not
signiﬁcantly altered by the presence of an URI in 15-18 month old children. Edmonson,
Davis, Hopfensperger, Berg, and Payton (1996) found no increase in vaccine failure for
the measles vaccine for children vaccinated during the respiratory virus season.

Research by Dietz et al. (1994) concluded vaccination coverage levels could be
raised 12% to 22% for a 42321 by simultaneously administering all vaccines due. Woodin
et a1. (1995) found physicians had more concerns than parents about the administration of
multiple injections at a single visit. Continuing education for providers are needed to
ensure simultaneous administration of vaccines (Woodin et al.).

In Georgia, research was conducted by Linkins, Dini, Watson, and Patriarca
(1994) regarding the use of computer-generated telephone messages. A study of
children younger than 2 years (N=8002), with listed telephone numbers in a computerized
database, who were due for or late for vaccines, where randomly contacted to receive a
computer-generated telephone message the day before the child was due for vaccines.
Children determined to be late for vaccines received a speciﬁc message, and children
determined to be due for a vaccine received a general message. Families presented for
immunizations at the health department within 30 days after the phone reminder at a rate
of 36.6%, compared to 28.4 % of the children that did not receive a computerized
telephone reminder. The results support the use of computer-generated immunization
telephone reminder messages to families of children younger than two years. However,

the cost of such systems are estimated at approximately $10,000 to start, and yearly

19

maintained at approximately $1,225, thus a large population would be necessary to justify
the expense (Linkins et al. 1994). Many statewide registries could justify the expense due
to the large pOpulation they are expected to serve.

Pediatric immunization delivery in primary care requires a planned process of
comprehensive interventions in order to achieve coverage levels of 90% set by the Healthy
People 2000 objective. Studies in the literature review support many of the
recommendations set out by the National Vaccine Advisory Committee to implement a
comprehensive plan to deliver immunizations to children. Maximizing interactions with
clients while they are in the health care system to provide information and services related
to vaccines, should help decrease added costs of tracking and recall related to missed
opportunities to vaccinate.

King’s General System Framework provides a comprehensive model to address
many of the possible barriers to complete vaccine delivery. Health care providers can
apply the model to identify family/caregiver, provider, and health care system barriers that
inﬂuence effective immunization delivery. The use of King’s framework allows providers
to visualize how a change in one part of the system effects the overall delivery system.
These theory components also support the recommendations set out by the National
Vaccine Advisory Committee to implement a comprehensive vaccine delivery plan. The
framework assists providers to identify barriers to vaccine delivery in a comprehensive
manner.

Issues speciﬁc to primary care are the wide variety of other provider services
available in this setting. Providers are delivering well child services, and sick child services
sometimes integrated in the same visit. In order for immunization delivery to be in the top
priority of services for children, providers must be aware of and assess immunization
needs for their clients at every encounter. In the past, immunizations have been obtained
by many families at the public health department immunization clinics because it has

20

traditionally been less expensive. Now many children are covered by insurance that
partially or fully compensates for vaccine costs, and ﬁnancial barriers to vaccines are
relatively infrequent occurrences.

Providers in primary care settings traditionally have not tracked immunization
status as closely as is now required in order to meet 90% coverage levels. This is a new
behavior that needs to be consistently and systematically implemented by primary care
providers toward the goal of complete vaccine coverage levels. Additionally, ﬁ'equently
changing vaccine schedules, accelerated schedules, and new vaccine products are
continuing to emerge to further complicate and conﬁrse vaccine delivery for providers and
families alike.

The purpose of this project was to develop an algorithm for primary care providers
to facilitate decision making about the process of immunization delivery systems for
preschool children in Michigan. Vaccine delivery continues to change and evolve, and is
expected to continue changing as new vaccines are available. Providers with a ﬂexible
system in place for vaccine delivery which addresses vaccine delivery in a comprehensive
manner with a team approach, are more likely to be able to adjust to new
recommendations by the CDC as new vaccines and information become available. The
algorithm delineates a sample process which can be applied in a primary. care setting, with
an emphasis on avoiding missed opportunities to vaccinate, in order to attain a
comprehensive vaccination delivery system. Advanced practice nurses in primary care
can implement the algorithm, with the team in which they practice, to insure their clients
meet the recommended goal of 90% vaccination coverage level.

Project Development
Approach '

This purpose of this project was to develop an algorithm for primary care

providers to facilitate decision making about the process of immunization delivery systems

for preschool children in Michigan. A algorithm develOped for primary care providers can

21

assist providers to consider the multiple immunization decisions that can occur in a single
primary care visit. The algorithm is based on a culmination of research from the literature
review and King’s General System Framework. The algorithm was particularly inspired
by the research study by Christy et al (1997) that concluded the use of an algorithm can
increase the rate of immunizations given at non-well child care visits. This project
incorporates many of the Standards of Pediatric Immunization Practices (DHHS, 1992) in
the algorithm to focus on avoiding missed opportunities for pediatric immunizations. The
algorithm is designed to be used in conjunction with the many readily available
immunization resources developed for primary health care providers. In Michigan, an
outstanding resource is the Provider Tool Kit for 1998 distributed by the Alliance for
Immunization in Michigan.
Assumptions

The algorithm is based on a few basic assumptions about the primary care provider
engaged in childhood immunization. One assumption is the provider ensures appropriate
vaccine handling and storage. Another assumption is the provider receives ongoing
education regarding current immunization recommendations, including how to educate
clients about immunizations in general, and about speciﬁc vaccines. A ﬁnal assumption is
the provider will operate and maintain a tracking and recall system, and will conduct
audits to measure immunization rates. With these systems in operation the primary care

provider is ready to assess client vaccination status and provide appropriate vaccines.

 

C hild presents to prim any care provider center:
Provider assesses for caregiver knowledge about im m unizations
Provider screens for child vaccination status at EV ERY VISIT
Provider enters child vaccination record in tracking and recall system
Provider ensures appropriate vaccine handling and storage in setting
Provider receives ongoing education on current recom m endations

 

 

 

Elam}. Assumption components of immunization algorithm

22

The algorithm is organized in a four basic sections for vaccine delivery. The initial
section is assessment. Assessment is an essential ﬁrst step in accurate and complete
vaccine delivery. The second section of the algorithm is education. Education is based on
the learning needs of the family, and includes both general and speciﬁc information related
to the risks and beneﬁts of vaccines. The third section delineates vaccine administration
concepts including vaccine handling and storage, following current schedule
recommendations, administration techniques, with emphasis on simultaneous
administration. The ﬁnal section of the algorithm contains documentation components
necessary to accomplish a complete vaccine delivery. Each fundamental section is a vital
and integral component of the algorithm.

Assessment

An identiﬁed primary care provider barrier is missed opportunities to vaccinate
eligible children. The ﬁrst step in avoiding missed opportunities is to screen children at
every visit for vaccination status. Knowledge of the current recommended vaccination
schedule is required to complete this step, as well as the child’s age, medical history, and
immunization history. Screening requires assessing the child’s record. Parent report is
not accepted as evidence of an up-to-date record. Sources for the vaccination record
include the vaccine card, any previous provider sites, and possibly a computer
immunization registry. Providers will continue to rely on personal immunization records
until computer registries are ﬁrnctioning reliably and consistently in the United States.

If the child has no record, the health care provider should try to obtain the
information from the previous provider of vaccines. In Michigan, the state is currently
trying to implement a statewide registry (MCIR) to assist providers in determining the
immunization status of their clients younger than 20 years of age. Immunization
information will be provided by both public and private health care providers. This
computer data base will help providers to assess immunization status of children that

obtain vaccines from multiple sites and do not have a current record with them. When a

23

child presents without a record, the provider can determine the needed vaccines based on
the history and age of the child, and decide what would usually be due for that age at that
visit.

The next step is to determine if the child has any contraindications to the

appropriate vaccines. This is accomplished with a screening questionnaire prior to giving

. the vaccines. A standard form used by all health care providers will promote consistency

and continuity for immunization delivery. The Immunization Action Coalition has
developed an easy to administer questionnaire which can be obtained from their newsletter
(Needle Tips) or internet site (www.immunize.org.). Contraindications can be conﬁrmed
by consulting the current guide to contraindications to childhood vaccinations published
by the Center for Disease Control.

The health care provider will have to determine if the regular or accelerated
schedule will need to be implemented to vaccinate the child. The regular schedule is
updated annually, usually in January, and represents a consensus of recommendations by
the American Academy of Pediatrics (AAP), the Advisory Committee on Immunization
Practices (ACIP), of the Centers for Disease Control and Prevention (CDC), and the
American Academy of Family Physicians (AAFP). The current accelerated schedule is
located in the current Red Book ( 1997) which is the report of the Committee on
Infectious Diseases published by the American Academy of Pediatrics. Immunization
providers should follow this schedule for children not immunized in the ﬁrst year of life.
Both of these schedules are similar, but the accelerated schedule allows the provider to
help children become immunized at a faster rate.

The algorithm was developed to help eliminate missed opportunities. The
emphasis of the algorithm is on the assessment phase. The decisions the providers make
during this stage have a large impact on the outcome of the immunization status of the
child. The multiple paths of the assessment phase of the algorithm are designed to lead to

the correct vaccination at the correct age for at least 90% of the children.

24

 

F

 

 

Child has vacc'ne record 7

 

 

I

Record not
up-to-date for age

l

l

 

 

Child has no record

 

 

Caregiver refuses vaccines
for Child

 

 

j

 

 

Provider attempts to locate previous

7 record or checks immunization registry

 

 

 

 

 

 

rovider screens for

 

 

 

 

0 Provider assesses for
speciﬁc refusal
reasons

0 Provider reviews rele-
vant information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P
l__.{ contraindications I
Record up-to-date . l
for age 7 l .
. . . Precautron .
No contrarndrcatrons Contrnue to
l” contra. reassess and
1 ‘ $310“ provide infor-
Provider refers to current im- gigoutzrmh
Conﬁrm up-to- munization schedule
date for new 0 Determ'nes vaccines due based
vaccines added on age &. history
to schedub such
as Hep B, Var
I ‘ v
A 7 f . ‘ Determine if pre—
Regular 7 Accelerated caution
Schedule Schedule

1

 

l .

 

 

 

 

 

 

 

l

 

 

 

Remilder to caregiver
when next due for vaccines

l l

Determine'if true
contra'mdication

 

 

 

 

 

l

l

 

o Withheld speciﬁc vacc'ne
0 Document contraindica-

 

Schedule if
appropr'nte

 

tion

 

 

 

 

fit to child
0 Consult with

0 Document
outcome

 

0 Give or withhold
vaccine depend-
ing on risk bene-

other providers

 

 

Eigutei Assessment component of the immunization algorithm.

25

Education

Providers need to inform parents about the beneﬁts and risks of immunizations.
The CDC has developed standardized Vaccine Information Statements, which are
periodically updated. Statements are available for Diphtheria-Tetanus-Pertussis vaccine,
Tetanus-Diphtheria (adult) vaccine, Pneumococcal vaccine, Polio vaccine, Inﬂuenza
vaccine, Chickenpox vaccine, Haemophilus inﬂuenzae type b vaccine, Hepatitis A vaccine,
Measles-Mumps-Rubella vaccine, and Hepatitis B vaccine. Health care providers are not
required to obtain the signature of the patient, parent, or legal representative
acknowledging receipt of the Vaccine Information Statement. Primary care providers
have the skills necessary to inform and educate parents/caregivers about the vaccines the
child is about to receive. Providers can speak about vaccines in general and speciﬁc
terms, and are able to assess the learning needs of the client.

Many primary care providers participate in the Vaccine for Children program
(VFC) which provides vaccines at no cost from the health department to eligible
providers. Providers are required to comply with the following rules in order to receive
these vaccines: comply with the appropriate schedules; provide VIS materials; provide
vaccine cards; impose no charge for vaccines; not deny vaccine if unable to pay an
administration fee; ﬁle claim forms for Medicaid-enrollees; provide reports for all doses;
comply with storage and handling standards; and share immunization records with the
health department. In addition providers may administer VFC vaccines only to a child less
than or equal to 18 years of age who: is enrolled in Medicaid; or has no health insurance;
Or is a Native American or Alaskan Native; or has health insurance that does not pay for
vaccines if clients of a federally qualiﬁed health center or rural health clinic. Providers are
required to maintain a record of eligibility for the child for at least three years, and can not
impose a charge for an administration fee of the vaccine in any amount higher that the

maximum fee established by DHHS.

26

 

Provides Vaccination Information Statements for each vaccine
Provider reviews risks [beneﬁts of each vaccine

Conﬁrm caregiver understanding of information

Review common reactions following vaccines

 

 

 

Figural Education component of immunization algorithm.

IC'!1"'

Primary care providers need to make every effort to provide all simultaneous
vaccines due to the child at that visit. This step can help raise immunization rates
12%-22% (Dietz et al., 1994) for 2 year old children. This step has greater importance as
more vaccines are added to the recommended schedule. Providers need to keep current
on new combination vaccines that become available, further changing the available options
to clients and providers. Use of the algorithm will remind providers to consider all the
options available, and consider minimum spacing intervals required between doses.

Providers also have to be aware of standards for vaccine stdrage and handling in
order to ensure vaccines given are effective doses, and to avoid unnecessary and costly
loss of vaccine. Package inserts clearly deﬁne storage and reconstitution information,
dosage and route of administration information. Reﬁigerator and freezer temperatures
need to be maintained, checked, and logged daily. Proper storage and handling needs to
be maintained while biologics are transported. Agency policy should deﬁne rules for
vaccine storage and handling, including steps to implement during power failure, and
resource phone numbers of vaccine suppliers regarding the handling of the affected
vaccine. A sample quality control program for vaccine handling and storage is delineated
in the 1997 Red Book, pages 6-8.

Following vaccine administration, clieirts should wait in the setting to observe for
reactions. Providers are required to report selected adverse events that occur after
vaccination to the Vaccine Adverse Event Reporting System (V AERS). The form was

last updated in March of 1997. Personnel administering biologic products or serum

28

month, day, and year of administration; (2) vaccine administered; (3) manufacturer; (4) lot
number (5) date of relevant VIS given to the patient or patient representative; and (6)
name, address, and title of the health care provider administering the vaccine. Many of
the computer software programs have warnings for invalid data entry which can reduce
the number of inaccurate entries. Finally, the parent/caregiver should be reminded again

to protect and bring the vaccination card to all health care visits.

 

01,. f ' f 11 - L ~ ~ - & . h . . 7Child with a scheduled
ervc or reaction 0 owrng vaccine In setting, revrew orne Instructions appointment receives .

Set up appointment f0! ”It YET“ . . . reminder call to house-
Documcnt on vaccrne card, billing system, In tracking system, & on chrld record hold prior ‘0 next
Reminder to bring immunization record to all visits appointment.

 

 

 

 

Eigurnl. Documentation component of immunization algorithm.

Evaluation of the Algorithm

Evaluation of the algorithm can be conducted in the primary care settings
implementing the algorithm for decisions about pediatric immunizations. If the site is
utilizing audits that can detemrine rates of missed opportunities, they can see if the
algorithm had any impact on these rates. If they are measuring series completion rates for
children ages 19-35 months, they can determine if any changes in rates occurred after
implementing the algorithm. A setting could measure the coverage rate to incorporate
new vaccines added to the vaccination schedule in the client population they serve.

A chart audit could be conducted comparing current and previous numbers of
vaccines given at non well-child care visits. A chart audit could be conducted to
investigate if any documentation occurred regarding reasons vaccines were withheld,
which could be evaluated if a true contraindication existed. A chart audit of reasons for
refusal of vaccines at a visit could be conducted, with a follow up audit of documentation

of continuing assessment of reﬁrsal rationale. An audit could be conducted to see if active

29

charts are in the computer database, if new clients are consistently added, if inactive clients
are identiﬁed, in the setting with computer capabilities.

A parent/caregiver survey could be conducted to evaluate satisfaction with
provider communication, ease of access, affordability of services, and continuity of
services. A survey could be conducted of provider satisfaction with the algorithm.

There are certainly several ways the algorithm can be evaluated, and revised to meet the
needs of a speciﬁc primary care setting.
Implications for the Advanced Practice Nurse in Primary Care

The algorithm developed in this project has direct relevance for advanced practice
nurses in primary care. Preschool children remain at high risk for preventable diseases as
long as they are not ﬁrlly immunized. APNs can have a signiﬁcant impact on
immunization rates in their practice. The APN can utilize the roles of assessor, clinician,
collaborator, and evaluator to ensure a high immunization rate in their practice area.

As an assessor, the APN can utilize a database to track immunization status in the
population. Ifa computer database is not available the APN can promote the need to
implement such a database to increase the ability to manage the immunization information.
The APN can utilize the information of coverage levels to make judgements about the
adequacy of care and relationships between the personal, interpersonal, and social system
barriers that can impact the adequacy of coverage levels. Collecting and updating the data
are appropriate roles of the APN.

As a clinician, the APN is providing direct primary care to the clients. The APN is
able to promote health, and impact the health of clients by providing accurate detailed
information about immunizations, and helping parents/caregivers deal with fears or
misunderstandings they may have about immunizations. The APN is able to interact with
the family, and brings to the relationship a wide variety of resources to help clients
maintain immunization coverage levels. The APN can identify and alter barriers that may

exist in the provider primary care setting.

30

A collaborator is able to participate with other health care providers to help clients
manage health care needs. The APN practicing in primary care is able to initiate and
encourage collaborative relationships with other providers involved with immunization
delivery. This can include working closely with the health department, working closely
with immunization action groups, working closely with interested community groups to
ensure a smooth immunization delivery system for their clients. The ability to identify and
modify barriers that can exist between agencies empowers the APN and other health care
team members to achieve joint accountability for increasing community immunization
levels.

Evaluators use guidelines or algorithms to appraise the quality and quantity of the
effectiveness of interventions. An APN in primary care can use the algorithm to guide the
multiple decisions about immunizations that can occur in a single visit. The APN can
measure immunization coverage levels and compare levels before and alter implementing
the tool for their clients. The APN can use the algorithm to help maintain a high coverage
level for the pediatric population. The APN is a primary care provider trained to develop
and implement practice guides to improve the quality of care for their clients.

Implications for Education

An algorithm is an important tool to increase knowledge for APNs in primary care.
The algorithm is based on ample resources to be used to implement the algorithm. The
APN can also use the algorithm to ensure other health care providers are aware of and
able to ﬁrlly immunize their clients. The algorithm focuses on avoiding missed
opportunities, which is a component providers can inﬂuence and manage. The algorithm
incorporates the Standards of Pediatric Immunization Practices which can also be an
educational tool to improve immunization delivery systems. Primary care providers can
also adapt the algorithm to their speciﬁc setting, or revise the algorithm as new vaccine

research or information becomes available.

31

The algorithm can also be utilized in preparing advanced practice nurse students
for their roles in primary care. The tool can help students visualize the process of
immunization delivery. The tool is also a framework to see how the steps in the process
can eﬁ‘ect the outcome of immunization status. APN students can utilize their knowledge
of Kings General Systems Framework to guide their delivery of immunization services to
cheats.

Implications for Research

The algorithm developed in this project presents many opportunities to research
the usefulness of the tool in primary care. It is the regular use of the algorithm and study
of the tool that improved processes can be developed. Although there are several studies
of missed opportunities, there is a serious lack of research about algorithms used to
improve pediatric immunization rates. This algorithm addresses the need for information
systems that can assist the provider to make decisions about immunizations. Computer
systems are only as good as the information that is put in them, thus the importance of
ensuring accurate and timely vaccine input to these systems. Providers will still need to
use other tools to help manage decisions about vaccine delivery, since computer systems
can be temporarily out of service. Inactive computer systems can create future barriers to
immunization delivery. Evaluating current research ﬁndings will allow the APN to apply
relevant ﬁndings to improving systems of pediatric immunization delivery.

SUMMARY

The purpose of this study was to develop an algorithm for primary care providers
to facilitate decision making about the process of immunization delivery systems for
preschool children in Michigan. King’s General System Framework supports the use of
tools such as algorithms to help guide the delivery of nursing services in the health care
system, and improve immunization delivery systems. Increasing immunization coverage
levels to the 90% goal delineated in the Healthy People 2000 report, is important for the

health of children and the health of the community. Failure to ensure high vaccination

32

levels puts the whole community at risk for preventable diseases. Advanced practice
nurses have the opportunity and responsibility to assess, plan, implement, and evaluate
immunization delivery systems that meet levels of 90% of the pediatric population less that

three years old are fully immunized against ten preventable diseases.

APPENDIX A

Immunization Opportunity Algorithm

33

 

Pediatric Immunization Opportunity

Algorithm for Primary Care Providers

 

 

Parent/earegiverconractsprimaryhealtheareprovider.
providerremindstobringimmunizationrecordtoeveryvisit

P

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Childpresemstoprimarycareprovidercenter: o Providerimplements
o Providerassemesforaregiverknowledgcabomimmmrintions monthlyuackingofvacci—
o ProviderscreensforchildvaccinationstamsatEVERYVlSl'l‘ nationrecords
o Provideremerschildvaccinaﬁonrwordinnsckingandrecallsystern ’0 Provideraendsreminder
- Providerensmesappropriatevacdnehandlingandstorageinsetting eardstochildrenonrecall
o Providerreceivesongoingerhrcariononcmrentrecommendations l list
I
l t j
{Childhasvaccinerecord @MNW‘EJ Caregivarefusesvac-
I cinesforchild

 

 

 

 

 

 

j—J—ﬁ Providerattemptstolocateprevitnrs

recordorchedrsrmnmnrzauonregrsuy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Recordrp-to- Recordnot
dateforage max“; I o Providerassessesforspeciﬁcreﬁrsal
. reasons
i l 4 Wm” . o Providerreviewsrelevaminformation
Conﬁrmup-to-datefornew ca on: I I
vaccinetaddedtoschedule I
m”“¢PEVﬂ’ LNOWM I Preeautionorcontra- i Continuetoreassecs
‘ indicationpresern andprovideinforma- 7
l :tionareachencotmtaJ

 

 

 

 

 

Remindertocrnrp' o Providerrcferstoarrrentimnnrnizationschedule
whcnnenrheform o Determinesvaccinesdnebasedonageahistory

i l j l . l '
[Awmsecaui] m3: mm»

1 l r l

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LScherhrleifappropriate]

 

 

 

 

 

 

 

 

 

o ProvidesVaccinationInformtionStaternentsforeachvaccine [, wmwspeciﬁc if. Giveorwithhold
o Providerreviewsriskslbeneﬁtsofenchvaccine vaccine 5 WW“
0 Conﬁrmcaregiverunderstandingofint‘ormation . Wong. E ingonrisklbene-
. Reviewcommonreactionsfollowingvaccines “wagon é ﬁrtochjld l
1 0 mm 1
o DetermineifeligibleforVaccineForChildrenvaccines I “"0"“. 5 g
o Selectvaccinesfromappropriatenrpplies " Documcrllout- i
o Provideroﬂ'ersimmrmizaﬁonaervimsﬁeeorforminimalfee i come i

 

 

 

 

, l
o PROVIDER vaccinares child with ALL SIMULTANEOUS VACCINES DUE AT VISIT
o Providerutilizescurrenrreeomcesregardingdosagerome, administrationtechniques

 

 

 

 

 

 

 

 

 

 

l
. C th scheduled
o Mfmmmﬂowingvaccineinsemng,&reviewhomeinsuuctions WW!
w o Setnpappor'ntmenrfornernvaccine remindercalltohouse—
if“ 0 Doamwvacdmeardbﬂhngsymmuackingsystmtonchﬂdmcord thIdll’IOIIOMXI
o Ranindertohringimnnmizationrecordtoallvisirs Wm.

 

 

 

 

W Pediatric immunization opportunity algorithm for primary care providers.

APPENDIX B

Provider Immunization Resources

34

APPENDIX B

Provider Immunization Resources

There are several resources available for Michigan primary care providers to refer
to for childhood immunizations. One particular comprehensive resource is the Alliance for
Immunization in Michigan Provider Tool Kit for 1998 which is distributed by the
Michigan Department of Community Health. Several sponsors have contributed to the
Tool Kit which is formatted in three colorful ﬁle folders; resources, posters, and
irmnunization management. References contained in each folder are listed below.

Resources. Immunization Training Opportunities for Physicians and Staff; Polio
Vaccine: New choices for your baby; Six common misconceptions about vaccination, and
how to respond to them; Vaccine adverse event reporting system; Ofﬁcial immunization
record; Health care professionals guide to the Michigan Communicable Disease
Rules and Michigan Department of Public Health Biologicals; How to order immunization
resource materials, How to order adult immunization resource materials; IAP and
immunization coordinators directory; Free vaccines available for your patients;
Immunization training opportunities; Legal issues; Michigan Department of Community
Health order form for immunization pamphlets and forms; and Hepatitis A-E resource
materials.

Rosters. Things you can do now to improve immunization levels of Michigan’s two year
olds; A summary for immunization requirements for children attending Michigan child care
programs; a summary for immunization requirements for children entering Michigan
schools; Guide to contraindications and precautions to immunizations; and Standards for

pediatric immunization practices.

35

WW. Injectable vaccine administration; Minimum age for initial
vaccination and minimum interval between vaccine doses, by type of vaccine;
Recommended childhood immunization schedule United States, January - December 1998;
Resource numbers stickers; Vaccine storage and handling poster for refrigerator;
Vaccination Information Statements for Hepatitis A vaccine, Hepatitis B vaccine,
Chickenpox vaccine, Hib vaccine, DTP/DTaP vaccine, MMR vaccine, Pneumococcal
vaccine, Td vaccine, Polio vaccine, Inﬂuenza vaccine; Vaccine storage temperature log;
Adult irmnunization schedule; and Misconceptions concerning vaccine contraindications.
The Provider Tool Kit is designed to have all the necessary resources conveniently
contained in ﬁle folders for effortless reference for irmnunization providers. The list of
resource materials includes standards and guides, print references, videos, slides,
periodicals, telephone hotlines, patient education print materials, patient education videos,
patient education telephone hotlines, and world wide web sites for providers and patients.
Of particular interest in the reference list is the book published by the Department of
Health and Human Services, Epidenﬁolomndhexenﬁonﬂamineﬁrexemahle
W 4th edition, 1998. This is the reference book for the CDC
satellite courses for immunization providers, and contains detailed information on each
vaccine, in addition to several delivery system resources. The Michigan tool kit assists
primary care providers to stay current with changes in immunization schedules and

guidelines.

APPENDIX C

Provider Barrier Identiﬁcation Tool

36

APPENDIX C

Provider Barrier Identiﬁcation Tool

Primary care providers can meet as a team to help identify potential barriers to
immunizations in their speciﬁc setting. This blank model, based on King’s General System
Framework, will act as a guide for providers to become aware of barriers that can impede
immunization delivery. Once barriers are identiﬁed, providers can develop strategies to
address the barriers, in order to reach the outcome of 90% of two year olds fully

immunized against ten preventable childhood diseases.
Pobrﬁal Barriers to lmmiation Deivery
in Priority Care 8m

’-- ----- -------—-------------‘

i
3
i
3

WM

3.7::

 

 

i
i

:>

‘----t

’-----

5--- -------------

‘----------------------------’

Emmi Provider barrier identiﬁcation tool. Adapted ﬁ'om King’s General System
Framework (King, 1981).

APPENDIX D

Recormnended Childhood Immunization Schedule - 1998

37

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_-------——-

APPENDIX E

Recommended Accelerated Immunization Schedule

39

TABLE 4. Recommended accelerated immunization schedule for infants and

children <7 years of age who start the series late“ or who are >1 month behind in
the immunization scheduie' (l.e., children from whom compliance with scheduled
return visits cannot be assured)

 

 

Timing Vaccine(s) Comment
First visit (:4 months of DTaP’. OPV‘. Hib‘. Must be :12 months of age to receive
age) hepatitis B. MMR. MMR and varicella. if :5 years of

 

 

 

 

varicella age. Hib is not normally indicated.
Second visit (1 month" DTaP‘. OPV‘. Hib’. '
after ﬁrst visit) hepatitis 8
Third visit (1 month after DTaP’. OPV‘. Hib‘
second visit)
Fourth visit (_>_6 months DTaP’, Hib‘. hepatitis B
after third visit)
4-6 years of age DTaP’. OPV. MMR Preferrably at or before school entry.

DTaP is not necessary if fourth dose
given on or after the fourth birthday.
OPV not necessary if third dose given ,
on or after fourth birthday.

 

11-12 years of age

 

 

Varicella. MMR. and/or
hepatitis B (if not already
received). Td if >5 years
since last dose

 

Repeat Td every 10 yrs throughout
life

 

ii initiated in me first year elite. administer DTaP doses 1. 2. and 3 and OPV doses 1. 2. and 3 according to this

schedule; administer MMR and varicella when the child reached 12-15 months of age. All vawines should be
admininstered sirmitaneousiy at the appropriate visit
t See individual AClP recommendations for detailed information on specific vaccines.
s Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) is preferred for all doses of the series. A
vaccine containing whole oel pertussis vaccine is an acceptable alternative.
I ifthepoiiovaccineserlesisbegun beforesmontl'isofage.ACIPrecorrmendsthehr'sttvvodosesbe
administered as inactivated polio vaccine (IPV). and the third dose (OPV) be administered at 12-18 months of

'99-
: RecommendedHibsdieduhvanesbyvacdnemnufacmmrandageofmmﬂdwhenvacdnaﬁonsedesb

 

started. "series is begunatage <6monthsofage.4doses are needed (only 3dosesareneededlfaldoses
are PRP-OMP [PedvaxHia Merckl). The fourth dose must be _>_2 months after the third dose and on or after the
ﬁrst birthday. if series started at age 7-11 months. 3 doses are needed with the third dose 32 months alter the

second dose and on or after the first birthday. if series started at age 12-14 months. 2 doses are needed. 32
months apart if series started at age 2,15 months, one dose ofany ﬁcensed conjugate Hib vaccine is

recommended.

it Anlntervalofzaormoredays.

Based on General Recommendations on minimization (1994). with modiﬁcations from subsequent ACIP

8M0”.

real-rd
0mm

REFERENCES

REFERENCES

American Academy of Pediatrics, Committee on Infectious Diseases. (1998).
Recommended childhood immunization schedule. WU), 154-157.

American Academy of Pediatrics. Wu
W. 24th Edition, Elk Grove Village, IL.

Bordley, W. C., Margolis, P.A., & Lannon, C. M. (1996). The delivery of

immunizations and other preventive services in private practices. WM),
467-473.

Centers for Disease Control and Prevention. (1993). Standards for pediatric
immunization practices. WWW Report RR-S.

Centers for Disease Control and Prevention. (1994). General recommendations on
immunization: Recommendation of the advisory committee on immunization practices.
WWW Report RR-l.

Centers for Disease Control and Prevention. (1994). Reported
vaccine-preventable diseases—United State, 1993, and the Childhood Immunization
Initiative. WWW“), 57-60.

Centers for Disease Control and Prevention. (1996). National, state, and urban

area vaccination coverage levels among children aged 19-35 months-United States, April

l994-March 1995. Wu). 145-150.

Centers for Disease Control and Prevention. (1997). Status report on the
childhood immunization initiative: National, state, and urban are vaccination coverage

levels among children aged 19-35 months-United States, 1996. MQEbidinLandMleity
W 657-664.

40

41

Christy, C., McConnochie, K. M., Zernik, N., & Brzoza, S. (1997). Impact of an
algorithm-guided nurse intervention on the use of immunization opportunities. Amhixes
ofPediatﬁcandAdnlescemMedicineJiL 384-391-

Darden, P. M., Taylor, J. A., Slora, E. J., Hasemeier, C. M. Asmussen, L.,
Recknor, J. C., & Wasserman, R. C. (1996). Methodological issues in determining rates
of childhood immunization in ofﬁce practice, a study from pediatric research in oﬂice
settings (PROS). AmhixeufﬁediatricandAdnlescsmMedicineiiﬂ, 1027-1031.

Dennehy, P. H., Saracen, C. L., & Peter, G. (1994). Seroconven'on rates to
combined measles-mumps-rubella-varicella vaccine of children with upper respiratory tract
infection. WM), 514-516.

Dietz, V. J., Stevenson, 1., Zell, E. R., Cochi, S., Hadler, S., & Eddins, D. (1994).
Potential impact on vaccination coverage levels by administering vaccines simultaneously
and reducing dropout rates. WW
943-949. I

Edmonson, M. B., Davis, J. P., Hopfensperger, D. .l., Berg, J. L. & Payton, L. A.
(1996). Measles vaccination during the respiratory virus season and risk of vaccine
failure. W6), 905-910.

Fairbrother, G., Friedman, S., DuMont, K. A, & Lobach, K. S. (1996). Markers
for primary care: missed opportunities to immunize and screen for lead and tuberculosis by
private physicians servicing large numbers of inner-city Medicaid-eligible children.
Wm), 785-790.

Holt, E., Guyer, B., Hughart, N., Keane, V., Vrvier, P., Ross, A., & Strobino, D.
(1996). The contribution of missed opportunities to children underimmunization in
Baltimore. WM), 474-480.

Hugart, N., Vivier, P., Ross, A., Strobino, D., Holt, E., Hou, W., & Guyer, B.
(1997). Are immunizations an incentive for well-child visits? Amhimnifﬂdiatmand

W11. 690-695.

42

Immunization Action Coalition. (1998). After the shots. {On-line}. Available:
http://www.immunize.org/

Institute of Medicine. (1994). W
summary. Washington, DC; National Academy Press.

King, I. M. (1971). Imardaﬂmfomursingﬁeneralmmptmﬂhumm
behavior. New York, New York; John Wiley & Sons.

King, 1. M. (1981). AlhmnﬂnuzsingLstxmmmmumss. New York,
New York; John Wiley & Sons.

Lannon, C., Brack, V., Stuart, J ., Caplow, M., McNeil, A., Bordley, C., &
Margolis, P. (1995). What mothers say about why poor children fall behind on
immunizations, a summary of focus groups in North Carolina. MW
AdolescemMedicincJAQ, 1070-1075.

LeBaron, C. W., Chaney, M., Baughman, A. L. Dini, E. F.. Macs, E., Dietz, V. &
Bernier, R. (1997). Impact of measurement and feedback on vaccination coverage in
public clinics, 1988-1994. humaliAmcﬁmMcdimlAssmiaﬂMﬁ) 631-635.

Lieu, T. A., Black, s. A., Sorel, M. 13., Ray, P., & Shinefreld, H. R. (1996).
Would better adherence to guidelines improve childhood immunization rates? Balm
28(6), 1062-1068.

Linkins, R. W., Dini, E. F ., Watson, 6., & Patriarca, P. A. (1994). A Randomized
Trial of the effectiveness of computer-generated telephone messages in increasing
immunization visits among preschool children. WWW
McdicingJAﬁ, 908-914.

Osguthorpe, N. C., & Morgan, E. P. (1995). An immunization update for primary
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Public Health Service. (1991). Healthy peOple 2000: National health promotion
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' .- DHHS publication no.

 

(PHS) 91-50212.
Rodewald, L. E., Szilagyi, P. G... Shiuh, T., Humiston, S. G., LeBaron, C., &

Hull, C. B. (1995) Is underimmunization a marker for insuﬁicient utilization of preventive
and primary care? AmhiycsmiﬁediatdgandAdnlssmMcdicineJﬁg 393-397.

Rodewald, L. E, Szilagyi, P. G., Humiston, S. G., Raubertas, R. F., Wassilak, S.,
Roghmann, K. J ., & Hall, C. B. (1996). Eﬁ‘ect of emergency department immunizations
on immunization rates and subsequent primary care visits. Amhixcsafﬁediatnaand

AdelescenLMedidnLIiQ 1271-1276.
Shefer, A., Mezoﬁ‘, J. Caspari, D. Bolton, M., & Herrick, P. (1998) What mothers

in Women, Infants, and Children (WIC) program feel about WIC and immunization
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WW5; 65-70.

Szilagyi, P. G., Rodewald, L. E., Humiston, S. G., Hager, J., Roghmann, K. J.,
Deane, C., Cove, L., Fleming, G. V., & Hall, C. B. (1994). Immunization practices of
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Szilagyi, P. G., Rodewald, L. E., Humiston, S. G., Pollard, L., Klossner, K., Jones,
A. M., Barth, R, & Woodin, K. (1996). Reducing missed opportunities for
immunizations, easier said than done. AmhimQLBediatdmdAdQlcmmMcdicinc.
150, 1193-1200.

Woodin, K. A, Rodewald, L. E., Humiston, S. G., Carges, M. S., Schaﬁ‘er, S. J .,
& Szilagyi, P. G. (1995). Physician and parent opinions, are children becoming
pincushions from immunizations? AnchtxcsgﬂﬁedtamgandAdlenLMedmnglﬁﬂ.
845-849.

Zimmerman, R. K., Ahwesh, E. A., Mieczkowsld, M. A., Block, B., Janosky, J.
E., & Barker, D. W. (1996). Inﬂuence of family functioning and income on vaccination in

44

inner-city health centers. WW
1054-1061.
Zimmerman, R. K., Schlesselman, J. J ., Baird, A. L. & Mieczkowski, M. A.

(1997). A national survey to understand why physicians defer childhood immunizations.

AmhixesafkediatricandAdolescemMedicinchL 657-664.
Zimmerman, R. K., Schlesselman, J. J ., Mieczkowski, T. A., Medsger, A. R., &

Raymund, M. (1998). Physician concerns about vaccine adverse effects and potential

litigation. W 12-19.

 

  
 

Pediatric Immunization Opportunity
Algorithm for Primary Care Providers

 

Parent/caregiver contacts primary health care provider:
provider reminds to bring immunization record to every visit

 

  

 

 

Child presents to primary care provider center:

 

Provider assesses for caregiver knowledge about immunizations
Provider screens for child vaccination status at EVERY VISIT
Provider enters child vaccination record in tracking and recall system 0
Provider ensures appropriate vaccine handling and storage in setting
Provider receives ongoing education on current recommendations

Provider implements

monthly tracking of vaccina-

tion records

Provider sends reminder
cards to children on recall
list

 

 

 

I i

l

 

 

Child has vaccine record

L Child has no record 1

 

 

 

 

1

 

i

 

 

 

t 1

 

 

 

Provider attempts to locate previous

Caregiver refuses vac-
cines for child

 

 

l

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

0 Provider assesses for speciﬁc refusal
reasons
0 Provider reviews relevant information

 

i

 

 

record or checks immunization registry
Record up-to- Record not
date for age up-to-date for age g
7 Provider screens for
' L——“ contraindications '

Confirm up-to-date for new I
vaccines added to schedule d

such as Hep 8’ Var No contraindications

 

 

 

 

 

 

Precaution or contra-
indication present

 

 

i i

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

. . Provider refers to current immunization schedule
Reminder to caregiver . . . .
when next due for o Determines vaccrnes due based on age & history
vaccines , 7
IRegular Schedule] I Accelerated Schedule 1
Schedule if appropriate 1 l

0 Provides Vaccination Information Statements for each vaccine
0 Provider reviews risks /benef1ts of each vaccine
0 Conﬁrm caregiver understanding of information
0 Review common reactions following vaccines

 

 

 

l

l
i

 

Continue to reassess
and provide informa-
tion at each encounter

 

i

 

 

Determine if true
contraindication

 

 

 

1

Determine if pre-
caution

i

 

 

 

 

o Withhold speciﬁc
vaccine

0 Document con-
traindication

 

 

 

Select vaccines from appropriate supplies

Determine if eligible for Vaccine For Children vaccines

Provider offers immunization services free or for minimal fee

 

l

 

o PROVIDER vaccinates child with ALL SIMULTANEOUS VACCINES DUE AT VISIT
0 Provider utilizes current resources regarding dosage, route, administration techniques

 

l

 

0 Give or withhold

vaccine depend-
ing on risk/bene-
fit to child

0 Consult with

other providers

0 Document out-

come

 

 

 

 

 

 

 

 

Observe for reaction following vaccine in setting, & review home instructions

Document on vaccine card, billing system, in tracking system, & on child record

0
his“: 0 Set up appointment for next vaccine
Sept 1998 a
0199: o Reminder to bring immunization record to all visits

 

 

 

Child with a scheduled
appointment receives a
_ reminder call to house-
7 hold prior to next
pointrnent.

arr

 

 

 

 

 

 

 

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