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Author Notes:

Evan W. Orenstein, MD, Department of Pediatrics, Emory University School of Medicine, 1405 Clifton Rd, Atlanta, GA 30322. Email: evan.orenstein@emory.edu

Dr Orenstein had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: Orenstein, ElSayed-Ali, Kandaswamy, Masterson, Blanco, Shah, Lantis, Dawson, Ray, Bryant, Iyer, Shane, Jernigan. Acquisition, analysis, or interpretation of data: Orenstein, Kandaswamy, Masterson, Kolwaite, Iyer, Jernigan. Drafting of the manuscript: Orenstein, Shah, Kolwaite. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Orenstein, Masterson, Kolwaite. Obtained funding: Orenstein. Administrative, technical, or material support: ElSayed-Ali, Masterson, Blanco, Shah, Lantis, Dawson, Ray, Bryant, Iyer, Jernigan. Supervision: Orenstein, Masterson, Shane, Jernigan.

Dr Orenstein reported being the co-founder of and having equity in Phrase Health, a clinical decision support analytics company, outside the submitted work. Dr Shane reported being a voting member of the US Food and Drug Administration Vaccines and Related Biological Products Advisory Committee. No other disclosures were reported.


Research Funding:

Drs Orenstein and Kandaswamy’s work was supported by the Agency for Healthcare Research and Quality award R03HS027689-01.


  • Science & Technology
  • Life Sciences & Biomedicine
  • Medicine, General & Internal
  • General & Internal Medicine
  • CARE

Evaluation of a Clinical Decision Support Strategy to Increase Seasonal Influenza Vaccination Among Hospitalized Children Before Inpatient Discharge

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Journal Title:



Volume 4, Number 7


, Pages e2117809-e2117809

Type of Work:

Article | Final Publisher PDF


Importance: Hospitalized children are at increased risk of influenza-related complications, yet influenza vaccine coverage remains low among this group. Evidence-based strategies about vaccination of vulnerable children during all health care visits are especially important during the COVID-19 pandemic. Objective: To design and evaluate a clinical decision support (CDS) strategy to increase the proportion of eligible hospitalized children who receive a seasonal influenza vaccine prior to inpatient discharge. Design, Setting, and Participants: This quality improvement study was conducted among children eligible for the seasonal influenza vaccine who were hospitalized in a tertiary pediatric health system providing care to more than half a million patients annually in 3 hospitals. The study used a sequential crossover design from control to intervention and compared hospitalizations in the intervention group (2019-2020 season with the use of an intervention order set) with concurrent controls (2019-2020 season without use of an intervention order set) and historical controls (2018-2019 season with use of an order set that underwent intervention during the 2019-2020 season). Interventions: A CDS intervention was developed through a user-centered design process, including (1) placing a default influenza vaccine order into admission order sets for eligible patients, (2) a script to offer the vaccine using a presumptive strategy, and (3) just-in-time education for clinicians addressing vaccine eligibility in the influenza order group with links to further reference material. The intervention was rolled out in a stepwise fashion during the 2019-2020 influenza season. Main Outcomes and Measures: Proportion of eligible hospitalizations in which 1 or more influenza vaccines were administered prior to discharge. Results: Among 17740 hospitalizations (9295 boys [52%]), the mean (SD) age was 8.0 (6.0) years, and the patients were predominantly Black (n = 8943 [50%]) or White (n = 7559 [43%]) and mostly had public insurance (n = 11274 [64%]). There were 10997 hospitalizations eligible for the influenza vaccine in the 2019-2020 season. Of these, 5449 (50%) were in the intervention group, and 5548 (50%) were concurrent controls. There were 6743 eligible hospitalizations in 2018-2019 that served as historical controls. Vaccine administration rates were 31% (n = 1676) in the intervention group, 19% (n = 1051) in concurrent controls, and 14% (n = 912) in historical controls (P <.001). In adjusted analyses, the odds of receiving the influenza vaccine were 3.25 (95% CI, 2.94-3.59) times higher in the intervention group and 1.28 (95% CI, 1.15-1.42) times higher in concurrent controls than in historical controls. Conclusions and Relevance: This quality improvement study suggests that user-centered CDS may be associated with significantly improved influenza vaccination rates among hospitalized children. Stepwise implementation of CDS interventions was a practical method that was used to increase quality improvement rigor through comparison with historical and concurrent controls.

Copyright information:

2021 Orenstein EW et al. JAMA Network Open.

This is an Open Access work distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/rdf).
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