While emergency staff are busier than ever these days, there is no denying that EDs are particularly well-positioned to recognize and address the healthcare needs of underserved patients, many of whom rarely receive preventive care services such as flu vaccinations. Furthermore, new research has shown that, with not much effort or time on the part of clinicians, EDs can double or even triple the percentage of unvaccinated patients who receive their flu vaccinations — a move that likely prevents more expensive, future healthcare use for some of these patients.
Robert Rodriguez, MD, the lead author of the research, an emergency physician at Zuckerberg San Francisco General Hospital and a professor of emergency medicine at the University of California at San Francisco, tells ED Management that the push for this type of research evolved organically. “Especially in emergency departments that are safety net-type EDs, we see people every day who don’t have access to primary care and really [face] great disparities in terms of vaccinations — and that leads to poor outcomes in those populations,” he says. “There’s about 25% to 30% of the population whose only interaction with the healthcare system occurs in emergency departments, so if you are going to get at that group, it really has to come through the ED.”
The trick, of course, is finding a way to reach these patients quickly and efficiently without disrupting the workflow of busy EDs. Consequently, in the PROFLUVAXED trial, Rodriguez and his co-investigators tested two low-resource interventions to assess their effect in terms of increasing the percentage of unvaccinated patients opting to receive flu vaccinations within 30 days of their ED encounters.1
• Patients in one of the intervention groups agreed to watch a three-minute video and read a one-page flyer pertaining to the flu vaccine while they were in the ED waiting room. They were then asked whether they would accept a flu vaccination. In cases where they indicated acceptance of the flu vaccine, ED providers were then notified.
• Patients in the second intervention group did not watch the video or read the flyer but were asked whether they would accept the flu vaccine. This was followed by provider notification if the patients indicated that they would take the vaccine.
• A third control group consisted of unvaccinated patients who did not receive either of the interventions.
The trial took place from October 2022 to February 2023, including a total of 767 patients who visited six participating EDs in five U.S. cities: San Francisco; Houston; Seattle; Durham, NC; and Philadelphia. Although the researchers anticipated that the interventions were likely to increase uptake of the flu vaccine in the two intervention cohorts, they were surprised at how effective the interventions turned out to be.
For instance, vaccine uptake within 30 days among patients in the group that saw the video and read the flyer was 41%. However, vaccine uptake among the group that just received the offer of a flu vaccine was impressive as well at 31% within 30 days — more than double the vaccine uptake of patients in the control group, which was 15%.
The researchers reported that more half of the trial participants were African American (36%) or Latino (16%), 16% lacked health insurance, and 32% lacked primary care. The vaccine status of participants was determined by a review of their electronic medical record as well as telephone follow-up.
Rodriguez observes that he has heard plenty of pushback to the idea of offering vaccines in the ED from clinicians concerned that they already have too much on their plates, not to mention a boarding crisis to deal with. “My response to that would be that our ED boarders were some of the best patients for this study because … they’re stuck there,” he explains. “Also, all the work that we did was during waiting times for patients. [The interventions] did not add time to ED stays.”
Rodriguez adds that while nurses administered the flu vaccines, providers needed to order the shots first.
While both the interventions tested in the study were fairly simple to implement, researchers now are looking to streamline their approach even further — perhaps offering an informational sheet about flu vaccines to patients at triage and/or providing patients with a QR code that they can use to watch the informational video while they are in the waiting room, explains Rodriguez. “We’re looking at various options to make [the process] easier in terms of workflow,” he says.
In addition, it is clear that the types of interventions applied to flu vaccinations in this trial also can be applied to other important vaccines.
“This is basically the second in a series of vaccination measures that we’ve tested, and that have gone through the ED,” notes Rodriguez, referring to another trial that looked at using vaccine messaging to improve the uptake of COVID-19 vaccinations among unvaccinated ED patients.2 “In that trial, we also showed that using vaccine messaging in the emergency department increases vaccine uptake by a lot,” states Rodriguez. “We basically tripled the uptake of COVID vaccines, but we were starting from a baseline of just 8%; we increased the uptake to about 23%.”
Rodriguez notes that the success of that earlier effort came despite more reluctance among ED patients to receive COVID-19 vaccines than to receive flu vaccines. “The messaging works,” states Rodriguez. “There is a lot more hesitancy, however, with COVID-19 vaccines for sure.”
In light of the success that Rodriguez and his colleagues achieved in significantly increasing the uptake of both flu and COVID vaccines, he is urging colleagues to consider implementing a similar approach.
“If you have large underserved populations that don’t have primary care access, you should consider this type of program,” he says, noting that all the messaging and other materials used in the PROFLUVAXED trial are available with links published with the research. “It’s not that involved, and it’s not that laborious,” he says. “It’s just a matter of having the vaccines available.”
REFERENCES
- Rodriguez RM, Eucker SA, Rafique Z, et al. Promotion of influenza vaccination in the emergency department. NEJM Evid 2024;3. doi: 10.1056/EVIDoa2300197.
- Rodriguez RM, Nichol G, Eucker SA, et al. Effect of COVID-19 vaccine messaging platforms in emergency departments on vaccine acceptance and uptake: A cluster randomized clinical trial. JAMA Intern Med 2023;183:115-123.
While emergency staff are busier than ever these days, there is no denying that EDs are particularly well-positioned to recognize and address the healthcare needs of underserved patients, many of whom rarely receive preventive care services such as flu vaccinations. Furthermore, new research has shown that, with not much effort or time on the part of clinicians, EDs can double or even triple the percentage of unvaccinated patients who receive their flu vaccinations — a move that likely prevents more expensive, future healthcare use for some of these patients.
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