Quality Improvement/Clinical Outcomes
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Shuait Nair, BSFS
Medical Student
Johns Hopkins Hospital
Baltimore, Maryland, United States
Shuait Nair, BSFS
Medical Student
Johns Hopkins Hospital
Baltimore, Maryland, United States
Shuait Nair, BSFS
Medical Student
Johns Hopkins Hospital
Baltimore, Maryland, United States
Matthew D. Price, MD, MPH
General Surgery Resident
Johns Hopkins Hospital, United States
Caitlyn Beane, PA-C
Physician Assistant
Johns Hopkins Hospital, United States
Libby Weaver, MD
Vascular Surgeon
Division of Vascular and Endovascular Surgery, Department of Surgery, University of Virginia, United States
Ramy El-Diwany, MD, PHD
Assistant Professor of Surgery, Department of Transplant Surgery
Johns Hopkins Hospital, United States
Stefano Tassinari, MD
General Surgery Resident
Johns Hopkins Hospital, United States
Brian Wu, MD
General Surgery Resident
Johns Hopkins Hospital, United States
Elliott Haut, MD, PHD
Vice Chair of Quality, Safety, & Service and Professor of Surgery
Johns Hopkins Hospital, United States
William R. Burns, MD
Assistant Professor
Johns Hopkins Department of Surgery
Baltimore, Maryland, United States
Patients who undergo splenectomy incur a 5% lifetime risk of overwhelming post-splenectomy infection (OPSI), a rapid and highly lethal form of sepsis. While OPSI can be prevented by vaccine administration, many patients are not immunized appropriately. We evaluated the implementation of a quality improvement initiative to increase perioperative vaccination rates in patients undergoing splenectomy on surgical oncology (SO) services.
Methods:
A multi-disciplinary team of providers from surgery, infectious disease, and pharmacy developed a comprehensive, guideline-concordant protocol for splenectomy vaccination. Implementation of this electronic order forced an alert to prevent hospital discharge without documentation of the immunization status. Furthermore, SO services received additional education on the full vaccination schedule; non-SO services did not participate in this initiative. To assess the impact of these interventions, records for patients who underwent splenectomy within 1 year prior to the initiative and up to 3 years following implementation were reviewed. Full vaccination was defined as completing all initial vaccine doses prior to or within 2 weeks of surgery; partial vaccination referred to incomplete initial immunization. Pre- and post-intervention vaccination rates were compared.
Results:
A total of 505 patients were included in the analysis with 71.7% captured in the post-intervention cohort. Among the 444 patients on SO services, pancreatic cancer was the most common indication for splenectomy (n=184; 41.4%) and the majority (n=261; 58.8%) underwent distal pancreatectomy with splenectomy. Pre-intervention rates of full vaccination were low (6%), whereas 61% were partially vaccinated and 33% were unvaccinated. There was a marked increase in full vaccination (82%) post-intervention with 2% partially vaccinated and only 16% unvaccinated (P< 0.01) (Figure 1). Prior to the intervention, 67% of patients on non-SO services were unvaccinated with 33% partially vaccinated and none fully vaccinated. There was a modest improvement in rates of full vaccination (pre: 0%; post: 26.5%) and a sharp decline in unvaccinated patients (pre: 66.7%; post: 24.5%) for patients on non-SO services post-intervention (P< 0.01).
Conclusions:
Implementation of post-splenectomy vaccination order sets led to a reduction in unvaccinated patients treated on SO and non-SO services. Moreover, additional provider education on SO services was associated with superior rates of full vaccination, likely enhancing protection from OPSI.