Pediatric COVID-19 Vaccination in the Inpatient Setting

Patients were deemed eligible for inpatient vaccination with the Pfizer COVID-19 BNT162b2 vaccine if they were admitted to any hospital unit including critical care units, over the Emergency Use Authorization minimum age threshold, were not COVID-19 positive or a Person Under Investigation, and were not already vaccinated. As the age threshold decreased to include patients who were 12 years and older in May 2021 and 5 to 11 years old in October 2021, additional patients became eligible. A Person Under Investigation was defined at our institution as any patient with clinical concern for COVID-19. These patients required 2 COVID-19 PCR tests 24 hours apart and were placed under COVID-19 precautions while awaiting the results. The requirement for 2 tests was removed in summer 2021, after which patients with 1 negative test on admission were eligible for vaccination.

A question asking patient’s families if they were interested, not interested, or unsure about inpatient COVID-19 vaccination for their child was added to the nursing admission questionnaire for eligible patients. If the patient had received a vaccination, the brand, dates, and number of prior vaccines were documented. The nurse documented family response in their admission assessment and alerted the primary team if the family was interested verbally. In October 2021, an alert in the Cerner electronic health record (EHR) was added. The alert was in the “Smart Zone,” which is a column adjacent to the patient’s medical record when opened that catalogs non urgent patient specific notifications and prompted providers to order vaccines or discuss family interest depending on their responses. Case managers also e-mailed the attending physician a list of their newly admitted patients who were eligible and interested in vaccination daily while awaiting implementation of the EHR alert. The primary team assessed medical stability and optimal timing for vaccination. Vaccines were available initially only during days of the week with outpatient vaccine clinics to reduce waste. By June 2021, vaccine access was expanded to 7 days per week. An infectious diseases consult service was available if needed for nuanced questions regarding appropriateness of vaccination during the admission. Infectious diseases involvement ranged from a curbside discussion with a designated COVID-19 consultant to a formalized consult and discussion with the family at the discretion of the primary team. If interested and medically ready, the primary team discussed with the family and ordered the vaccine, the bedside nurse obtained consent and provided Emergency Use Authorization documentation, information on v-safe, and potential side effects, and a nurse administered it before discharge. The vaccine card was delivered to the bedside with the vaccine from pharmacy and given to the family after administration. If the patient required another dose, a follow-up clinic visit was scheduled at an affiliated outpatient vaccination site.

Admissions database questionnaires were audited to identify prevalence of vaccine interest. Vaccine administration was tracked for reporting and compliance purposes from the EHR via automated monthly reports. These reports were collated together and repeat encounters were eliminated. Unique patients were identified and only the first encounter for each patient was included. Our team analyzed vaccine interest and ultimate administration for each eligible patient admitted during the study period. This was approved by the hospital’s Institutional Review Board.

Descriptive statistics were used to express interest in vaccination and vaccine administration before hospital discharge.

From April 26, 2021 to February 12, 2022 there were 1615 unique patients who were eligible to be screened for interest in an inpatient COVID-19 vaccine and 1601 had their interest recorded on admission. Twenty-one percent (344) of these families were interested in obtaining an inpatient COVID-19 vaccination before discharge, 50% (794) were not interested, and 28% (454) were unsure (Fig 1).

Twenty-nine percent (100) of patients interested in vaccination on admission were ultimately vaccinated before discharge. Six percent (29) of patients were vaccinated before discharge after initially expressing uncertainty about the vaccine. Two percent (17) of patients who were not interested in vaccination on admission were vaccinated before discharge (Fig 1). Figure 2 illustrates the interest in vaccination over time.

Vaccination against COVID-19 is an evidence-based strategy to decrease morbidity and reduce viral spread.¹¹  Providing access to COVID-19 vaccinations in the inpatient setting could improve vaccine uptake specifically for the under-vaccinated and more medically vulnerable hospitalized pediatric patients.^8–10 

Our study describes a successful implementation of a COVID-19 vaccination program for children admitted to the hospital. Through multidisciplinary teamwork, we were able to identify, consent, and efficiently vaccinate previously un- or under-vaccinated individuals during multiple stages of the pandemic. Although the absolute number of vaccinated inpatients was small in comparison with community-based vaccine efforts, the costs of program implementation were minimal as much of the infrastructure for vaccine administration already exists in the inpatient setting, and the benefit for those hospitalized patients who would have otherwise had difficulty accessing vaccine were great. This demonstrates the positive impact pediatric hospitals can play on vaccination efforts.

Our study demonstrates that ∼1 in 5 eligible patient’s families were interested in inpatient vaccination against COVID-19. There remained an ongoing demand for inpatient vaccines throughout multiple stages of the pandemic.

There were many patient’s families who were unsure or uninterested in COVID-19 vaccination. Reasons for uncertainty or declination were not recorded during admission screen, but prior research indicates it could be because of concerns about safety or efficacy of the vaccine for their child.¹²  Forty-six children whose families were either not interested or unsure about vaccination changed their mind during the hospitalization and were vaccinated before discharge. Families report trusting advice about vaccines from their doctor above all other sources and 1 on 1 conversations between patients and their physicians as the most important factor in the vaccination decision.^13–18  The inpatient setting provides the opportunity for multiple interactions with providers over a short time. Complex conversations can be sustained over days and families have time to contemplate their decision, unlike a short office visit. Readily available subspecialty services to discuss nuances in vaccination appropriateness and timing for medically complex children may help families to agree to vaccination.

This study illustrated that the hospital is an effective setting for COVID-19 vaccination but also highlighted multiple areas of further investigation and improvement work. There was a significant proportion of individuals who expressed interest but did not receive a COVID-19 vaccine before discharge. One challenge at our institution early in the pandemic was that inpatient vaccine doses were coordinated with outpatient clinic dates to reduce vaccine waste, which may have limited vaccine uptake for interested individuals before access expanded to daily in June 2021. This study did not gather data on reasons for missed vaccination of interested individuals. Further investigation could identify areas of improvement in local processes to increase vaccine administration. We did not collect information on reasons for hesitancy or declination on admission, nor were the reasons for acceptance by those individuals later in the hospitalization captured. Understanding those barriers and turning points could improve inpatient vaccination rates. We did not collect information regarding social determinants of health, such as a family’s living situation, preferred language, financial means, and educational attainment, or additional patient level factors, such as primary reason for admission, which in future work could add a deeper understanding of which families were interested and ultimately vaccinated in the inpatient setting.

Pediatric hospitals can deliver COVID-19 vaccines effectively to eligible patients during admission. Inpatient vaccination programs provide a venue for improved access to vaccines and an opportunity to increase uptake in patients initially hesitant to vaccination.

We wish to acknowledge the operational leadership at Children’s National Hospital, including Dr Melanie Anspacher and Dr Rahul Shah for their support of the inpatient COVID-19 vaccine service line.