Effect of Emergency Department Immunizations on Immunization Rates and Subsequent Primary Care Visits

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Abstract
Background: The Standards for Pediatric Immunization Practices recommend the routine use of emergency department (ED) encounters for screening the immunization status of children and, if indicated, immunizing them. Objective: To test the hypothesis that ED immunizations will improve immunization rates without decreasing subsequent primary care visits. Design: A randomized controlled trial of 2 interventions. Children (aged 6-36 months) (n=1835) were enrolled in the study in the ED; informed consent was obtained from their parents. They were randomized into 1 of 3 groups: (1) the control group (n=614), in which no intervention was undertaken; (2) the letter group (n=610), in which a letter to the primary care physician was written indicating the child's estimated likelihood of being underimmunized; and (3) the ED vaccination group (n=611), in which, based on a decision rule, those likely to be underimmunized were offered immunizations in the ED. After randomization, parents were interviewed in the ED using a decision rule to estimate the likelihood of the child being underimmunized. One year after enrollment in the study, the medical records of the children at their primary care sites were reviewed to determine the immunization status of the children and primary care use patterns. Setting: An urban ED and 54 primary care sites in Monroe County, New York. Results: The mean age of the participants was 17.9 months. Medical record review–verified underimmunization rates at the time of the ED visit were 33%, 31%, and 28% for the control, letter, and ED vaccination groups, respectively. The demographic characteristics and baseline immunization rates were not different among study groups. According to the decision rule, 248 children (41%) in the ED vaccination group were likely to be underimmunized. Parents of these 248 children were offered immunizations for their children; 117 (47%) accepted, and their children were immunized (with 230 separate immunizations). One month after the ED visits, the underimmunization rates of the study groups were 31%, 28% (P=.40 compared with the control group), and 23% (P=.002). One year later, these rates were 28%, 25% (P=.20), and 25% (P=.20). No clinically meaningful differences were present at either of these times. One year after the ED visit, no differences in the rates of primary care use were found among groups. Conclusions: This study provides evidence that the immunization of children in this ED was ineffective at raising their immunization rates; primary care attendance was also unaltered. Major obstacles were as follows: (1) an inability to ascertain accurately the immunization status in the ED and (2) a high rate of parental refusal to accept immunizations in the ED. The standards should be modified to de-emphasize the ED as a routine immunization site for children with access to primary care. Efforts and resources should be directed toward strengthening the primary care system and tracking immunization status. Arch Pediatr Adolesc Med. 1996;150:1271-1276