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 17 740 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 = 11 274 [64%]). There were 10 997 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. (continued) Key Points Question Is a clinical decision support (CDS) strategy associated with improved influenza vaccination rates before discharge among eligible hospitalized children? Findings In this quality improvement study, the combinination of a defaultchecked influenza vaccine order in admission order sets for eligible p...

Background Viral bronchiolitis is a common respiratory infection that often affects term, otherwise healthy infants. A small literature suggests maternal stress during pregnancy is associated with bronchiolitis. However, the association between maternal exposure to lifetime traumatic stress, including traumatic events occurring in childhood or throughout the life course, and bronchiolitis has not been studied previously. Objectives To investigate the association between maternal exposure to total lifetime and childhood traumatic stress events and infant bronchiolitis. Methods We studied mother‐infant dyads enrolled in a prospective prenatal cohort, recruited 2006‐2011, and Tennessee Medicaid. During pregnancy, we assessed maternal lifetime exposure to types of traumatic events by questionnaire. We captured bronchiolitis diagnoses in term, non‐low birthweight infants’ first 12 months using linked Medicaid data. In separate models, we assessed the association of maternal lifetime traumatic events (0 to 20 types) and a subset of traumatic events that occurred during childhood (0 to 3: family violence, sexual, and physical abuse) and infant bronchiolitis using multivariable log‐binomial models. Results Of 629 women, 85% were African American. The median count (interquartile range) of lifetime traumatic events was 3 (2, 5); 42% reported ≥1 childhood traumatic event. Among infants, 22% had a bronchiolitis diagnosis (0 to 2 lifetime traumatic events: 24%; 3 events: 20%; 4 to 5 events: 18%; 6 or more events: 24%). Total maternal lifetime traumatic events were not associated with bronchiolitis in multivariable analyses. For maternal childhood traumatic events, the risk of infant bronchiolitis increased with number of event types reported: adjusted Risk ratios were 1.12 (95% confidence interval [CI] 0.80, 1.59), 1.31 (95% CI 0.83, 2.07), and 2.65 (95% CI 1.45, 4.85) for 1, 2, and 3 events, respectively, vs none. Conclusions Infants born to women reporting multiple types of childhood trauma were at higher risk for bronchiolitis. Further research is needed to explore intergenerational effects of traumatic experiences.

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Chlorinated ethenes are among the most common environmental contaminants and are known or suspected carcinogens. This class of compounds includes perchloroethene (PCE), trichloroethene (TCE), and their breakdown products, including dichloroethene (DCE) isomers and vinyl chloride (VC). Engineers and scientists must be able to measure concentrations of these chemicals in water samples to assess site contamination, monitor clean-up progress, and test possible remediation technologies. Gas chromatography with flame ionization detection (GC/ FID) is a common method for measuring these contaminants in environmental samples. In this study, we tested the hypothesis that FID response factors are equal for all chlorinated ethene compounds. The rationale for the investigation was that if the hypothesis is correct, a single calibration curve can be used for GC/FID analysis of all chlorinated ethene compounds, saving time and money during sample analysis. Based on our measurements, a single calibration curve (FID response versus mass of analyte injected) is applicable to analysis of PCE, TCE, and all three DCE isomers (r 2 = 0.990, n = 50 measurements), allowing for simplified quantification of those chemicals. However, the apparent FID response factor for VC was lower by *40%, indicating that a separate calibration curve would need to be used to accurately estimate the VC concentration in water samples. The difference in the apparent VC response factor is caused predominantly by losses of VC to volatilization during the analysis.

Background: Pediatric influenza vaccination rates remain <50% in the United States. Children with chronic medical conditions are at higher risk of morbidity and mortality from influenza, yet most experience missed opportunities for immunization in outpatient settings. In an adult cohort study, 74% of patients who had not received the influenza vaccine before or during hospitalization remained unvaccinated through the rest of the season. Thus, inpatient settings represent another important opportunity for vaccinating an especially susceptible population. In addition, 4 published studies have shown promise in improving inpatient pediatric influenza vaccination. However, these studies had limited effect sizes and included interventions requiring ongoing maintenance with dedicated staff. In this study, we hypothesized that a clinical decision support (CDS) intervention designed with user-centered design principles would increase inpatient influenza vaccine administration rates in the 2019–2020 influenza season. Methods: We performed a workflow analysis of different care settings to determine optimal timing of influenza vaccine decision support. Through formative usability testing with frontline clinicians, we developed electronic health record (EHR) prototypes of an order set module containing a default influenza vaccine order. This module was dynamically incorporated into order sets for patients meeting the following criteria: ≥6 months old, no prior influenza vaccine in the current season in our medical system or the state immunization registry, and no prior anaphylaxis to the vaccine. We implemented the CDS into select order sets based on operational leader support. We compared the proportion of eligible hospitalized patients in which the influenza vaccine was administered between our intervention period and the 2018–2019 season (historical controls). To account for secular trends, we also compared the vaccination rates for hospitalized patients exposed to our CDS to those that were not exposed to the CDS during the intervention period (concurrent controls). Results: During the intervention period (September 5, 2019–November 1, 2019), influenza vaccine was administered to 762 of 3,242 (24%) of eligible patients, compared to 360 of 2,875 (13%) among historical controls (P < .0001). Among the 42% of patients exposed to the CDS, vaccination rates were 33% compared to 9% for concurrent controls (p < .0001). Our intervention was limited by end-user uptake, with some physicians or nurses discontinuing the default vaccine order. In addition, early in the intervention, some vaccines were ordered but not administered, leading to vaccine waste. Conclusions: CDS targeting eligible hospitalized patients for influenza vaccination incorporated early into the workflow of nurses and ordering clinicians can substantially improve influenza vaccination rates among this susceptible and hard-to-reach population.Funding: NoneDisclosures: None

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