EFFECT OF EMERGENCY DEPARTMENT IMMUNIZATIONS ON IMMUNIZATION RATES AND SUBSEQUENT PRIMARY-CARE VISITS

Background: The Standards for Pediatric Immunization Practices recomme nd the routine use of emergency department (ED) encounters for screeni ng the immunization status of children and, if indicated, immunizing t hem. Objective: To test the hypothesis that ED immunizations will impr ove immunization rates without decreasing subsequent primary care visi ts. Design: A randomized controlled trial of 2 interventions. Children (aged 6-36 months) (n=1835;) were enrolled in the study in the ED; in formed consent was obtained from their parents. They were randomized i nto 1 of 3 groups: (1) the control group (n=614), in which no interven tion was undertaken, (2) the letter group (n=610), in which a letter t o the primary care physician was written indicating the child's estima ted likelihood of being underimmunized; and (3) the ED vaccination gro up (n=611), in which, based on a decision rule, those likely to be und erimmunized 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 enrol lment in the study, the medical records of the children at their prima ry care sites were reviewed to determine the immunization status of th e children and primary care use patterns. Setting: An urban ED and 54 primary care sites in Monroe County, New York. Results: The mean age o f the participants was 17.9 months. Medical record review-verified und erimmunization rates at the time of the ED visit were 33%, 31%, and 28 % for the control, letter, and ED vaccination groups, respectively. Th e demographic characteristics and baseline immunization rates were not different among study groups. According to the decision rule, 248 chi ldren (41%) in the ED vaccination group were likely to be underimmuniz ed. 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 underi mmunization rates of the study groups were 31%, 28% (P=.40 compared wi th the control group), and 23% (P=.002). One year later, these rates w ere 28%, 25% (P=.20), and 25% (P=.20). No clinically meaningful differ ences were present at either of these times. One year after the ED vis it, no differences in the rates of primary care use were found among g roups. 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 wer e as follows: (1) an inability to ascertain accurately the immunizatio n status in the ED and (2) a high rate of parental refusal to accept i mmunizations in the ED. The standards should be modified to de-emphasi ze the ED as a routine immunization site for children with access to p rimary care. Efforts and resources should be directed toward strengthe ning the primary care system and tracking immunization status.