Frustrated with low vaccination rates, the ED at Children’s Wisconsin in Milwaukee implemented a screening protocol to offer the flu vaccine to every eligible child who presents for care. Now in its third year, the nurse-driven intervention has proven successful, with leaders working to expand the approach ahead of an expected COVID-19 vaccine.

  • Screening questions have been integrated into an already-established electronic medical record workflow that nurses carry out on every patient once they have been taken to a room in the ED.
  • Nurses encourage parents to sign off on the shot for eligible children. If families hesitate, a physician can be activated to discuss the issue further.
  • Once the patient’s provider approves the vaccine, a nurse administers the shot at the point of discharge from the ED.
  • During the 2019-20 flu season, the screening protocol was used to successfully vaccinate more than 3,000 children in the ED, about half of whom were minorities who usually vaccinate at a rate lower than the state’s already-small percentage rate.

For good reason, EDs tend to resist taking on added responsibilities beyond the scope of emergency medicine. Their plates are full already, particularly with a serious pandemic that is straining resources and commanding the full attention of frontline clinicians. However, long before COVID-19, the ED at Children’s Wisconsin in Milwaukee saw an opportunity to address the low influenza vaccination rates in children.

“Within the state of Wisconsin, the vaccination rates in children are ... close to 38% or 40%. We see disparities in vaccinations where minorities and uninsured or underinsured [children] are less likely to get the vaccine,” says, Shannon Baumer-Mouradian, MD, BS, a pediatric emergency physician at Children’s Wisconsin. Everything from lack of transportation and misinformation to difficulty scheduling a time affect vaccination rates. However, Baumer-Mouradian explains an innovative nurse at Children’s Wisconsin saw the ED was uniquely positioned to break down some of these barriers, and came up with the idea of offering the flu vaccination to every pediatric patient who presents.

From here, developers fine-tuned a screening protocol aimed at making the process as easy as possible without disrupting flow. Now in its third year of implementation, the ED has steadily improved its performance in vaccinating kids. In fact, developers are looking to leverage the protocol further, perhaps for the COVID-19 vaccine when it becomes available to children, along with other important pediatric shots.

Once it became clear the ED could raise the pediatric vaccination rate, a multidisciplinary committee was established to figure how to implement such an intervention in the most seamless and efficient way possible. Baumer-Mouradian was part of this panel, but she notes it also included representatives from nursing, medical school faculty, and pharmacy, along with an electronic medical record (EMR) analyst.

“What we developed were adaptations to the EMR to make it easy for nurses to screen every patient who came to the ED, and ask them if they have had all of their vaccines,” Baumer-Mouradian explains.

Follow-up questions focused on whether patients had received their flu vaccine for the current year. If not, staff asked patients whether they would consent to receive the vaccine during the ED encounter. “The literature actually shows that a strong recommendation from a provider or a nurse goes a long way with a family,” Baumer-Mouradian explains. Before, nurses might have asked a plain question like “Would you like the flu vaccine?” Now, nurses say something along the lines of “We recommend you obtain the vaccine this season for the health of your child.” Subtle changes like these have paid dividends.

For instance, during the 2017-18 flu season, before the screening protocol, only 75 children who presented to the Children’s Wisconsin ED received the flu vaccine. After implementation, in the 2018-19 flu season, more than 1,300 vaccines were given to children in the ED. “That was 9% of the unvaccinated population that presented to our ED,” Baumer-Mouradian shares.1

Since that first year, developers have tweaked the protocol, leading to additional improvements. “During this last season [2019-20], we vaccinated almost 3,200 children in our ED, and about half of these children were minorities,” Baumer-Mouradian reports.

Further, she states more than three-quarters of these children were uninsured or underinsured, qualifying them for a federally funded program that provides the vaccines at no charge. “The ED vaccine initiative is really filling a neat void in the need for promoting vaccines in children,” Baumer-Mouradian adds.

It is never easy to add steps to the ED’s busy workflow. The nuts and bolts of precisely how this intervention would be added were critical. For instance, Baumer-Mouradian explains developers decided against asking about flu vaccination during triage, where the primary focus is to identify whether a child is sick.

“We ask these questions when the patient gets to a room. They are part of a normal nursing workflow where we ask a series of questions for every child,” she explains. Also, the specific questions pertaining to flu vaccine are only asked during the period when the shot is available and typically provided through the season.

Abigail Kleinschmidt, DNP, CPNP-PC, RN, CPN, a pediatric nurse in the ED at Children’s Wisconsin who helped lead the vaccine initiative, attributes much of the program’s success to making the process as convenient and seamless as possible for staff.

“Our ED is incredibly busy during flu season and it puts a lot of strain on us as nurses,” she says. “We wanted to make sure that we weren’t adding a ton to their workflow, so we added the flu vaccine screening to an already-established [EMR] workflow. It is just one extra click where nurses already do initial patient screenings. We embedded not only the suggested scripting, but also the one-step ordering and a pop-up of the inclusion/exclusion criteria.”

For instance, the nurse will click a button to indicate whether the child has received his or her flu shot. Then, if the family indicates they would like to vaccinate their child, the nurse will click a button indicating the family’s affirmative request. The order goes to the pharmacist and physician to verify. “When the patient is about to go home, the physician has already met [with him or her] and determined the level of their illness,” Baumer-Mouradian says. “If the patient is very sick and requires hospitalization, the patient is ineligible for the vaccine.”

When a physician determines a child is eligible to receive the shot, he or she can click an approval button. “That approval goes to the nurse, and the nurse administers the vaccine at the time of discharge,” Baumer-Mouradian reports. “It is about five additional minutes to administer the vaccine.”

Address Hesitancy

The vaccine initiative team added another intervention to the protocol whereby the physician can weigh in on the issue with families who remain reluctant even after a nurse recommendation.

“If a family says no and declines the flu vaccine ... the nurse is able to click that the patient has not yet been vaccinated, but intentionally needs some more information,” Baumer-Mouradian explains.

This added step can be particularly helpful in cases in which the family expresses “red flags” such as a concern the vaccine might cause the flu or might be unsafe. In these cases, the nurse can tag the patient on the tracking board where all the ED patients are listed. “We have an icon there that [indicates vaccine] hesitancy. It is a little question mark,” Baumer-Mouradian observes. “The provider is able to recognize those patients ... and go immediately to discuss [the flu vaccine] further.”

Within the system, there is a resource that helps providers guide these conversations. “Last year, with that additional effort, there were 140 more vaccines given in cases where initially the families told the nurse ‘no, thank you,’” Baumer-Mouradian says. “Upon the provider re-discussing the issue, and focusing on that vaccine hesitancy, we had some improvement.”

Since the process began, Children’s Wisconsin staff managed to stock the vaccine in the ED. By no longer waiting on shots to arrive from the pharmacy, the department shortened wait times and cut the number of patients who could not or would not hang around to wait for the shot. Kleinschmidt adds that vaccination rates “skyrocketed” thanks to this change.

Kleinschmidt also attributed higher vaccination rates to the fact nurses became more comfortable with the whole process over time. Adding an option for a physician assist has helped even more.

Obtain Buy-In

Considering emergency clinicians tend to resist adding tasks to their already busy workloads, it can be challenging to introduce changes like this. “Traditionally, EDs offer the tetanus vaccine because we see exposures to dirty wounds. There is a lot of literature on the fact that EDs do a great job of offering the tetanus vaccine, but we don’t do a great job of offering any other vaccine,” Baumer-Mouradian laments.

However, that is precisely why Baumer-Mouradian views the vaccine initiative at Children’s Wisconsin as “exciting, groundbreaking” work. “This was initially started as a nursing initiative, and the nurses give out at least 85% of the vaccines that we administer every year,” she says. “The physicians are kind of the second tier.”

Further, Baumer-Mouradian stresses that obtaining buy-in to offer the vaccine in the emergency setting is a critical early step to making any such initiative a success. “We did a lot of campaigning and education about why the flu vaccination was really important,” she says.

This came prior to the start of the COVID-19 pandemic, so the importance of prioritizing flu vaccinations has only increased since the early days of the vaccine initiative.

Kleinschmidt says the team driving the vaccine initiative focused considerable attention on how administering more shots could help ED staff directly in the ED. “We would hope to have a less chaotic viral season [based on] the more kids we vaccinated, and overall a healthier community,” she says.

A somewhat trickier aspect of securing buy-in concerned ensuring that it did not adversely affect patient flow, always a high priority in the ED. “The complicated thing about our ED is that it is an academic center. We have trainees involved at all different levels,” Baumer-Mouradian says. She estimates on top of 30 physicians and another 15 advanced practice providers, there might be 10 to 20 residents rotating through the department every month.

Leaders sent weekly updates on how well the ED was performing. “I specifically targeted our little red question marks on the patients we knew needed more information,” Baumer-Mouradian says. “I gave feedback about that every week.”

Further, once the nurses became accustomed to clicking the extra button to inform physicians about reluctant families, Baumer-Mouradian targeted her messaging efforts toward the physicians. “Every week, we would recognize people for not just [administering] the flu vaccine, but also going up to those families who were hesitant and convincing them. We did shout-outs very frequently, and I think that raised morale,” she says.

Many providers are worried about their own personal safety, the safety of their families, and caring for all the patients who are presenting with COVID-19. Still, Baumer-Mouradian notes the Children’s Wisconsin ED performed at least as well, if not a little better, on administering flu shots in the most recent season than in previous years.

Knowing a COVID-19 vaccine is not far away, Baumer-Mouradian says plans are in the works to expand the screening protocol to six urgent care sites in the region, and then to integrate it across the health system to primary care, specialty clinics, and in the hospital. The goal is to administer nearly 100,000 flu vaccines to children systemwide.


  1. Baumer-Mouradian SH, Kleinschmidt A, Servi A, et al. Vaccinating in the emergency department, a novel approach to improve influenza vaccination rates via a quality improvement initiative. Pediatr Qual Saf 2020;5:e322.