REBEL Cast Ep100: REVVED UP – COVID-19 Vaccination in the ED

Background:

COVID-19 is now a vaccine preventable illness but, unfortunately, many have not received the COVID-19 vaccine due to a number of reasons including access, misinformation and a lack of confidence.  In the US, the emergency department is the safety net of healthcare and could play a bigger role in increasing vaccination rates in vulnerable populations (i.e. immigrants, homeless, impoverished, minorities, without primary care, and uninsured).

REBEL Cast 100.0 – REVVED UP – COVID-19 Vaccination in the ED

Paper: Rodriguez RM et al. The Rapid Evaluation of COVID-19 Vaccination in Emergency Departments for Underserved Patients Study. Ann Emerg Med 2021. PMID: 34272104 [Access on Read by QxMD]

Clinical Question: What are the emergency department patient concerns around COVID-19 vaccination in the ED?

What They Did:

  • Cross-sectional, in-person, survey study conducted from December 2020 to March 2021 at 15 safety net US EDs
  • Rapid Evaluation of COVID-19 Vaccination in EDs for Underserved Patients (REVVED UP)
  • Vaccine hesitancy = No or unsure response to question, “Would you accept the COVID-19 vaccine when it becomes available?”

Outcomes:

  • Primary:
    • COVID-19 vaccine hesitancy rate
    • Reasons for low vaccine confidence
    • Willingness to get the COVID-19 vaccine in the ED

Inclusion:

  • Adults >18 years of age presenting to the ED

Exclusion:

  • Major trauma
  • Transfer from another facility
  • Incarceration
  • Psychiatric hold
  • Intoxication
  • Altered mental status
  • Critical illness
  • Temporary visit from another country

Results:

  • 2,575 patients approached
    • 2,301 (89.4%) participated
    • 339 (14.7%) previously diagnosed with COVID-19
    • 81% of respondents had primary care doctors or clinics
    • 4% lacked a regular source of medical care
      • 65% of this group use the ED as their usual source of healthcare
    • Overall rate of lack of vaccine confidence = 39% (Range 28 to 58%)
      • Lacking a regular source of medical care was more common among those with low confidence in vaccines than those with a regular source of medical care: 47% vs 38%; 9% difference; 95% CI 4% to 14%
    • Other characteristics associated with greater lack of vaccine confidence:
      • Younger age (median 40yrs vs 52yrs)
      • Female sex (45% vs 33%)
      • Black race (54% vs 30%)
      • Latinx ethnicity (39% vs 30%)
      • Not having received an influenza vaccine in the past 5 years (58% vs 31%)
      • Homelessness and uninsured status were not associated with greater lack of vaccine confidence
    • Reasons for Lack of Vaccine Confidence:
      • Concerns about side effects and safety: 65%
      • Need for more information: 47%
      • Having heard stories in the media or online: 24%
      • Respondents who had primary care: “Don’t believe the vaccine will work” = 12%
      • Respondents who did not have primary care: “Not worried about getting COVID-19 infection” = 16%
    • Of the 61% who would accept a COVID-19 vaccine, 21% stated they lacked a primary physician or clinic at which to receive it
      • 95% of these respondents would accept the COVID-19 vaccine as part of their care in the ED

Strengths:

  • Asks a clinically important question
  • In-person survey study of patients conducted in real-world setting
  • Survey developed by reviewing existing literature on vaccine hesitancy and consulting with experts in survey development
  • Survey pilot tested on 6 ED patients at the core site with excellent comprehension and response consistency
  • No language restrictions (i.e. all surveys done in patients preferred language)
  • Objective definitions of lack of vaccine confidence and lack of regular source of medical care

Limitations:

  • Used convenience sampling which could create a selection bias
  • Excluded incarcerated patients which is a very high-risk population
  • All sites were urban EDs affiliated with academic medical institutions. Therefore, findings may not apply to rural, nonacademic ED populations
  • People who have highest distrust of health care and highest vaccine hesitancy may be less likely to come to an ED for care
  • Survey instrument used was not independently validated
  • Survey conducted when vaccines were only available to healthcare workers, therefore there were no questions about attempts to obtain the COVID-19 vaccine

Discussion:

  • Of note two thirds of patients who lacked a regular source of medical care and used the ED as a usual source of care were Black or Latinx. Both groups have experienced a disproportionately high morbidity and mortality during the COVID-19 pandemic
  • Many internet-based signups and drive through mass vaccination programs may not be feasible for patients who lack internet access and cars. Additionally considering 2/3rds of respondents lack a primary care provider, the ED may be the optimal site for this intervention in these high-risk groups
  • A pragmatic consideration would be using the single-dose Johnson and Johnson vaccine to alleviate any issues with scheduling return visits for a second COVID-19 injection
  • It is important to understand that vaccination against COVID-19 markedly reduces the risk of getting any illness and, to a greater extent, reduces the risk of severe infection, hospitalizations, and death. Having a positive test after vaccination is not the same as what matters more, which is moderate to serious disease.  Currently, 99% of hospitalizations and deaths from COVID-19 in the US are in the unvaccinated (Link is HERE).

Author Conclusion:

“ED patients who lack a regular source of medical care are particularly hesitant regarding COVID-19 vaccination. Most COVID-19 vaccine acceptors would accept it as part of their care in the ED.  Eds may play pivotal roles in CVODI-19 vaccine messaging and delivery to highly vulnerable populations.” 

Clinical Take Home Point:

In this cross-sectional, in-person survey study across 15 EDs in the US, nearly 40% of the respondents lacked confidence in the COVID-19 vaccine, 20% of those who would accept a COVID-19 vaccine reported they did not have a clinic or physician they could visit to get it, and of those who did not have a place to get the vaccine, >95% would accept it in the ED. The ED could be an optimal site to increase vaccination rates in vulnerable populations such as immigrants, homeless, impoverished, minorities, patients without primary care physicians, and the uninsured.

References:

  1. Rodriguez RM et al. The Rapid Evaluation of COVID-19 Vaccination in Emergency Departments for Underserved Patients Study. Ann Emerg Med 2021. PMID: 34272104 [Access on Read by QxMD]

Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami)

Cite this article as: Salim Rezaie, "REBEL Cast Ep100: REVVED UP – COVID-19 Vaccination in the ED", REBEL EM blog, August 23, 2021. Available at: https://rebelem.com/rebel-cast-ep100-revved-up-covid-19-vaccination-in-the-ed/.
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Salim Rezaie

Emergency Physician at Greater San Antonio Emergency Physicians (GSEP)
Creator & Founder of REBEL EM

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