Optimising vaccinations in patients with chronic lymphocytic leukaemia

A Quality Improvement Project (QiP) in the Haematology Department, Royal Cornwall Hospital Trust (RCHT)

Authors: Dr Rebecca Wood and Dr Ziad Zeidan (presenter)

Background

Chronic Lymphocytic Leukaemia (CLL) is a largely indolent lymphoproliferative disorder that can be managed in its early stages in primary care. Hypogammaglobulinemia and immune paraesis occur in 20-70% of patients with CLL, with infective complications accounting for up to 50% of all CLL related deaths1. Measures to reduce infection risk include vaccination, prophylactic antibiotics and Ig replacement therapy. The British Society of Haematology advises that all patients newly diagnosed with CLL should receive vaccinations for Seasonal Influenza, Pneumococcus & Hib2

Issues Identified

• Documentation of vaccination advice in outpatient clinic correspondence for patients newly diagnosed with CLL

• Deficiency in patients’ knowledge and uptake of required vaccinations

Aims

• Optimise resilience to infection in patients newly diagnosed with CLL by improving vaccine uptake

• Create a sustainable change in the long-term management of new patients with CLL at the Royal Cornwall Hospital

Methodology

1. The clinic letters of the 14 most recent diagnoses of CLL in the department and 9 most recently commenced on acalabrutinib were reviewed for vaccination advice. In addition, patients were interviewed via telephone regarding their knowledge of required vaccinations

2. The data was presented at the Haematology Department Governance Meeting, along with guidance on documentation of vaccination advice

3. The data was remeasured for the most recent diagnoses of CLL, following which patient vaccine cards were implemented

4. The data was remeasured for the most recent diagnoses of CLL, following which GP information sheets were sent to primary care with each new diagnosis

5. The data was then remeasured following implementation of the GP information sheets, following which, the overall data of the project was analysed

PDSA Cycle

Act: Departmental presentation, patient vaccination card distributed & professional educational resource in primary care employed

Results

Plan: Optimise resilience to infective complications in patients with CLL

Uptake of Pneuomococcal vaccine (Cycle 3)

Documentation of vaccine advice (Cycle 3)

Uptake of pneuomococcal vaccine (Cycle 2) of vaccine advice (Cycle 2)

Analysis of Documentation of Vaccination Advice in Clinic Letters and Uptake of Pneumococcal Vaccine Following Implementation of QI Cycles Yes No

• Initially, 78% of clinic letters did not document the vaccination guidance, this was reflected with a 50% uptake of the pneumococcal vaccine amongst patients

• Following the first cycle, the documentation improved to 80% of clinic letters, with a 40% uptake of the pneumococcal vaccine

Study: Reduced vaccine uptake amongst patients with CLL and need for further education identified

Do: Investigate vaccination advice, patient knowledge & primary care knowledge

Cll Vaccination Card

I have recently been diagnosed with CLL and require the following vaccines:

Vaccines at diagnosis:

Prevnar (pneumococcal conjugate)

Haemophilus influenza type b conjugate vaccine

Fluvax

• Meningitis ACWY

Pneumovax II (pneumococcal polysaccharide) 2 months after Prevnar

Boosters:

Pneumovax II every 5 years

• Fluvax annually

• Following the second cycle, the implementation of the vaccine cards improved the uptake of the pneumococcal vaccine to 75% of patients; however, only 50% of clinic letters documented the vaccination guidance

• Following the third cycle, the uptake of the pneumococcal vaccine was noted to be 89%, with 78% of clinic letters accurately documenting the vaccination guidance

• Interestingly, following the third cycle the uptake of the Hib vaccine improved to 50%, whereas previous cycles had demonstrated a 0% uptake of this vaccine

Discussion & Conclusion

• The main limitation encountered during this project was the presence of low patient numbers during the first two cycles, which was likely secondary to reduced capacity during the COVID pandemic

• Nevertheless, it was noted in the final cycle that a significant number of patients were able to be included in the data analysis

• Patients initially reflected difficulties in accessing primary care during this period, which may have affected vaccine uptake; however, it was noted that the vaccine cards empowered them to follow it up

• Distribution of the vaccine cards and primary care resource is now standard practice for all patients newly diagnosed with CLL

• In order to confirm the long term sustainability of this project, a re-audit is planned to take place in the latter part of 2023 with a potential to audit pneumococcal antibody titres as a marker for resilience to infection