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Increasing Appropriate Vaccination: Standing Orders

Standing orders authorize nurses, pharmacists, and other healthcare personnel where allowed by state law, to assess a client's immunization status and administer vaccinations according to a protocol approved by an institution, physician, or other authorized practitioner. The protocol enables assessment and vaccination without the need for examination or direct order from the attending provider at the time of the interaction.

Standing orders can be established for the administration of one or more specific vaccines to clients in health care settings such as:

  • Clinics
  • Hospitals
  • Pharmacies
  • Long-term care facilities

In settings that require attending provider signatures for all orders, standing order protocols permit assessment and vaccination in advance of the provider signature.

Summary of Task Force Recommendations and Findings

The Community Preventive Services Task Force recommends standing orders for vaccinations based on strong evidence of effectiveness in improving vaccination rates:

  1. In adults and children
  2. When used alone or when combined with additional interventions; and
  3. Across a range of settings and populations

Task Force Finding and Rationale Statement

 

Results From the Previous and Updated Systematic Reviews

The Task Force finding is based on evidence from a Community Guide systematic review published in 2000 (search period 1980-1997) combined with more recent evidence (search period 1997-2009). The Task Force recommendation for this intervention remains unchanged.

Learn more about the original review and Task Force finding in the Vaccinations to Prevent Diseases section of our publications page.

Previous Review (Search Period 1980-1997)

Eleven studies qualified for the systematic review. Included studies examined the effects of standing orders alone or as part of a broader intervention that included additional components.

  • Vaccination coverage: median increase of 27 percentage points (Interquartile interval [IQI]: 16 to 61 percentage points; 10 study arms)
    • Standing orders when used alone: median increase of 53 percentage points (range: 27 to 81 percentage points; 5 study arms)
    • Standing orders with additional components: median increase of 16 percentage points (range: 6 to 26 percentage points; 4 study arms)
  • Only one study looked at the use of standing orders with childhood vaccinations and found no overall improvement in vaccination rates.

Updated Review (Search Period 1997-2009)

Twenty-nine studies qualified for the updated systematic review. Included studies examined the effects of standing orders alone or as part of a broader intervention that included additional components. Interventions were evaluated in a wide range of clinical settings and among diverse populations.

  • Median increase in vaccination rates:
    • Overall: 24 percentage points (IQI: 14 to 37 percentage points; 24 studies, 25 study arms)
    • Standing orders when used alone: 17 percentage points (IQI: 13 to 32 percentage points; 8 studies, 8 study arms)
    • Standing orders with additional components: 31 percentage points (IQI: 13 to 43 percentage points; 17 studies, 17 study arms)
      • Among children: 28 percentage points (Range: 8 to 49 percentage points; 4 studies, 4 study arms)
    • Standing orders were effective in increasing vaccination rates when implemented in a range of clinical settings, among various providers and client populations.
    • Standing orders were effective for vaccine delivery to children (universally recommended vaccinations) and adults (influenza and pneumococcal).
    • Few studies evaluated the impact of standing orders on vaccination rates for the delivery of Hepatitis B and tetanus vaccines and immunizations administered for adolescents.

Economic Review

Two hospital-based studies from the updated search period qualified for the economic review. Monetary values are reported in 2009 U.S. dollars.

  • One study evaluated standing orders against provider reminders for influenza and pneumococcal vaccinations of high risk patients.
    • Program cost per patient was $4.66 for standing orders and $6.25 for provider reminders.
    • Cost per additional vaccinated patient was $65.42 for standing orders and $101.87 for provider reminders.
  • Another study evaluated standing orders for pneumococcal vaccinations for elderly patients.
    • The program cost ranged from $4.85 to $5.36 per patient.
    • The intervention was found to be cost-effective at $2,836 to $10,329 per QALY, based on a conservative threshold of $50,000 per QALY.

The effectiveness and economic review findings are based on systematic review of all available studies, conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice and policy related to vaccinations to prevent diseases.

Publication Status

Full peer-reviewed articles of this systematic review will be posted on the Community Guide website when published. Subscribe External Web Site Icon to be notified when we post these publications or other materials. See our library for previous Community Guide publications on this and other topics.

 




Disclaimer

The findings and conclusions on this page are those of the Community Preventive Services Task Force and do not necessarily represent those of CDC. Task Force evidence-based recommendations are not mandates for compliance or spending. Instead, they provide information and options for decision makers and stakeholders to consider when determining which programs, services, and policies best meet the needs, preferences, available resources, and constraints of their constituents.

Sample Citation

The content of publications of the Guide to Community Preventive Services is in the public domain. Citation as to source, however, is appreciated. Sample citation: Guide to Community Preventive Services. Increasing appropriate vaccination: standing orders. www.thecommunityguide.org/vaccines/universally/standingorders.html. Last updated: MM/DD/YYYY.

Review completed: December 2009