Universally Recommended Vaccinations: Standing Orders

Task Force Finding & Rationale Statement

Definition

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, and 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.

Recommendation

The Community Preventive Services Task Force recommends recommends standing orders for vaccinations based on strong evidence of effectiveness in improving vaccination coverage: (1) in adults and children; (2) when used alone or when combined with additional interventions; and (3) across a range of settings and populations.

Rationale

In 1997 the Task Force found strong evidence of effectiveness for standing orders. Based on the findings of this 2009 update, the Task Force reaffirms their original recommendation.

Our previous review (search period 1980-1997) included 11 studies. Of these, 10 studies provided a common measurement of change in vaccination coverage, with a median absolute percent increase of 27 percentage points (interquartile interval [IQI]: 16 to 61 percentage points). Five study arms that evaluated standing orders when implemented alone documented a median absolute percent increase of 53 percentage points (range: 27 to 81 percentage points). Four study arms that evaluated standing orders with additional components had a median absolute percent increase of 16 percentage points (range: 6 to 26 percentage points).

The updated review identified 29 additional studies (search period 1997-2009). Of these, 24 studies provided a common measurement of change in vaccination coverage rates with a median absolute percent increase of 24 percentage points (IQI: 14 to 37 percentage points). Eight study arms that examined the impact of standing orders alone documented a median absolute percent increase of 17 percentage points (IQI: 13 to 32 percentage points). Seventeen study arms that evaluated standing orders when combined with additional interventions documented a median absolute percent increase of 31 percentage points (IQI: 13 to 43 percentage points).

The reviewed studies evaluated the effectiveness of standing orders in a wide range of clinical vaccination settings and client populations.

No evidence of harms regarding the use of standing orders was identified in either the original or the 2009 review.

The Task Force notes that in the original review, insufficient evidence was identified to support a conclusion regarding standing orders for children. However, the 2009 review identified four studies with children that had a median absolute percent increase of 28 percentage points (range: 8 to 49 percentage points). Based on this finding the Task Force now recommends the use of standing orders to increase vaccination coverage among children.

In addition, a subset of the included evidence suggests that standing orders may be more effective in improving vaccination rates in both inpatient and outpatient settings when compared to a provider reminder system.