Vaccination Programs: Standing Orders

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Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends standing orders for vaccinations when used alone or when combined with additional interventions to increase vaccination rates among adults and children from different populations or settings.

The full CPSTF Finding and Rationale Statement and supporting documents for Vaccination Programs: Standing Orders are available in The Community Guide Collection on CDC Stacks.

Intervention

Standing orders authorize nurses, pharmacists, and other healthcare providers 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 provider.

Standing orders can be established for administration of one or more specific vaccines to clients in healthcare settings such as clinics, hospitals, pharmacies, and long-term care facilities. In settings requiring attending provider signatures for all orders, standing order protocols allow assessment and vaccination in advance of the provider signature.

About The Systematic Review

The CPSTF finding is based on evidence from a Community Guide systematic review completed in 2009 (29 studies, search period 1997-2009) combined with more recent evidence (6 studies, search period 2009-February 2012).

Study Characteristics

  • Studies were conducted in a wide range of clinical settings, including healthcare clinics, hospitals, and long-term care facilities
  • Interventions were used with different vaccination providers including nurses and pharmacists

Summary of Results

Thirty-five studies were included.

  • Overall, vaccination rates increased by a median of 24 percentage points (27 studies)
    • Standing orders used alone: median increase of 16 percentage points (9 studies)
    • Standing orders combined with additional interventions: median increase of 27 percentage points (19 studies)
  • Standing orders increased vaccination rates among children by a median of 28 percentage points (4 studies)
  • All studies that did not provide common measure reported favorable results (7 studies)

Summary of Economic Evidence

Three U.S. studies evaluated economics of standing orders for pneumococcal, influenza, and Tdap vaccines (search period 1980-2012). Monetary values in 2013 U.S. dollars.

  • Median intervention cost: $5.55 per person per year (3 studies)
  • Median cost: $29 per additional vaccinated person (3 studies)
  • Intervention groups had median size of 11,813 clients (3 studies)

Applicability

Findings applicable to:

  • Various clinical settings (e.g., clinics, hospitals, long-term care facilities)
  • Different vaccination providers (e.g., nurses, pharmacists)
  • Children, adolescents, and adults
  • Inpatient and outpatient settings

Evidence Gaps

  • How effective are these interventions for adolescent populations?
  • How effective are these policies in communities with disparities in vaccination rates?
  • What are strategies to address implementation barriers for standing orders in systems of care?

Implementation Considerations and Resources

Standing order interventions may improve efficiency and flow of patient care in busy inpatient and outpatient care settings.

Barriers to implementation include:

  • Gaps in staff education, training, and perceived benefit
  • Personnel concerns about additional workload
  • Staff reluctance to administer vaccines without a physician’s order
  • Attending physicians’ resistance to having hospitalized patients vaccinated
  • Logistical difficulties
  • Concern that vaccination would interfere with scheduled treatments or procedures

Crosswalks

Healthy People 2030 icon Healthy People 2030 includes the following objectives related to this CPSTF recommendation.