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Systematic Review
The CPSTF recommends standing orders for vaccinations on the basis of strong evidence of effectiveness in increasing vaccination rates among adults and children; when used alone or with additional interventions; and across a range of settings and populations. The Task Force 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). Based on the combined evidence, the Task Force reaffirms its recommendation based on strong evidence of effectiveness.
The Task Force considered evidence from 35 studies. Of these, 27 studies provided a common measurement of change in vaccination rates with a median increase of 24 percentage points (IQI: 12 to 35 percentage points). Nine studies that examined the impact of standing orders alone documented a median increase of 16 percentage points (IQI: 9 to 29 percentage points). Nineteen studies that evaluated standing orders when combined with additional interventions documented a median increase of 27 percentage points (IQI: 13 to 40 percentage points). Seven studies that did not provide a common measure of change for vaccination rates all reported favorable results after implementation of standing orders.
The reviewed studies evaluated the effectiveness of standing orders across a wide range of clinical vaccination settings, health care personnel, and client populations. Standing orders were found to be effective in various settings including clinics, hospitals, and long-term care facilities. Interventions were effective when used with different vaccination providers including nurses and pharmacists. While most studies looked at adult populations, four examined intervention effectiveness among children and found a median absolute percent increase of 28 percentage points (range: 8 to 49). While no studies specifically evaluated the impact of standing orders for vaccination of adolescents, evidence from this review is likely applicable to this population. 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.
One paper from the updated search period described the following barriers encountered during implementation of a pneumococcal vaccination standing orders program in three hospitals: gaps in staff education and training; personnel concerns about additional workload; staff reluctance to administer vaccines without a physician's order; attending physicians' resistance to having hospitalized patients vaccinated; and logistical difficulties. Some attending physicians expressed concern that vaccination would interfere with scheduled treatments or procedures. Other attending physicians did not consider inpatient stays to be an appropriate time for vaccinations (Middleton et al. 2005).
An additional study reported barriers to implementation of influenza and pneumococcal vaccination standing orders in various health care settings. Findings suggested that the adoption of these policies may have been too difficult to administer, staff were unclear or unconvinced of program benefits, and there was perceived physician discomfort with delegating responsibility for immunizations to nursing staff. A few of the respondents also indicated that resources, effectiveness of the vaccine, and time required to administer the vaccine were barriers for adoption. The majority of these barriers were specific to the administration of the influenza vaccine (Goldstein et al. 2005).
This CPSTF concludes that standing orders were shown to be effective in increasing vaccination rates for influenza and pneumococcal vaccines. Additional research is needed, however, to determine if these interventions are effective for different vaccines (e.g. hepatitis, tetanus and vaccines recommended for adolescents). More evidence is also needed on ways to address barriers to the implementation of standing orders in health systems.