Standing Orders for Vaccination Providers to Increase Vaccination Coverage in Children and Adults: An Update

Background:
Standing orders programs authorize nurses and pharmacists, where allowed by state law, to assess a client's immunization status and administer vaccinations according to an institution- or physician-approved protocol without the need for a physician's examination or direct order at the time of the interaction. In 1998, based on results from their systematic review of 11 studies, the Task Force on Community Preventive Services issued a recommendation for the use of standing orders to increase vaccination coverage in adults. This same review identified insufficient evidence to determine the effectiveness of standing orders for increasing vaccination coverage in children.

Objectives:
To update the earlier systematic review and to evaluate the additional evidence on effectiveness of standing orders to increase vaccination coverage for adults and for children.

Methods:
Using methods developed for the Guide to Community Preventive Services (Community Guide), we conducted a systematic search for new evidence published in the period 1998–2007. Published intervention studies were evaluated, results were summarized, and findings were translated into conclusions on effectiveness according to Community Guide rules of evidence.

Results:
We identified 26 studies of standing orders programs published in the update period 1998–2007. Of these, 22 studies indicated a median absolute percent increase of 28 percentage points (interquartile interval [IQI]: 16.0 to 37.0 percentage points) in vaccination coverage among patients. Four studies evaluated the impact of standing orders on vaccination coverage among children and found a median absolute increase of 28 percentage points (range: 8 to 49.0 percentage points).

Conclusions:
According to Community Guide rules of evidence, strong scientific evidence demonstrates that standing orders remain an effective intervention option to improve vaccination coverage in adults. Sufficient scientific evidence identified in this update now indicates that standing orders are also effective in increasing vaccination coverage in children.