10 Steps To Implementing Standing Orders For Immunization

10 steps to implementing standing orders for immunization

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10 Steps to Implementing Standing Orders
for Immunization in Your Practice Setting
Standing orders are written protocols approved by a physician or other authorized prac-
titioner that allow qualified health care professionals (who are eligible to do so under state
law, such as registered nurses or pharmacists) to assess the need for and administer
vaccine to patients meeting certain criteria, such as age or underlying medical condition

The qualified health care professionals must also be eligible by state law to administer
certain medications, such as epinephrine, under standing orders should a medical emer-
gency (rare event) occur

Having standing orders in place streamlines While this guide focuses on
your practice workflow by eliminating the need to obtain implementing standing orders
an individual physician’s order to vaccinate each patient. for influenza vaccination, the
Standing orders carried out by nurses or other qualified basic principles included can
health care professionals are the most consistently effective be used to implement standing
means for increasing vaccination rates and reducing missed orders for other vaccines and
opportunities for vaccination, which improves the quality for any age group desired

of care for patients

Standing orders are straightforward to use. The challenge is to integrate them into the practice
setting so they can be used to their full potential. This process requires some preparation up front
to assure everyone in the practice understands the reasons why standing orders are being imple-
mented. Suggested steps to help you work through this process are shown below

Phase 1: Get Ready – Build Support of Leadership
step 1 Discuss the benefits of implementing standing orders protocols with the leadership
(medical director, clinicians, clinic manager, lead nurses) in your medical setting

Standing orders will:
• Facilitate efficient assessment for and administration of influenza vaccine in your practice

• Improve influenza vaccination rates in your practice

• Protect more of your patients from influenza

• Empower nurses and/or other eligible staff to use standing orders to protect more patients

• Decrease opportunities for influenza transmission in your health care setting

It is important to get buy-in from physician and nurse leadership from the start

Immunization Action Coalition Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org
www.immunize.org/catg.d/p3067.pdf • Item #P3067 (5/20)
Immunization Action Coalition 10 Steps to Implementing Standing Orders page 2
Medical Director – This person is responsible for signing the standing orders protocols or supervises
the clinician who signs them, so it is critical that he/she agrees with the need for standing
orders and supports their use

Clinician – Determine which clinician will review and sign the standing orders protocols for the practice

Providers – Identify issues that might lead to any resistance among other providers

Nurse Leaders – Involve nurse leaders in the planning from the start. Nurses are the key players in
implementing and carrying out standing orders programs

If possible, determine the influenza vaccination rate in your practice prior to meeting with leadership

Measured vaccination rates are inevitably lower (sometimes much lower) than perceived rates

Lower-than-expected vaccination rates will help support the need for a standing orders program

As appropriate for your medical setting, you also may want to discuss the standing orders protocols
with your legal counsel to be sure they comply with all applicable state requirements

2 Identify the person who will take the lead and
be in charge of your standing orders program

• In most practices, the lead person will be a nurse,
nurse practitioner, or physician assistant

• The lead person must be an influential leader who
has medical knowledge, understands the standing
orders protocols, and is able to answer questions about them from other staff members

• The lead person must be motivated to protect patients by improving the adult vaccination levels
in your practice – a true immunization champion

3 Reach agreement about which vaccine(s) your practice will administer using standing

It may be best to start using standing orders only for influenza vaccine if you have not implemented
standing orders previously. Later, when staff are trained and know how standing orders work, you
can expand their use to additional vaccines. Standing orders work well for improving coverage for
child, adolescent, and adult vaccines

Completing Phase 1 means you are on your way. You have buy-in from your medical director and
clinicians, buy-in from nurse leadership, have identified your immunization champion to lead the
effort, and have decided on the vaccines you want to provide. Now you’re ready to move to Phase 2

Phase 2: Get Set – Develop Materials and Strategies
4 Create standing orders protocols for the vaccine(s) you want to administer

• Don’t reinvent the wheel! The Immunization Action Coalition (www.immunize.org) has standing
orders templates for all routinely recommended vaccines available to download at www.immunize

org/standing-orders. IAC standing orders are reviewed by the Centers for Disease Control and
Prevention (CDC) for technical accuracy. You may use IAC’s standing orders templates as written,
or you may modify them to meet your practice’s needs

Immunization Action Coalition 10 Steps to Implementing Standing Orders page 3
• Have the standing order(s) reviewed and signed by the medical director or clinician responsible
for the program

note: Immunization Action Coalition (IAC) also has standing orders templates available for manag-
ing vaccine reactions, which include the administration of medication. These templates are available
at www.immunize.org/catg.d/p3082.pdf for adults and at www.immunize.org/catg.d/p3082a.pdf
for children

5 Hold a meeting to explain your new standing orders
program to all staff members

• It is crucial that all staff understand the program because
they will all be involved directly or indirectly

• To get buy-in from staff, you will need to explain WHY you
are starting this program. Some of the reasons are shown
in the box below:
Why are •  isease should be prevented whenever
D • S tanding orders have been demon-
we starting possible, and vaccines can do this. strated to streamline the assessment
and delivery of immunizations in

a standing O
 ur patients are counting on us to
medical practices

keep them healthy

orders • T he burden of disease as a result of
Adult vaccination rates in the United
program? States are low and significant racial
vaccine-preventable diseases is seen
not only in increased morbidity and
and ethnic disparities exist

mortality, but also in increased costs
• V
 accination levels among adults are to the health care system

inadequate in most practices

• Review how standing orders work and the specific protocols and procedures with all staff members
who will be involved

6 Determine the role various staff members will play in implementing/using standing orders

Here are some general and specific questions that will help you plan:
WHO in your practice:
• is eligible under state law (RNs, pharmacists, others? ) to assess a patient’s vaccination needs
and provide vaccinations using the standing orders protocols?
• can help determine the need for a patient to be vaccinated? ( For example, the receptionist or the
person who rooms patients can inquire if they have had their influenza vaccine yet this season.)
• will check the patient’s chart to find out if they need vaccinations?
• will provide screening checklists for contraindications and precautions to patients, and who will
review the patients’ answers. (available at www.immunize.org/handouts/screening-vaccines.asp)
Can these questions be added to your electronic medical record (EMR)?
Immunization Action Coalition 10 Steps to Implementing Standing Orders page 4
(continued) WHO in your practice:
• will give Vaccine Information Statements (VISs) (legally required documents given before vacci-
nation) to patients? (www.immunize.org/vis)
• will administer the vaccine?
• will ensure the patient’s personal record is
updated and given to the patient?
WHAT is the role of:
• the front desk staff? How can they help?
• the nurse?
• the medical assistant?
WHERE in your practice:
• will vaccine be administered?
• will vaccine administration information be recorded (e.g., EMR, paper document in medical
chart, state/local immunization information system or “registry”)? If you don’t use an EMR and
don’t already have a medical record chart form for vaccination, you can use the Immunization
Action Coalition’s record forms for adults (www.immunize.org/catg.d/p2023.pdf) or children

step 7 Determine your standing orders operational strategy

Review your existing vaccination services logistics. Are there ways to improve patient vaccination
and flow and to maximize your office immunization rates?
Here are some proposed modifications to consider:
• Assess the influenza vaccination status of every patient who enters the office by asking the
patient directly and checking the chart

• Consider providing vaccinations in an easy-to-access site in your practice, separated from the
normal traffic pattern through the office

• Consider offering vaccinations under standing orders on a walk-in basis

• Discuss expanding your vaccination services when using standing orders. For example, can you:
●  old vaccination clinics on evenings or weekends?
● Have “nurse-only” visits for vaccination?
● Offer “express” service for vaccination during regular office hours for both patients with
appointments and those who are “walk-ins”?
• If you use an EMR, consider whether the standing orders protocols and screening questionnaires
can be added as prompts within your existing system

• If viable in your clinic setting, determine your current immunization rates so you will be able to
measure your improvements after implementing standing orders

Immunization Action Coalition 10 Steps to Implementing Standing Orders page 5
step 8 Identify strategies and publicize your program to your patients

Your enhanced vaccination program is of more value if your patients know the service is available

• Review your current methods for contacting patients, e.g., appointment reminders, laboratory
results, prescriptions, online communications, text messaging, etc. Can these methods also be used
to tell patients about their need for vaccination and the availability of a convenient new program?
• Consider whether your existing communication systems are sufficient to inform patients about
enhanced vaccine availability

• Implement reminder/recall systems. (A reminder system notifies the patient of an upcoming
appointment. A recall system contacts a patient who misses an appointment and encourages
them to reschedule.) Your state/local health department often can help you with ideas on how
to do this

• Here are strategies for informing and identifying patients who need vaccines:
●  t each visit, inform all patients about when they should come for influenza vaccine

● Email or text the information

● Put a notice about the program on the practice’s website, if applicable

● Use social media (such as Facebook or Twitter)

● Place advertisements in local media

● Use promotional mailings

● Add promotional telephone messages or “on hold” messaging

● Place appropriate signs and posters in the office

Materials You Will Need to Have on Hand
• Adult and child vaccine administration record forms, if
All these materials are FREE on the IAC website:
you don’t use an electronic medical record (EMR) and
www.immunize.org don’t already have a medical record chart form ( available
• A copy of the signed standing orders protocol at your at www.immunize.org/catg.d/p2023.pdf and www.immunize

fingertips for each vaccine you plan to use (templates org/catg.d/p2022.pdf)
available at www.immunize.org/standing-orders)
• I nformation on how to report vaccinations to your state/
 dult and child contraindication screening checklists local immunization information system (registry)
to help you determine if there is any reason not to if one is available. (See www.cdc.gov/vaccines/programs/
vaccinate your patient (available at www.immunize.org/ iis/contacts-registry-staff.html)
catg.d/p4065.pdf and www.immunize.org/catg.d/
 o give to your patients: a personally-held vaccination
record card (available for purchase at www.immunize.org/
 accine Information Statements for all vaccines you plan shop/record-cards.asp ) or a printed copy of the vaccine
to administer (available in English and additional languages administered, including the date it was given

at www.immunize.org/vis)
* Completing Phase 2 has helped you to get your standing orders logistics figured out. You have
determined who will do what, and when they will do it. You have made your patients aware of
enhanced vaccine availability. Time to move to Phase 3

Immunization Action Coalition 10 Steps to Implementing Standing Orders page 6
Phase 3: Go! – Make It Happen
9 Start vaccinating!
Make sure the nursing and medical staff have all the tools they need to run a successful vaccination
program. Listing all these materials is beyond the scope of this guide, but topics can include proper
storage and handling of vaccines, vaccine administration techniques, strategies to avoid vaccine
administration errors, documentation requirements for administering vaccines, and materials
to help answer questions of vaccine-hesitant patients. Visit www.immunize.org/clinic for many
helpful resources

10 Review your progress

As with all quality improvement activities, it’s wise to review your standing orders program shortly
after it begins, check in with staff each week until it’s running well, and then every few months
until the end of influenza vaccination season. Compare the number of doses of vaccine you gave
this season with a season before your standing orders program was put in place. Hold a staff
meeting to get input from everyone involved in the program to find out what went right and how
the program could be improved for next season. Consider whether you are ready to expand your
use of standing orders to additional vaccines

* Congratulations on implementing standing orders in your
practice! Both you and your patients are now benefitting
from this proven method to streamline your office practice
while improving your patients’ quality of care

Orders templates for all routinely recommended vaccines available to download at www.immunize. org/standing-orders. IAC standing orders are reviewed by the Centers for Disease Control and Prevention (CDC) for technical accuracy. You may use IAC’s standing orders templates as written, or you may modify them to meet your practice’s needs. 2 3 4

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