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Implementing a Standing Order Immunization Policy: A Minimalist Intervention

From the Department of Family Medicine, University of North Carolina at Chapel Hill

Correspondence: Corresponding author: George R. Gamble, PhD, 201 Vuelta Roble, Santa Fe, NM 87501 (E-mail: ggdee{at}QWEST.net)

Introduction: Standing order immunization policies (SOIPs) for influenza and pneumococcal vaccinations have been found to be among the most effective strategies for increasing immunizations rates. Despite their proven efficacy these policies have not been widely adopted and there has been limited attention focused on testing particular adoption/implementation strategies. This pilot research assessed the efficacy of a minimalist strategy to implement an SOIP.

Methods: A convenience sample of 3 primary care outpatient clinics in North Carolina agreed to participate in this study and adopt and implement an SOIP for influenza and pneumococcal immunizations for their patients 65 years old. The adoption procedure included 1-hour training for clinic nurses and providers, the provision of appropriate forms, and 2 brief reminders of protocols during the study period. Chart audits of appropriate patients who had a clinic visit during flu season (October through February) at each clinic during the baseline year of policy implementation (1999) and the year after (2000) allowed calculation of influenza and pneumococcal immunization rates as primary outcome measures.

Results: There was little evidence to indicate that these clinics made changes to implement a SOIP policy. Immunization flow sheet use, a critical process measure of SOIP implementation, was found to be less consistent than would be expected under a well-implemented SOIP. It was also found that, although influenza immunization rates did increase slightly in the 3 intervention clinics, the changes were not statistically significant. Pneumococcal immunization rate changes were also inconsistent across clinics and from baseline to post-intervention periods.

Conclusions: This minimalist effort to implement the SOIP seems not to have had sufficient impact to significantly change clinic practices. Flow sheet use, as one critical measure of SOIP implementation, did not change over the course of the intervention period. We did not find the expected increase in influenza and pneumococcal immunization rates as a result of a newly adopted SOIP. Additional research on improved strategies to fully implement SOIPs is needed to insure effective adoption of this proven systems intervention.

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