Technically Speaking: Could Standing Orders Work in Your Office?

According to the Community Preventive Services Task Force (Task Force):

Standing orders authorize nurses, pharmacists, and other healthcare personnel, 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. The protocol enables assessment and vaccination without the need for examination or direct order from the attending provider at the time of the interaction. Standing orders can be established for the administration of one or more specific vaccines to clients in health care settings . . . . In settings that require attending provider signatures for all orders, standing order protocols permit assessment and vaccination in advance of the provider signature.

Using standing orders

When I think of standing orders, I include a variety of opportunities and approaches to tweak existing office procedures:

• Example #1: A knowledgeable and motivated nurse checks the electronic records of all patients coming for well care visits the next day. For all vaccines due the next day, the nurse puts in orders that will be signed at a later time by the provider, sometimes referred to as “pending” the orders. (Some people would distinguish this as a pre-order, rather than a standing order.) When the patients come in, they receive their vaccines at the beginning of the visit, so the recommended 15-minute post-vaccination waiting period is over by the time the provider is done with the history and physical. The provider can sign the “pended” orders for that patient at the time of the visit (and confirm whether any vaccinations were inadvertently overlooked). Alternatively, if the workload doesn’t allow for that, the “pended” orders can be signed at a later, more convenient time, if this is permissible in the practice setting.
• Example #2: Each morning, the assigned physician receives a list of patients with a planned visit (of any type) that day who are due or overdue for their second HPV vaccine. Since few parents who accepted a first dose refuse a second one, the physician orders HPV vaccine for all these patients.
• Example #3: The medical director signs a protocol that lays out the details of the standing order for influenza vaccination. The nurse manager posts the protocol and uses one huddle to review contraindications and precautions with all staff. Every eligible patient is then urged to get the vaccine at any visit, meaning most patients will be offered the vaccine if they have yet to receive it.

While the workflow for each example is different, the objective is the same: enable nursing staff to vaccinate patients without a provider having to write a patient-specific order during the hectic part of the workday. The Task Force recommends the use of standing orders based on strong evidence of its effectiveness as demonstrated in a systematic review they completed in 2009 (29 studies, search period 1997–2009) and six subsequent studies. Notably, no risk of harm was identified in the studies. Likewise, implementation costs were low, and some of the studies suggested that standing orders may be more effective in improving vaccination rates when compared with provider reminder systems.

Overcoming barriers to implementing standing orders

The barriers to using standing orders may include concerns from both providers and nursing staff. Giving more vaccines protects more patients but takes more time. However, if standing orders are incorporated into existing procedures, they can improve vaccination coverage without adding significant time. Likewise, standing orders can be implemented for one vaccine as a way to collectively “dip your toe” in this approach, gaining insights and, hopefully, support over time. Other objections often can be resolved through training. Everyone involved in the process needs:

1. A clearly written standing order
2. A strong understanding of minimum vaccination ages and intervals between doses in a vaccine series (See Table 3-2 in the “Timing and Spacing of Immunobiologics” section of the General Best Practice Guidelines for Immunization.)
3. Knowledge of true contraindications and precautions (See Table 4-1 in the “Contraindications and Precautions” section of the General Best Practice Guidelines for Immunization.)

Resources and closing thoughts

Perhaps you are intrigued by the possibility of using standing orders to spark better coverage with some vaccines or the protective monoclonal antibody, nirsevimab. If so, I recommend two documents from Immunize.org:

• Using Standing Orders for Administering Vaccines: What You Should Know – This resource addresses questions, such as what standing orders are, who recommends standing orders for vaccination, who is authorized to administer vaccines under standing orders, and who is authorized to sign standing orders.
• Steps to Implementing Standing Orders for Immunization in Your Practice Setting – This resource covers the basic principles of implementing standing orders for immunizations.

Since time is of the essence for both office personnel and families, standing orders can help improve efficiency and, therefore, office immunization rates. Your team need not use standing orders for all vaccines or even all doses of a vaccine in a series. Perhaps you want to start with just one or a small number of vaccines, such as influenza, the second dose of quadrivalent meningococcal vaccine, or nirsevimab. The risks are minimal, especially with some staff immunization training, and the potential for getting more patients protected is great.