VACCINATION RATESIncreasing immunity to disease among adults is best achieved by improving vaccination rates in this population. A number of strategies have been developed to accomplish this goal, such as standing orders, computerized record reminders, chart reminders, performance feedback, home visits, mailed or telephoned reminders, expanding access in clinical settings, patient education, and personal health records. Improving vaccination rates begins with seizing each opportunity to access a patient’s vaccination history and with vaccinating patients when immunization is recommended. Several practices can help to identify patients who need immunization.

Standing Orders

Vaccine standing orders are a set of orders that can be executed by nurses or pharmacists without a physician’s signature. These orders can be developed as physician-approved protocols in outpatient or institutional settings. Implementing a standing-order program has been shown to increase the rate of pneumococcal vaccinations in hospital settings. One hospital-based study showed an increase in the immunization rate from 0 to 78%.
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The success of standing orders has been observed in both long-term care facilities and in outpatient clinic settings when pharmacists and nurses execute the orders.

Pharmacists often have excellent opportunities to identify and to vaccinate elderly patients. Many older patients suffer from chronic disease and must visit a pharmacy at regular intervals for medications. These visits provide multiple opportunities to update immunization histories and to immunize patients as necessary. Although legal barriers in many states prevent pharmacists from administering vaccine, some states, including Washington and Mississippi, allow pharmacists to immunize patients at pharmacies.

The ACIP recommends that procedures be developed to address the following goals:

  • identifying persons eligible for vaccination based on (1) their age, (2) their vaccination status (e.g., persons not previously vaccinated or those recommended for vaccination according to the schedule), or (3) the presence of a medical condition that puts them at high risk
  • informing patients or their guardians about the risks and benefits of a vaccine and documenting the delivery of this information
  • recording patient refusals or medical contraindications
  • recording administration of a vaccine and any post-vaccination adverse events according to an institution-approved or a physician-approved protocol
  • providing documentation of vaccine administration to patients and their primary care providers

The NCAI recommends that standing-order programs include a standard personal and institutional immunization record to verify the immunization status of patients and staff members. The orders can be constructed to meet the age-specific needs of patients seen in clinics or hospitals. With this documentation placed in the permanent medical record, it is readily retrievable when needed. cialis canadian pharmacy

For pharmacist-administered vaccinations, the pharmacy computer system may be utilized to track and document immunizations. In order for hospitals, long-term care facilities, and home health agencies to be paid by Medicare or Medicaid for services provided, they must meet specific standards of practice, known as federal Conditions of Participation (COPs). However, no dual standard of care may exist such that patients with other payers would be cared for differently.

Until recently, a practitioner’s order was required for all immunizations to comply with COP standards. This requirement, however, can be met only if practitioners remember to order immunizations for patients who need them. Standing-order programs are designed to automatically order assessments and treatments without requiring a practitioner’s order. COP standards had not allowed such standing-order programs to function independently from practitioner orders. Ironically, standards created to improve care actually hindered immunization campaigns.

In October 2002, the DHHS changed the COPs for hospitals participating in Medicare and Medicaid. The new rules state the following:

All orders for drugs and biologicals must be in writing and signed by the practitioner or practitioners responsible for the care of the patient as specified under § 482.12(c) with the exception of influenza and pneumococcal polysaccharide vaccines, which may be administered per physician-approved hospital policy after an assessment for contraindications.


Reminders, another successful method of improving immunization rates, can take several forms; technology systems can be used, or clinicians can simply place reminder notes in paper medical charts. These reminders may be targeted at health care providers or patients.

Strategies for reminding health care providers include written notes in medical charts and computer messages that emphasize the need to immunize. Reminders for patients include telephone messages, mailed letters or postcards, and home visits. With many pharmacies already using such computers for prescription records and patient information, it is possible that this system might provide monthly reminders to patients to be immunized during influenza season or to seek a pneumococcal vaccination.

As computerized medical charts become more widespread, automated yearly reminder notes may become more common in clinic and hospital settings. Computerized reminders are less subject to human error and offer an advantage over paper and handwritten reminders.

Patient Education

Education programs have been implemented in both clinical settings and community-based programs (e.g., in printed materials and advertising campaigns). One evidence-based review of the medical literature found insufficient verification that these programs were effective at increasing vaccination rates.53 The authors cited small sample sizes and an inability to isolate interventions as the cause.

Increasing access to vaccinations can also provide improved immunity at other sites in the community. Vaccines can be provided at malls or grocery stores where large groups of people are present. Nursing homes and retirement communities, which often house populations at risk for influenza, are excellent sites for establishing these clinics.
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Vaccines are a cost-effective means of decreasing health care costs, including hospitalizations; of improving quality of life; and of lowering overall morbidity and mortality rates. Despite widely publicized recommendations for the routine vaccination of older adults, many people remain at significant risk for vaccine-preventable diseases. In fact, serosurveys and surveillance reports of vaccine-preventable diseases (i.e., influenza, invasive pneumococcal disease, and tetanus) show that older Americans are the group least protected from these illnesses. Patients remain at risk largely because of inadequate efforts to ensure appropriate immunization in this population.

Clinicians can improve vaccination rates by seizing on opportunities to assess their patients’ immunization histories and to vaccinate those patients who are at risk for infection. Standing orders and physician-approved protocols are effective means of increasing immunity in older populations. Vaccination campaigns provide an opportunity for pharmacists to partner with physicians to reach patients who might not visit a physician’s office. These initiatives are cost-effective measures that can improve immunity in the vulnerable elderly population. Similar programs in hospitals and long-term care facilities have been successful.
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Pharmacy information systems can play a crucial role in identifying and tracking people who are scheduled for immunizations. These systems can aid in pharmacist-administered vaccine programs by reminding patients to obtain vaccines each year. Pharmacists, physicians, nurses, health care organizations, and public health agencies need to collaborate to improve immunization rates in the community.

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Tags: HOST SUSCEPTIBLITY, Influenza Vaccine, Looking Ahead, Tetanus Toxoid

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