The STanding Orders Protocol (STOP): A Pharmacy Driven Pneumococcal and Influenza Vaccination Program

Purpose: A Medical Board-approved pharmacy-based inpatient STanding Orders Protocol (STOP) for influenza and pneumococcal vaccination was designed and implemented at Montefiore Medical Center in response to fed- eral and state regulations put in place in 2006. This vaccination program aims to improve historically poor vac- cination rates in a complex, urban patient population. Developing this initiative in a large health care system with high turnover and a diverse (many non-English speaking) population represented a formidable challenge. Methods: In 2006 the institution initiated a program to improve patient care. The program involved a clinical pharmacist rounding on patient care units specifically to encourage the acceptance of the pneumococcal and influenza vaccine in patients at least 65 years of age at 1 of the 2 campus sites in the Bronx, New York. Medical residents were also employed to facilitate the pharmacist and achieve national standards. Registered nurses and licensed practical nurses are authorized to administer standing orders for vaccines and anaphylaxis treatment agents as needed under this protocol without direct physician examination. Vaccine information sheets (VIS) and gender- and ethnicity-specific patient teaching aids provide statistical information regarding disease and mortali- ty rates. Language barriers are reduced by providing VIS in both Spanish and English, and telephone translation in most languages are utilized when necessary. Documentation of refusal of, previously received, or a newly ordered vaccination is placed in the patient's chart and in the central database. Discussion: Prior to the STOP program, the total in-hospital vaccination encounter rates according to various Center for Medicare and Medicaid Services (CMS) audits was approximately 18% for pneumococcal and 27% for influenza vaccinations, respectively. The institution's current encounter rates have dramatically increased to more than 85% for pneumococcal and 55% for influenza vaccine. Conclusion: The cooperative efforts of physicians, pharmacists, and nursing staff have led to the creation of a suc- cessful inpatient-based vaccine standing orders protocol. As a result, in 2007 the institution approved a second clinical pharmacist to allow for coverage at both of Montefiore's hospital sites. The hospital's goal is to ultimate- ly decrease pneumococcal disease and its severity, increase and maintain the highest vaccination rates in New York City, and comply with national standards. The implication for decreasing morbidity and readmission of patients is promising. Future plans include the development of an ambulatory-based program with a similar design model.