Gamble George R, Goldstein Adam O, Bearman Rachel S
Department of Family Medicine, University of North Carolina at Chapel Hill, NC, USA.
J Am Board Fam Med. 2008 Jan-Feb;21(1):38-44. doi: 10.3122/jabfm.2008.01.060179.
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.
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 >or=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.
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.
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.
流感和肺炎球菌疫苗接种的常规免疫政策（SOIPs）被认为是提高免疫接种率最有效的策略之一。尽管这些政策已被证明有效，但尚未得到广泛采用，并且在测试特定的采用/实施策略方面关注有限。这项试点研究评估了实施SOIP的极简策略的效果。
北卡罗来纳州3家初级保健门诊诊所的便利样本同意参与本研究，并为其65岁及以上的患者采用和实施流感和肺炎球菌免疫的SOIP。采用程序包括为诊所护士和医护人员提供1小时培训、提供适当表格，并在研究期间进行2次简短的方案提醒。在政策实施的基线年份（1999年）和之后的年份（2000年），对每个诊所在流感季节（10月至2月）就诊的合适患者进行病历审核，从而计算流感和肺炎球菌免疫接种率作为主要结局指标。
几乎没有证据表明这些诊所为实施SOIP政策做出了改变。免疫接种流程图的使用是SOIP实施的关键过程指标，结果发现其一致性低于完善实施的SOIP预期。还发现，尽管3家干预诊所的流感免疫接种率略有上升，但变化无统计学意义。各诊所之间以及从基线期到干预后期，肺炎球菌免疫接种率的变化也不一致。
实施SOIP的这种极简努力似乎没有产生足够的影响来显著改变诊所的做法。流程图的使用作为SOIP实施的一项关键指标，在干预期内没有变化。我们没有发现新采用的SOIP导致流感和肺炎球菌免疫接种率如预期那样上升。需要对完善实施SOIP的改进策略进行更多研究，以确保有效采用这一已被证实的系统干预措施。
