Association of Standing-Order Policies With Vaccination Rates in Dialysis Clinics: A US-Based Cross-sectional Study

Background: Patients with end-stage renal disease are at increased risk of morbidity and mortality because of infection. Quality improvement efforts for this patient population include assessment of institutional policies and practices that may increase vaccination rates for influenza, hepatitis B, and pneumococcal disease. Study Design: A survey of vaccination practices, beliefs, and attitudes was sent to all dialysis centers in End-Stage Renal Disease Networks 6, 11, and 15. Setting & Participants: Of 1,052 dialysis facilities considered, 683 returned the survey, reported vaccination rates for 2005 to 2006, and had 20 or more patients. Predictor or Factor: Standing-order policy of the dialysis facility, categorized as facility-wide orders, preprinted admission orders for each patient (chart orders), physician-specific orders, and individual orders. Outcomes: Vaccination rates for influenza, hepatitis B (full or partial series), hepatitis B, and pneumococcal vaccine. Measurements: Patient vaccination, given at or outside the center. Results: Overall vaccination rates were 76% +/- 18% (SD) for influenza, 73% +/- 22% for hepatitis B full or partial series, 62% +/- 25% for hepatitis B full series, and 44% +/- 34% for pneumococcal vaccine. Compared with individual orders, facility-wide standing orders and chart orders were not associated with greater vaccination rates for influenza (0.4%; confidence interval, -4 to 5; and 1.27%; confidence interval, -3 to 5, respectively), but were associated with greater vaccination rates for hepatitis B full or partial series (9%; confidence interval, 3 to 15; and 11% confidence interval, 5 to 17, respectively), hepatitis B full series (11%; confidence interval, 4 to 17; and 13%; confidence interval, 7 to 19, respectively), and pneumococcal disease (21%; confidence interval, 14 to 29; and 20%; confidence interval, 13 to 27, respectively). Limitations: Data are cross-sectional, and vaccinations outside the center were self-reported. Conclusions: Existing facility-wide or chart-based order programs may be effective in promoting vaccination against hepatitis B and pneumococcal disease. Am J Kidney Dis 54:86-94. (c) 2009 by the National Kidney Foundation, Inc.