Extrapyramidal symptoms following administration of oral perphenazine 4 or 8 mg: an 11-year retrospective analysis.

BACKGROUND: Perphenazine is a treatment option in postoperative nausea and vomiting (PONV) prophylaxis. Chronic administration and high dose are known to cause extrapyramidal system (EPS) dysfunction at a frequency of 8%, but the incidence of acute EPS after a single 4 or 8 mg dose is unknown. OBJECTIVE: A retrospective analysis of patient medication billing data and departmental quality records was performed (January 2001 to 10 July 2012) to identify patients who experienced EPS dysfunction after oral perphenazine. DESIGN: A retrospective analysis. SETTING: Surgical outpatients presenting to any one of 10 hospitals in the area of Pittsburgh, Pennsylvania, USA. PATIENTS: Overall, 45 766 patients received 4 or 8 mg of perphenazine before same-day surgery. MAIN OUTCOME MEASURES: EPS dysfunction was defined as acute dystonia, akathisia or pseudoparkinsonism. Records were reviewed to determine the likely number of reactions to perphenazine, the nature of these reactions and impact on patient care. RESULTS: There were four 'likely' cases of EPS dysfunction, and two 'possible' cases. Five reported events were consistent with akathisia, with the sixth being a dystonic reaction. All six patients had resolution of symptoms, with five receiving intravenous diphenhydramine for treatment. The incidence of EPS dysfunction was 1.3 events per 10 000 patients (95% confidence interval (CI) 0.4 to 3.0, based on six events). All patients who experienced reactions pre-operatively were able to proceed to surgery without complications or delay. One patient required unplanned admission and 3-h observation owing to sedation from diphenhydramine. The incidence of EPS dysfunction after oral perphenazine is low. Reactions that did occur were mild and easily treated. CONCLUSION: Given the infrequent side effects, this single, low dose of perphenazine should be encouraged as a low-risk adjunct to any multimodal PONV prophylaxis regimen, based on the selection criteria described.

A Pharmacotherapy Scholars Program to Provide Intensive Training to Enhance Pharmacy Students' Postgraduate Readiness.

Objective. To design, integrate the curriculum for, and evaluate an innovative program to facilitate placement of students into postgraduate pharmacy residency training programs involving direct patient care. Methods. The Pharmacotherapy Scholars Program (PSP) was designed to prepare fourth-professional year students to become highly proficient in a direct patient care role and to successfully match with postgraduate residency training programs. The following elements were included in the year-long curriculum: integrated synchronous advanced pharmacy practice experiences with personal advising, team-based mentoring, peer-to-peer learning, longitudinal research, and professional development. Program goals were modeled after the accreditation standards for postgraduate year one (PGY1) pharmacy residency programs. Program faculty members ensured that the PSP had a broad scope, included rigorous student assessments, had a strong research focus, and provided scholarship opportunities. Results. Sixty-eight students completed the program from fall 2013 through spring 2019. The overall residency match rate was 93%. Students' performance on both knowledge and clinical skills assessments significantly improved after completing the program. There was an approximately 15% increase in knowledge and a 30% improvement in clinical skills based on comprehensive readiness assessments and an intermittent clinical examination that used patient simulation, respectively. Conclusion. The Pharmacotherapy Scholars Program is an innovative training program designed to enhance PharmD students' preparation for advanced clinical training. Students who completed the PSP achieved a high PGY1 residency placement rate while demonstrating significant improvements in pharmacotherapy knowledge and clinical skills in direct patient care activities.

Clinical outcomes of intravenous immune globulin in severe clostridium difficile-associated diarrhea.

OBJECTIVES: Our objective was to determine if use of intravenous immune globulin (IVIG) decreases the incidence of mortality, colectomies, and length of stay in the hospital in patients presenting with severe Clostridium difficile-associated diarrhea (CDAD). METHODS: A retrospective analysis was undertaken of 79 patients who had a positive C. difficile toxin titer and severe disease admitted to the University of Pittsburgh Medical Center Presbyterian between July 2001 and July 2003. Standard therapy for severe CDAD including intravenous metronidazole, oral vancomycin, or vancomycin enema was administered to all patients. Eighteen patients also received IVIG treatment (200-300 mg/kg); these were pair matched by propensity scoring with 18 patients who had the most similar characteristics and severity of CDAD from the available pool of 61 subjects who did not receive IVIG treatment. RESULTS: No significant difference was observed in the baseline characteristics between the two groups. There were no statistical differences in clinical outcomes as measured by all cause mortality, colectomies, and length of stay. CONCLUSIONS: These data demonstrate that the use of IVIG in severe CDAD remains unsubstantiated. This study, although limited by a small sample size, does not support the use of IVIG at this dose for severe CDAD outside of a controlled trial.

Use of lipid emulsion to reverse local anesthetic-induced toxicity.

OBJECTIVE: To evaluate the use of lipid emulsion for reversal of local anesthetic-induced toxicity. DATA SOURCES: Literature was accessed through PubMed and OVID (1966-May 2007) using the search terms lipid emulsion and local anesthetic. Reference lists were consulted to identify additional publications. STUDY SELECTION AND DATA EXTRACTION: All articles published in English were evaluated for inclusion. Publications describing the use of lipid emulsion for reversal of local anesthetic in either humans or animals were included. DATA SYNTHESIS: It has been suggested that lipid emulsion (Intralipid) may reverse local anesthetic toxicity by extracting lipophilic local anesthetics from aqueous plasma or tissues or by counteracting local anesthetic inhibition of myocardial fatty acid oxygenation. Studies in rats and dogs have shown that lipid emulsion is effective in resuscitating animals who are asystolic after the administration of intravenous bupivacaine. Three case reports support the use of lipid emulsion to reverse systemic toxicity, including seizures, electrocardiogram abnormalities, and cardiac arrest, resulting from the administration of levobupivacaine, ropivacaine, bupivacaine, or mepivacaine. The regimens used in these cases consisted of bolus doses of 1.2-2 mL/kg followed by continuous infusions of 0.25-0.5 mL/kg/min. All of the patients recovered fully with no neurologic sequelae. CONCLUSIONS: Literature describing animal studies and human case reports suggests that lipid emulsion is effective in the reversal of local anesthetic toxicity. The potential risks of administering the relatively high doses of this agent are uncertain, and the optimal dose has not been established. In light of these uncertainties, it is appropriate to administer lipid emulsion only after advanced cardiac life support has failed and prior to cardiopulmonary bypass.

Evaluation of conflicting literature and application to formulary decisions.

PURPOSE: Guidelines were developed for grading the quality, quantity, and consistency of drug literature in support of formulary recommendations. METHODS: Four developmental steps were taken to create a comprehensive literature evaluation system. The first step identified the attributes of a body of literature that were most reflective of its applicability to patient care. The next step defined each domain (quality, quantity, consistency), as determined by the Agency of Healthcare Research and Quality (AHRQ), in terms of the specific qualities to be assessed; a value was assigned to those qualities. Also, a literature search was conducted to identify strategies for evaluating bodies of literature employed in published assessment tools. Following the analysis of previously published systems, which were evaluated with respect to their inclusion of the AHRQ-identified domains, the next step was the development of specific domains and definitions to get a composite grade (with "better" evidence earning more points) for formulary recommendations. The final step was the creation of a system that aggregated the final score for the recommendation. The recommendation was categorized according to quality, quantity, and consistency of supporting evidence, and the total number of points was calculated and the recommendation given letter and numerical grades. RESULTS: The guidelines that were developed allow the user to accurately, consistently, and easily determine the strength of recommendations for a body of literature that may be conflicting. The addition of criteria for quantity and consistency to previously-published grading systems has made the guidelines more objective. CONCLUSION: A system that accounts for the quality, quantity, and consistency of drug literature was developed to assist in making formulary decisions.

Designing and implementing a hospital-based vaccine standing orders program.

PURPOSE: An inpatient pneumococcal polysaccharide vaccine (PPV) vaccination program was designed and implemented to meet federal and state regulatory requirements and national vaccination goals. SUMMARY: In 2002, the Centers for Medicare and Medicaid Services published a final rule removing the federal requirement for an individual patient physician-signed order for the pneumococcal and influenza vaccines in Medicare- and Medicaid- participating hospitals. This statute authorized implementation of standing orders programs (SOPs) in health care institutions. At the University of Pittsburgh Medical Center-Presbyterian (UPMC-P), institutional vaccination rates and the existing mechanism for providing adult vaccinations were evaluated. At the peak of the program's effectiveness in 2000, in-hospital total vaccination rates were 31%; those rates fell to 15% by the end of 2003. To rectify this poor rate of vaccination, a multidisciplinary team convened to evaluate the existing program and to design the tools and processes for a conversion to a vaccine SOP. A standing order form was designed, and it was determined that the SOP should be pharmacy driven. As a result of the SOP, the PPV vaccination rate increased dramatically; in 2005, the average rate was 69%, with the highest rate occurring in March 2005 (87%). CONCLUSION: The cooperative effort of a multidisciplinary work group including physicians, nursing staff, and pharmacy personnel led to the creation of a successful inpatient PPV SOP. Analysis of the previous vaccination program and careful planning were instrumental in designing the SOP. Defined responsibilities for daily performance and user-friendly tools with clear instructions were also crucial to the success of the program.

Role of student pharmacist interns in hospital-based standing orders pneumococcal vaccination program.

OBJECTIVE: To describe the role of student pharmacist interns in supporting a standing orders program (SOP) for pneumococcal polysaccharide vaccination in hospitalized patients. SETTING: University of Pittsburgh Medical Center (UPMC) Presbyterian, an academic teaching hospital in Pittsburgh. PRACTICE DESCRIPTION: The hospital-based Drug Use and Disease State Management (DUDSM) program designs, implements, and promotes evidence-based practice guidelines to ensure safe and cost-effective drug therapy. PRACTICE INNOVATION/INTERVENTIONS: Paid student pharmacist interns provide manpower for screening and maintaining the vaccination SOP. Student preparation includes classroom learning about immunization concepts, on-site SOP workflow training, and direct patient care activities. Students participate in the vaccination SOP by (1) screening daily admissions through computerized information systems, (2) reviewing databases for documented prior vaccination, (3) completing preprinted orders for pharmacists, (4) inserting orders into patient charts, (5) checking vaccine administration, (6) educating nurses, and (7) managing the databases. Pharmacists verify and sign vaccine orders. Nurses obtain patient history and consent and administer vaccines. MAIN OUTCOME MEASURES: Hospital vaccination rates as determined monthly for quality improvement reporting, and student time required to complete SOP functions. RESULTS: In 2005, an average monthly vaccination rate of 70% for hospitalized elderly was achieved by this inpatient SOP, with the highest rate (89%) occurring in March. On average, 800 patients were screened each month, with 480 vaccine orders placed into patient charts. CONCLUSION: A vaccination SOP is resource-intensive and requires a diligent effort from qualified personnel. In our institution, trained student interns in the DUDSM program perform the necessary daily functions, such as patient screening, that are instrumental in maintaining the SOP.

Routine multimodal antiemesis including low-dose perphenazine in an ambulatory surgery unit of a university hospital: a 10-year history. Supplement to: Eliminating postoperative nausea and vomiting in outpatient surgery with multimodal strategies including low doses of nonsedating, off-patent antiemetics: is "zero tolerance" achievable?

For 10 years, we have used intravenous and oral perphenazine as part of a multimodal antiemetic prophylaxis care plan for at least 10,000 outpatients. We have never encountered an adverse event, to our knowledge, when the intravenous dose was less than or equal to 2 mg, or when the single preoperative oral dose did not exceed 8 mg (with no repeated dosing). As a single-dose component of multimodal antiemetic prophylaxis therapy, we believe that this track record of anecdotal safety in adults who meet certain criteria (age 14-70, no less than 45 kg, no history of extrapyramidal reactions or of Parkinson disease, and no Class III antidysrhythmic coadministered for coexisting disease) constitutes a sufficient patient safety basis for formal prospective study. We believe that future perphenazine studies should include routine coadministration with prospectively established multimodal antiemetics (i.e., dexamethasone and a 5-HT3 antagonist). In settings where droperidol is still routinely used and deemed acceptable by local scientific ethics committees, we believe that oral perphenazine 8 mg should be compared head to head with droperidol 0.625-1.25 mg in patients receiving coadministered dexamethasone and 5-HT3 antagonists in order to determine differences in synergistic efficacy, if any. Similar trials should be performed, individually evaluating cyclizine, transdermal scopolamine, and aprepitant in combination with coadministered dexamethasone and a 5-HT3 antagonist. Such studies should also quantify efficacy in preventing nausea and vomiting after discharge home, and also quantify the extent to which the prophylaxis plans reduce postanesthesia care unit (PACU) requirements (i.e., increase PACU bypass), reduce the need for any nursing interventions for postoperative nausea and/or vomiting (PONV), and influence the extent to which any variable costs of postoperative nursing care are reduced.

Eliminating postoperative nausea and vomiting in outpatient surgery with multimodal strategies including low doses of nonsedating, off-patent antiemetics: is "zero tolerance" achievable?

For ondansetron, dexamethasone, and droperidol (when used for prophylaxis), each is estimated to reduce risk of postoperative nausea and/or vomiting (PONV) by approximately 25%. Current consensus guidelines denote that patients with 0-1 risk factors still have a 10-20% risk of encountering PONV, but do not yet advocate routine prophylaxis for all patients with 10-20% risk. In ambulatory surgery, however, multimodal prophylaxis has gained favor, and our previously published experience with routine prophylaxis has yielded PONV rates below 10%. We now propose a "zero-tolerance" antiemetic algorithm for outpatients that involves routine prophylaxis by first avoiding volatile agents and opioids to the extent possible, using locoregional anesthesia, multimodal analgesia, and low doses of three nonsedating off-patent antiemetics. Routine oral administration (immediately on arrival to the ambulatory surgery suite) of perphenazine 8 mg (antidopaminergic) or cyclizine 50 mg (antihistamine), is followed by dexamethasone 4 mg i.v. after anesthesia induction (dexamethasone is avoided in diabetic patients). At the end of surgery, ondansetron (4 mg i.v., now off-patent) is added. Rescue therapy consists of avoiding unnecessary repeat doses of drugs acting by the same mechanism: haloperidol 2 mg i.v. (antidopaminergic) is prescribed for patients pretreated with cyclizine or promethazine 6.25 mg i.v. (antihistamine) for patients having been pretreated with perphenazine. If available, a consultation for therapeutic acupuncture procedure is ordered. Our approach toward "zero tolerance" of PONV emphasizes liberal identification of and prophylaxis against common risks.

Assessing and monitoring override medications in automated dispensing devices.

BACKGROUND: Medication override is not without risk because the absence of pharmacist review may increase the potential for a medication error. The University of Pittsburgh Medical Center's Department of Pharmacy and Therapeutics assessed the safety of the automated dispensing device (ADD) override process to reduce the number of override medications stored in the ADD. METHODS: A representative expert panel developed criteria for override access and revised the override medication list; an override monitoring tool was used to perform random audits and determine nursing compliance; and changes in override practices for use of opioids, a high-alert medication class, were measured. RESULTS: The expert panel reduced the number of medications and dosage forms on the override list by 42%, from 119 different medications (in 244 different dosage forms) in 2001 to 92 different medications (in 163 different dosage forms) by December 2003. By May 2004 the opioid override rates were significantly decreased; although slight increases in rates occurred by December 2004, possibly reflecting the lack of formal override monitoring by nursing and pharmacy, the rates were still significantly lower than the baseline in October 2003. CONCLUSION: Pharmacists, in collaboration with the medical and nursing staffs, developed a sustainable process for preventing unauthorized and inappropriate override medication dispensing from ADDs.

Designing a strategy to promote safe, innovative off-label use of medications.

Innovative off-label medication use (defined as prescribing with reasonable rationale for use, but insufficient evidence to allay safety, efficacy, and cost-effectiveness concerns, yet is not clinical research) is common practice and provides challenges to ensuring high-quality health care and patient safety. This article describes a strategy to promote policy and standardization of innovative off-label medication use, ensure oversight of patient safety, and prospectively assess efficacy. A multidisciplinary group developed a policy and process to regulate innovative off-label medication use that standardizes formulary review, maximizes peer expertise input, and minimizes institution liability by evaluating the effectiveness of use, promoting evidence-based practices, and ensuring ethical obligations to patients and society. This strategy has been implemented through institutional staff structure. The review process balances benefits/risks for biologically plausible therapy that lacks rigorous data support. The authors' strategy illustrates collaboration that enables a priori consideration for innovative off-label medication use while providing safety surveillance and outcomes monitoring.

United States medical practice summary: innovative off-label medication use.

Data are limited regarding how academic medical centers (AMCs) deal with medication use that represents a departure from product labeling; has reasonable rationale for use, but insufficient evidence to allay safety, efficacy, and cost-effectiveness concerns; yet is not clinical research (defined as innovative off-label medication use). This report describes national trends in management of innovative off-label medication use. A cross-sectional survey of US AMCs was conducted. Survey questionnaires were directed to drug information centers or pharmacy directors. Of 469 AMCs contacted, 104 responded (22%). Fifty-nine AMCs identified innovative off-label use as a challenge. Only 18 AMCs developed strategies to address this issue: 12 requiring initial reviews and 8 requiring clinical monitoring. Sixty-five AMCs indicated interest in data sharing of clinical outcomes for innovative off-label protocol(s). Innovative off-label medication use is a widely recognized challenge; however, few prospectively active AMC responses exist. The authors suggest development of systematic structured approaches within and across AMCs.

Implementation of a new dantrolene formulation across a multifacility health system.

PURPOSE: An initiative to optimize the treatment of malignant hyperthermia in surgical patients through a dantrolene product conversion program is described. SUMMARY: A large health system's formulary evaluation of a new dantrolene sodium product indicated that despite a higher cost per treatment course, the product could offer key advantages over older formulations of dantrolene in terms of preparation and administration time, product content, and storage requirements. A work group, consisting of pharmacy personnel, an anesthesiologist, a nurse anesthetist, and a representative of the health system's group purchasing organization, determined that a switch to the new dantrolene product would offer both patient care benefits and process benefits. With the approval of the health system's pharmacy and therapeutics committee, the new product was added to the formulary as the preferred dosage form of dantrolene, and existing dantrolene product stock was converted to the new formulation. Key implementation steps included (1) concurrent replacement of dantrolene stock on all "malignant hyperthermia carts" across the 15-hospital health system, (2) development of educational materials to raise awareness of the conversion and revised product preparation procedures, (3) anesthesiology provider and pharmacy staff education, (4) revision of dantrolene listings in each hospital's computerized prescriber-order-entry system, and (5) redistribution of returned dantrolene product stock. The dantrolene product conversion occurred over a four-month period. CONCLUSION: A multifacility health system was successful in converting an existing stock of dantrolene to a newly available formulation.

Overcoming barriers to establishing an inpatient vaccination program for pneumococcus using standing orders.

OBJECTIVES: To identify and classify barriers to establishing a standing orders program (SOP) for adult pneumococcal vaccination in acute care inpatient facilities and to provide recommendations for overcoming these roadblocks. Vaccination rates in hospitals with SOPs are generally higher than those in hospitals that require individual physician orders. The array of solutions drawn from our experience in different hospital settings should permit many types of facilities to anticipate and overcome barriers, allowing a smoother transition from initiation to successful implementation of an inpatient pneumococcal vaccination SOP. DESIGN: Descriptive study of barriers and solutions encountered during implementation of a pneumococcal vaccination SOP in three hospitals of the University of Pittsburgh Medical Center Health System (UPMC) and in the scientific literature. SETTING: As of 2004, two UPMC tertiary-care hospitals and one UPMC community hospital had incorporated SOPs into existing physician order-driven programs for inpatient vaccination with pneumococcal polysaccharide vaccine. RESULTS: Barriers were identified at each step of implementation and categorized as patient related, provider related, or institutional. Based on a process of continual review and revision of our programs in response to encountered barriers, steps were taken to overcome these impediments. CONCLUSIONS: A strong commitment by key individuals in the facility's administration including a physician champion; ongoing, persistent efforts to educate and train staff; and close monitoring of the vaccination rate were essential for successful implementation of a SOP for pneumococcal vaccination of eligible inpatients. Legal statutes and evaluations of external hospital-rating associations regarding the effectiveness of the vaccination program were major motivating factors in its success.

Building an outpatient cancer center pharmacy program across a tristate region.

PURPOSE: The transition to a hybrid model of oncology pharmacy services including remote order verification across a regional network of cancer centers is described. SUMMARY: Five years ago the University of Pittsburgh Medical Center (UPMC) began a major expansion of its cancer care services, gradually integrating 19 community-based physician practice sites into its tristate oncology network as affiliated hospital-based clinics (HBCs). The network expansion was achieved through a stepwise process including (1) development of oncology medication protocols, (2) interdisciplinary efforts to modify oncology care workflows, (3) implementation of a hybrid practice model to optimize the use of clinical pharmacy resources, and (4) focused staff training programs. Under the hybrid practice model, first checks of antineoplastic medication orders, premedication orders, and laboratory values are performed by either onsite or remote pharmacists, with all second checks performed remotely. In 2013, network pharmacists implemented large numbers of medication therapy interventions to improve chemotherapy and biological response modifier dosing (n = 641) and nonchemotherapy medication use (n = 1082); other documented interventions included patient counseling to help optimize the use of erythropoietin-stimulating agents and other medications (n = 441) and anticoagulation-related dosing adjustments and patient education (n = 102). CONCLUSION: Nineteen ambulatory care centers were successfully integrated into the UPMC oncology network as affiliated HBCs through a stepwise process that included workflow modifications, staff training, and a hybrid pharmacy services model that ensures a two-pharmacist check of antineoplastic orders in accordance with regulatory and quality standards.

Addressing innovative off-label medication use at an academic medical center.

PURPOSE: A large hospital's systematic and evidence-based approach to adjudicating, monitoring, and ensuring the safety of off-label medication use is described. SUMMARY: In 2003 the University of Pittsburgh Medical Center (UPMC)-Presbyterian implemented a policy that created a formal process for the systematic evaluation of formulary requests and drug-utilization patterns indicating or suggesting off-label use. Explicit criteria were developed for differentiating "innovative off-label use" (i.e., use based on a reasonable rationale yet lacking definitive scientific support in the form of fully published randomized controlled trials) from medication use more appropriately classified as clinical research. The UPMC-Presbyterian policy also outlined a process for the development, implementation, and evaluation of guidelines on innovative off-label use, including the collection of efficacy and safety outcomes. As of October 2012, 31 proposals for off-label medication use had been evaluated by the medical center's pharmacy and therapeutics committee and formulary subcommittee. Thirteen requests resulted in a determination of innovative off-label use and the development of prescribing guidelines, and 10 prompted the extension of an agent's current formulary status; in 6 cases, proposed off-label uses were determined to constitute clinical research. In some instances, innovative off-label medication use generated safety and outcomes data that led to changes in local standards of care. An algorithm to guide decision-making with regard to requests and proposals for off-label medication use is provided. CONCLUSION: The UPMC-Presbyterian experience indicates that off-label medication use can be effectively managed using evidence-based principles and peer review mechanisms.

Pharmacodynamics and clinical efficacy of fentanyl iontophoretic transdermal system for post-operative pain in hospitalized patients.

INTRODUCTION: The fentanyl iontophoretic transdermal system (ITS) is a patient-controlled transdermal system allowing needle-free administration of on-demand doses of Fentanyl of 40 µg over a 10-min period up to 80 doses or over a 24-h period. It is indicated in opioid naïve patients for the treatment of acute postoperative pain in the hospitalized patients for up to 72 h. AREAS COVERED: It has been demonstrated to be effective and safe in randomized trials and to provide comparable analgesia versus morphine intravenous (i.v.) patient-controlled analgesia (PCA) with adverse events similar between groups. EXPERT OPINION: Fentanyl ITS has shown high patient satisfaction rates, and was described by patients and investigators as easy and convenient to use. These properties make this technology interesting when considering perioperative pain management. In the present health care environment additional data are required to establish the cost-benefit ratio of this technology in optimizing patient's recovery from surgery.

Increasing pneumococcal vaccination rates among hospitalized patients.

OBJECTIVE: To increase the proportion of inpatients vaccinated against pneumococcal infection. DESIGN: Pre- and post-intervention study. SETTING: University medical center-affiliated, suburban community teaching hospital. PATIENTS: Unvaccinated inpatients 65 years and older and those 2 to 64 years old who had chronic medical conditions predisposing them to invasive pneumococcal infection. INTERVENTION: The nursing staff screened newly admitted patients for eligibility based on age, diagnosis, or medications from a computer-generated admissions list and placed a pre-printed order form for the pneumococcal polysaccharide vaccine (PPV) on the charts of eligible patients. Following the physician's order, the nursing staff administered the PPV and recorded it Ongoing quality improvements including admission vaccination screening and computer-based record keeping were initiated to identify unvaccinated eligible patients and track vaccination status. RESULTS: Efforts resulted in rates of in-hospital vaccination ranging from 3.1% to 7.9% (mean, 5.2% +/- 1.7% [standard deviation]) and significant improvements in the assessment of previous vaccination status, reaching 54% of eligible patients after 1 year. Ascertainment of a previous vaccination increased significantly following the initiation of the use of admission forms that specifically assessed vaccination status and a system to permanently record vaccination status in an electronic medical record (P < .05). CONCLUSION: Concerted efforts using electronic medical records significantly improved the assessment and documentation of inpatient vaccination status. Greater improvement of the rates of in-hospital vaccination will require healthcare system-wide efforts such as a standing order policy for vaccinating all eligible patients. Standing orders for inpatient immunization supported by effective assessment and tracking systems have the potential to raise vaccination rates to the goals of Healthy People 2010.