Standing Orders

Theresa Brown writes about the use of standing orders in the United States. A standing order, also (and more properly) called a medical directive, is a protocol that delegates to nurses certain actions usually reserved to physicians. In the emergency department where I work — and this true in most Ontario EDs — standing orders, after mandated training and certification, are a routine part of every nurse’s practice. Their purpose in the emergency department is not only to hasten patient care, offer in some cases immediate symptomatic relief, and ultimately to speed up patient disposition, but also to protect nurses themselves from going beyond their scope of practice in situations where a physician’s presence is clearly unnecessary.

In other words, if you come in with a potential colles fracture, for example, the triage nurse will splint you, order appropriate x-rays and send you off to radiology even before you see the physician. We have medical directives for x-rays of all extremities and in some cases, chest films; we order blood work for chest pain, abdominal pain, uncontrolled bleeding, and trauma; in emergent situations we test blood sugar and can intervene if  the patient is hypoglycemic; we collect and send urine samples; we do ECGs; we give initial treatment for asthma; we give out medications like acetaminophen and ASA (for chest pain); we start IVs if we think them necessary; and lastly we can intervene immediate in cases of cardiac arrest/lethal arrhythmias by defibrillating, cardioversion and administering medication, if the physician is not present.

The eye-opener for me was the potential cost-savings in their use, and the bureaucratic obstacles in their use. Brown writes:

Nurses and doctors in our surgical ICU worked together over several months to develop a set of rules for taking post-operative patients off mechanical ventilation as soon as possible. This process is called weaning, and initiation of ventilator weaning in the surgical ICU was being delayed by waiting for doctors to do their rounds.

Development of the protocol drew on research regarding ventilator weaning, and while the ICU doctors approved it, several layers of hospital administration also had to sign off on it. Once the protocol was adopted, the SICU nurses could slowly — and according to clearly delineated steps — reduce the amount of ventilatory support patients received. If patients began to struggle to breathe, the ventilator could be returned to its original settings and no harm done.

[snip]

Sounds like a win-win situation. Except that the vent-weaning protocol did not meet CMS’s criteria for correct signing of physician orders, so the protocol got put on hold for a few months while the hospital worked to follow those rules.

The cost of one day in an ICU starts at $3,000. That bureaucratic requirement about signing orders –ostensibly used to enforce nurses’ not going outside our “scope of practice” — effectively mandated longer and more expensive hospital stays and poorer care for the patients in that ICU. A government agency was moving health care in the wrong direction.

I’m a big supporter of medical directives for a number of reasons. In many ways they allow nurses to practice at their full scope, and demonstrate the potentiality of nurses taking a greater role in the overall management of patient care. More importantly, they represent a model of collaborative practice between nurses and physicians that benefits the patients allowing us to provide faster, more standardized care.

I was a bit surprised, then, by the bureaucratic resistance to standing orders in the United States. I suspect this difficulty is probably caused a combination of factors such as an outdated view of the role of nurses and physicians, and professional territoriality. Another barrier might be the lack of legislative and regulatory support for the practice. In Ontario (and most Canadian provinces) medical directives are permitted by both Regulated Health Professions Act and the College of Nurses of Ontario, the nursing regulatory body. In this context it’s important to note the accountability here lies not with the physician but with the nurse, who using professional judgement, initiates the standing order. Nurses own it, in other words. When I worked in the U.S. I was never quite so clear nurses worked under a similarly strong regulatory framework — which ultimately protects both the nurse and the patient.

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  1. #1 by SarahBethRN on Thursday 13 January 2011 - 1053

    Good post.

    I think we will see the increasing need for standing orders in all facilities in all departments. Like you said, it increases patient outcomes, decreases hospital stays, and effectively betters patient outcomes.

  2. #2 by Dr Dean on Thursday 13 January 2011 - 1201

    I have never noticed CMS looking after us physicians or our territory….

    Most CMS decisions, IMHO, are bureaucratic decisions based on a kernel of patient safety decision or financial savings, then over-interpreted by hospital bureaucrats.

    Our facility spends a lot of time and resources enforcing time and date of signatures, but almost none on peer review, and protocols. The former is easy pick-in’s and the later requires all stakeholders to get on the same page…Difficult at best!

    Standing orders are necessary, as long as they are well thought out and supported by evidence based medicine, which most are.

  3. #3 by L on Thursday 13 January 2011 - 2138

    In my experience the appropriate x-rays are often not the ones ordered. For example Ottawa rules are misinterpreted resulting in unnecessary irradiation, pain, discomfort.

  4. #4 by Jenn Jilks on Sunday 16 January 2011 - 1948

    There comes a point when we must accept that the professionals are just that: the pros.
    Excellent post. We must have faith in the Canadian educational system that turns out women and men, like yourself, who do they job well and with purpose.

  5. #5 by Cartoon Characters on Saturday 29 January 2011 - 1310

    twenty years ago in California, we had printed standing orders in L&D for each type of patient. There was the one for your standard woman in labor, then another added to it if they had PIH, one for antepartum etc.
    It was so easy and legible….. of course it was tailored for each one if necessary. I missed that when I came back to B.C.

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