ER admit orders | Forum

Topic location: Forum home » Order Management » Orders
Nov 13 '17
2017-11-13 13:50:09
Hi,
I'm wondering how other institutions are handling ER admit orders. We have an ongoing debate/dilemma regarding these orders. We currently do not use the EDM but use another vendor instead. Our ER physicians do not want their names to be attached to ongoing orders once the patient leaves the ER. For example, series lab orders for Sepsis, medication orders, etc. Our attending physicians do not want to sign in and enter orders when the patient is in the ER. Our ER director doesn't want the nurses to be taking verbal orders. Our administration is trying to improve our CPOE numbers. IT is stuck in the middle. Any and all suggestions of how you handle these orders would be greatly appreciated.

Thanks,
Brenda C. Rittof, RN
Sr. Clinical Application
brittof@morrishospital.org<mailto:brittof@morrishospital.org>
815-705-7509
Nov 13 '17
2017-11-13 14:45:19
We has similar argument with ED. Our ED has Meditech. Yet, ED physicians did not want to be responsible for ongoing orders. We have an orderset for admission. After the ED physician does the manage transfer then the inpatient practitioner is responsible for ongoing orders. The orderset does include ongoing orders to manage care until the inpatient practitioner has a chance to evaluate the patient. We had to remind the ED physician that it is about patient care.
Yours sincerely,
Paula June Akers RN
Nurse Analyst
Morrow County Hospital
Paula.akers@ohiohealth.com<mailto:Paula.akers@ohiohealth.com>
419-949-3006
Nov 13 '17
2017-11-13 15:09:35
We also have had similar arguments with the ED Providers. Our ED uses Meditech and places the orders for care in the ED and then places the Admit order. The admitting provider addresses all orders in Manage Transfer when the patient is admitted. They select whether the order is continued or stopped upon admission. We had to emphasize that the admitting provider makes the decision once the patient leaves the ED.
Thanks,
Angela Clark, MSN, RN, CEN
Clinical Informaticist
Catawba Valley Medical Center
aclark@cvmc.us
(828)326-3611

Nov 13 '17
2017-11-13 18:19:50
Brenda,
This age old question has never been resolved and it causes issues such as holding patients in the ER until the admitting physician comes into see the patient and then do their admit order. It delays admission to make another bed available in a busy ED so the next patient by triage gets the next available bed. It increases waiting times in the ER and can cause ambulance diversions (if that is a practice still done in larger cities/towns with multiple hospitals). This is not a process that supports the patient's best care or interests so middle ground has to be found. Of course you know this and why you are asking the question.
First question is what is the primary goal for the ED? These days it is to be able to accommodate all the patients in a timely manner which means having empty rooms as soon as possible and if you are a big or busy ED and have 2-3 patients waiting to be moved upstairs to their admit beds, that is 2-3 patients waiting to brought to ED rooms. Yes you could put the admit patients or new patients in the hall, but then ask yourself this; If you are the patient being admitted or being brought back to a hallway bed to be seen, is that where you want your care to be? Personally I would not.
Second question, where does liability lay? The admitting provider may not agree that the patient needs to be admitted and send them home and this is the biggest argument that admitting providers have. Admitting or not admitting is a liability issue either way. They are taking the assessment and evaluation of another provider to make a decision to admit. Next the ED has a liability and responsibility to all the patients in the ED and the ones who have not arrived yet but will. Addressing the miss use of the ED is a big win if you can adopt a program to move their (the patients) revolving door practice of using the ED instead of a primary care doc. The opioid initiatives coming should help reduce some of this but more needs to be done.
Our ED docs did not do the series orders either, it was left to the admitting doctor to do those which can create a problem off timing of the orders. All patients in the ED were given their starting antibiotics agreed upon by the phone consultation with the admitting doc. Cardiac patient series orders were left to the admitting provider, but these patients that were on the fence for Cath Lab didn't leave the ER. Providers would have to pay attention and "think" when tests were ran in the ED and time the subsequent orders from there. Prior to electronic, the admitting provider had to look to see when the labs were ran in the ED to time them on the floor, nothing has changed it just lives electronically and "looks" different. This is better because the older providers who were practicing during the transition to electronic have retired or about to.
We had used Empath to correct many of the practices thru out the facility and improved every aspect of patient flow thru the facility. ED wait times went to zero, ambulance diversions went to zero, and as this became known in the community the ED volumes increased more than predicted. We had good system processes in place that accommodated this such as when the ER physician had seen the patient and felt that admission was very probably, they had 60 minutes to prove the case by announcing a "heads up admit" (the ED doc could make this decision anytime his/her confidence level was high). This started admission processes putting a hold on a room upstairs. This notice went to the floor and floor always tried to have 2 beds ahead to support the process. The ED doc would then order the tests to support his assumption and once validated would call the doc to admit the patient. Once the phone consult was completed the ED doc submitted admit orders that only gave supported care until the admitting provider come to the floor to write the rest of the orders. The minimal care orders were based upon the conversation with the admitting provider and the care needs based upon diagnosis. In the event that labs & imaging studies weren't very conclusive then we held the patient in the ED for the primary or admitting provider to come in. Once the 60 minutes was up the bed became available again for another admit. This process improved the diagnostic skills of ED providers and intuition (this is more powerful than you'd think and should not be discredited because you don't have data to support it-it was common practice 2-3 decades ago prior to the imaging capabilities we have now) but over time habits and weak administration allowed this to change back to the old ways.
Disparate systems, having an ED module that isn't the same as your Primary EHR will create issues unless they are integrated and seamless as if they were the same vendor. For the admission process to be seamless and not create more work and errors, I strongly advocate for same system modules and this is the weak point of any vendor, they have strong builds in a few modules and weaker in others or, more to the point, not the favorite of the specific field practitioners as they have used "something better". The "Transfer Routine" is a good design, room for improvement in at least the Magic platform, yes! Perfect, no. Nothing is perfect or will make everyone happy, at least not yet. Post Meaningful Use I see this improving because for the past decade EHR design was focused on MU and not as much on functionality.
Common ground could be that the admit orders from ED to the floor could have a qualifier (supported by the documentation) of who the admitting doc is, and also have the admit provider electronically co-sign the order for admit. Secondly, and this was an issue, the floor if they needed additional orders needed to call the admitting doctor, not the ED doc for additional orders if patient condition changed. If the patient when in the ED showed signs of decompensating they didn't leave the ED until admitted by the admitting provider, stabilization came first prior to moving to the floor unless it was an ICU patient, then again, it was determined where the provider wanted to stabilize based upon the condition of the patient. Basically common practice doesn't change for the 20% of patients that are really sick.
Regards,
David E Brown, RN
Senior Consultant
Cell: 509-991-5874
david.brown@hsi-corp.com
www.hsi-corp.com
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