By Michael J. Yao, MD, CMD, Chief Medical Officer, Golden Living
Dr. Jancey was upset. His patient, Mrs. Moss, had been admitted a few weeks ago for a total hip replacement and was on a quinolone antibiotic for a urinary tract infection. She had some abdominal discomfort and then some loose watery stool. Per his standing order, the nurse administered Imodium for diarrhea. After the initial dose, Mrs. Moss had another small amount of liquid stool, so she received another dose. A few days later, a sample was sent for C. difficile toxin following one more episode of watery stool. During this time, no one notified Dr. Jancey of the situation since standing orders were in place. No additional stool samples were recorded.
After a week, the patient began to have severe abdominal pain. Dr. Jancey was notified and the patient was transferred to the emergency room for evaluation. She was found to have a stool impaction and a perforated bowel and was rushed to surgery. After a rocky course, she recovered well enough to be transferred from the hospital to a skilled nursing facility. The family decided they did not wish to have her come back to the care of Dr. Jancey.
Dr. Jancey thought about this case. Could he have managed anything differently? Certainly it would have been good to catch what turned out to be a stool impaction earlier, and he definitely would not have prescribed Imodium, particularly in addition to the narcotic pain medications on board since her surgery. In retrospect, he would rather have been called about the watery stool, so he could have done a rectal exam to ensure there wasn’t a stool impaction.
Are order sets good for patient care? This depends upon the setting. If an order set helps outline and standardize a plan of care for a frequently encountered diagnosis, then this can be beneficial because it helps define a clinical pathway. When clinical pathways are followed, studies demonstrate better outcomes in the hospital with better performance on quality measures and superior outcomes. In the skilled nursing facility, order sets associated with clinical pathways have been associated with better responses to changes in condition, more judicious usage of medications and fewer readmissions. They can assure appropriate antibiotic regimens and can remind the physician to give orders which might not come to mind immediately in the midst of a busy day or in the middle of the night.
When can order sets be harmful?
On hospital services, many medical students are advised by “wizened residents” to write anticipatory admission orders to head off “nuisance calls” from the floors. The rationale is that if the usual bothersome complaints could be prevented with p.r.n. orders then one might have more time for admissions, or even sleep. These orders, familiar to all house officers, ranged from “Tylenol 650 mg p.o. Q4 H p.r.n. pain” to meds for sleep, nausea, constipation, diarrhea or diarrhea. I have even seen an admission orders manual with a 14 page section on “Care and Comfort Drugs.”
When doctors carry this practice to the skilled nursing facility, however, these types of orders have the potential for danger. They can delay physician awareness of changes in condition. Since daily rounds are not typical in a SNF setting, the doctor may not hear of a change until either their next time on the floor, or when a condition advances to medical urgency. Without a p.r.n. order the nurse is compelled to contact the doctor in order to secure an appropriate order. This assures notification and provides opportunity for real-time discussion.
Does this mean p.r.n. orders are always inappropriate? No they are not, but one should be aware of the balance between having an order that expedites patient care and one that short-circuits the communication between nursing staff and attending physician.
Are parameters appropriate in your particular SNF setting? While sliding scale insulin coverage is appropriate in NPO hospital settings, consensus is that sliding-scale coverage is something to be transitioned off of in the SNF setting. Especially in a setting where “routine” lab result turnover may be variable, it is not a good idea to give parameters for treatment of abnormal labs (e.g. a potassium level) without a conversation with the staff. Not all of these are emergencies, but automatic adjustments may put your patient at risk, and by the time you get called, your only recourse may be to order hospital evaluation.
I hope this gives you some food for thought. Thoughtful order sets, particularly those which are evidence-based and disease specific, when combined with a nursing education component, can be a powerful way to improve care. Standing orders like those of the fictitious doctor in this article can be harmful and a disservice to our patients and nursing staff. Check out the highlighted box “Standing Orders- Questions to Ask.” If each medical director took a few minutes this month to discuss the orders with their DNS and consulting pharmacist that it would be time well spent.
Until next month…