Monthly Archives: January 2015

When Standing Orders Become a Problem


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.

Order sets

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…

Medical Direction Meeting Reminder

If you haven’t done so, kick off the New Year with a sit-down meeting with your Executive Director and Director of Nursing. As we’ve discussed, this Medical Direction Meeting has been designed to get your input into the strategic direction of your LivingCenter and to identify goals for the next year. We know that demands on your time are many, and that there aren’t enough hours in the day to accomplish all that a Medical Director would like to do in a facility. For this reason, it’s important to establish mutually agreed-upon objectives that go on the top of the list. This will establish a foundation for achieving success as Medical Director, and the GLC EDs and DNSs are committed to working toward these objectives with you. If you’d like some further guidance regarding what should happen in this meeting, please feel free to reach out to me or your Regional Medical Director.

Regional Medical Director contact information:

CA, IN, MN, SD, WI  –   Dr. APS Sidhu ( (559) 681-7800)

MO, KS, NE, KY, TN, AL, MS – Dr. David Barthold ( (205) 706-5010)

WV, MD, VA, NC, GA – Dr. Mary Evans ( (434) 242-7077)

MA, PA, OH, NJ – Dr. Murali Ramadurai ( (617)792-4187)

Watch for Town Hall Meeting Conference Calls

Keep a lookout for notices this month regarding Town Hall Meetings.  Dr. Murali Ramadurai, Regional Medical Director for GLC in MA/PA/OH/NJ will lead a discussion regarding polypharmacy and judicious choices in medications in the elderly.  There will be a group of three calls, so it will be convenient for you to find a time slot that works with your busy schedule. This will be part of a continuing series of calls designed to keep you updated on the latest in medication management, and there will be a focus on a different drug class each quarter.  Doctors will be able to engage in dialogue to discuss best practices and concerns regarding real world medication management in our LivingCenters. Many attendees have found these town halls to be very informative and also a forum for discussing other medication related issues which we encounter.

2014-15 Influenza Season Update for Medical Directors and Attending Physicians











Source: CDC Influenza Surveillance website  (

Note to Medical Directors:  This article is a copy of the communication sent out to medical directors last week.  If you have not received it, please contact Reene Dux (972) 372-6311, so that we may put you on this e-mail list.  Executive Directors – please feel free to print this out to share with your medical directors in written form.

This flu season is becoming very significant.  The CDC has just informed us that the epidemic threshold has been reached, and there are at least 36 states reporting widespread flu cases.  As of this week, the CDC reports that this season is primarily an Influenza A season, with less than a third of identified A strains being similar to the A/Texas/50/2012 H3N2 strain contained in this season’s trivalent vaccine.  The rest of Influenza A isolates are most similar to the A/Switzerland/9715293/2013 strain.   Anecdotally, we still have found that individuals coming down with the flu who have been vaccinated are recovering much faster than those who have not been vaccinated at all.

While manufacturers still may  say that there isn’t a shortage, for practical purposes there are nationwide Tamiflu availability issues that need to be taken into account when making decisions regarding prophylaxis dosing of patients and/or GLC employees, so that we can have enough medication to treat our symptomatic patients.  Please make sure that your DNS or ED contacts our GLC Pharmacists Steve Hord (404.904.7741) or Eric Stratford (919.895.8488), in order to discuss oseltamivir (Tamiflu) availability and to get assistance with logistics.

We recognize that it’s up to you (and the Department of Health) to decide about antiviral prophylaxis.  You may determine that it may be necessary to prophylax a patient’s roommate, unit, floor or entire facility clinical staff depending upon the setting.

As I’m sure, you’re aware,

Our typical dosing for treatment is:

     Tamiflu 75mg BID x 5 days

And our typical prophylaxis dose is:

     Tamiflu 75 mg Daily x 14 days, and up to 7 days since the last known case.

One way to write the prescription, in case a facility outbreak goes on for a while, is to write for 10 days with a refill. Guidelines will vary from 10-14 days regarding prophylaxis, with guidelines for facility outbreaks tending more toward the 14 day recommendation.

Renal dosing adjustment may be necessary.

If you have any questions, please feel free to contact me, or one of your Regional Medical Directors.

Regional Medical Director contact information:

CA, IN, MN, SD, WI  –   Dr. APS Sidhu ( (559) 681-7800)

MO, KS, NE, KY, TN, AL, MS – Dr. David Barthold ( (205) 706-5010)

WV, MD, VA, NC, GA – Dr. Mary Evans ( (434) 242-7077)

MA, PA, OH, NJ – Dr. Murali Ramadurai ( (617)792-4187)