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ED Accreditation Update
Standards on verbal orders rank high among common compliance problems
Among the most challenging standards from The Joint Commission for the first half of 2008 was standard IM.6.50 — "Designated qualified staff accept and transcribe verbal or telephone orders." According to the organization, 40% of hospitals were not in full compliance.
This problem is not surprising to ED managers, who say the hectic pace in their departments can make compliance with this standard quite challenging. "In an emergency setting, you do not take care of one patient at a time; it's not a linear process," notes India Owens, MSN, CEN, director of emergency services at Clarian West Medical Center in Indianapolis. "It's a different world than, say, the inpatient world."
Owens offers this hypothetical situation: A patient is vomiting, and the doctor has ordered medication in written format. The nurse goes in to recheck the patient and sees he has continued to vomit. She seeks out the doctor, who is heading to another room where a second patient is having a heart attack. The nurse tells the physician the patient is still vomiting, and he says the dosage should be increased. "This is all done on the go," she says. "The nurse writes down or asks the doctor write down the order when they get the chance."
This is not to say the "transcription" part of the standard is impossible to meet. Owens says she has devised solutions for paper-based and electronic systems. (Her department switched to computerized physician order entry [CPOE] about nine months ago.)
"Prior to the switch, we solved the problem somewhat by having a single sheet that was used by both doctors and nurses," she says. "On one side at the top was the physician order, and at the bottom was the nurse's sign-off."
With this system, she explains, if the nurse wrote the verbal order down, the doctor still had access to that same piece of paper to sign it, and vice versa. "In many places there are two different sheets of paper," notes Owens. "Here, the nurse could just hand the doctor the chart and say, 'Write it on the clipboard.'"
Now that the department has switched to CPOE, "you would not have this problem as consistently with verbal orders because the system 'forces' the doctor to write," Owens says. As soon as a nurse enters a verbal order, she explains, it flows to the physician's inbox for him or her to sign. "If you set your system up well, it closes the gap on this problem," Owens says.
A solid policy will address the issue of having only qualified personnel transcribe the orders, adds Kathy Hendershot, RN, ED clinical director at Methodist Hospital in Indianapolis. "We have a policy that verbal orders cannot be taken by anybody except a registered nurse employed by the hospital," she says.
Documentation also can be a problem, Hendershot says. "It clearly starts with the policies and procedures within your organization meeting the standard; then, you 'teach to the test,'" she says. Once the policy was written and rolled out, Hendershot says, it was "cascaded" through organization management. "It's important to make sure the medical staff understands it," she adds.
Because the hospital still is on a paper system, "unless it is an emergent situation — usually resuscitation — we tell nurses they can't take a verbal order," Hendershot says. "They know now that in case they need an order, they will carry a form with them and ask the physician to write it down."
In cases where verbal orders are used, the nurse is required to call back the order to the physician. "Usually, we document the order on the chart as a read-back a verbal order, or RBVO, and the physician has to sign off on that," she explains.
To help ensure compliance, Hendershot conducts a significant amount of education. "Within our department we've done inservices, unit meetings, posters, mass e-mails, and we've made it part of our National Patient Safety Goal education," she says.
Verbal orders placed in new chapter
The Joint Commission (TJC) has noted that its verbal order standard, IM.6.50, has been one of the more difficult to comply with, but "ED managers who now wish to brush up on that standard will have to look elsewhere, says Louise Kuhny, RN, MPH, MBA, CIC, TJC's senior associate director of standards interpretation.
"The information management chapter used to have two components — verbal orders and patient information — but we split out verbal orders," she explains. "It really pertains to record of care; so, it is now in a new 'RC' chapter: RC02.03.07."
The standard still addresses the same issues, Kuhny notes. "You need to have a policy that says who can receive verbal orders, and they must be authenticated within the time frame specified," she says.
The latter requirement, she reports, leads to the great majority of requirements for improvement. "[The Centers for Medicare & Medicaid Services] put out a communication about 18 months ago that said if there are no pre-existing state regulations, the default is 48 hours," Kuhny says. "A few states use 24 hours, which is particularly challenging, and others have 30 days; but the vast majority of states go to the default of 48 hours."
What if an ED manager is not sure what the state requirement is? "I recommend they check with the quality folks in the hospital," she replies.
How does Kuhny suggest ED managers ensure compliance? "You need to put systems in place to be sure to prompt providers to sign the order when they next see the patient, and the providers need to be diligent," she advises. "You should put a reminder in your electronic system or a flagging system on your charts to remind the doctor or other allied licensed practitioner."
Audits help manager track compliance
Nurse managers say they find chart audits extremely effective in tracking staff compliance with The Joint Commission's standard on verbal orders.
Kathy Hendershot, RN, ED clinical director at Methodist Hospital in Indianapolis, for instance, uses a random, generalized chart audit. India Owens, MSN, CEN, director of emergency services at Clarian West Medical Center in Indianapolis, also uses audits to track compliance. While Owens considers her compliance initiative to be a work in progress, she reports that compliance in her department has risen from 30% to about 75%.
"Any time there is a medical error in the ED, we check to see if there was a written or verbal order," Hendershot says. "If it is not signed, we will scrutinize it." If the order is documented as verbal, she will make sure it has been documented correctly.
"Also, we will routinely ask the staff if they understand what the policy is," Hendershot reports. "We will randomly select staff and ask if they understand what an RBVO [read-back verbal order] is. If they fail the test, we will go back and re-educate them."
This is not an easy "test," she says. "When we ask them what it is, they have to say, 'Read back' for the correct answer," Hendershot explains. "When surveyors were coming along, they would ask them, and they'd say, 'Repeat back,' and we'd be 'dinged' on that clarification."
"The way we've done audits is through inpatient admissions: How many of them have their completed meds reconciliation form on their chart from the ED as they go upstairs," Owens explains. In addition, she says, "our secretaries scan every chart into a computerized medical record, and they double-check the charts [for medication reconciliation]. They have been empowered to 'slap nurses around' if it is missing."