CMS memo OKs use of standing orders

Physician's signature no longer required

ED managers, hospital leaders, emergency medicine, and hospital organizations breathed a sigh of relief on Oct. 24, 2008, when the Centers for Medicare & Medicaid Services (CMS) issued a memorandum that clarified the use of standing orders in hospitals.

The memorandum read, in part: "The use of standing orders must be documented as an order in the patient's medical record and signed by the practitioner responsible for the care of the patient, but the timing of such documentation should not be a barrier to effective emergency response, timely and necessary care, or other patient safety advances." (Editor's note: To find a copy of the memorandum, go to At the top of the page, click on "Medicare." Under "Provider Enrollment & Certification," click "Survey & Certificat-ion — General Information." Next, click on "Policy & Memos to States & Regions." In the "Sort By" window on the next page, select "Fiscal year Descending." Then select "Standing Orders in Hospitals Revisions to SandC Memoranda.")

The world of emergency medicine had been thrown into a state of turmoil with guidance issued on Feb. 10, 2008, that said: "If a hospital uses other written protocols or standing orders for drugs or biologicals that have been reviewed and approved by the medical staff, initiation of such protocols or standing orders requires an order from a practitioner responsible for the patient's care."

"A notice went out to state directors in February which included an interpretation of the regulations that said physicians had to sign off on orders first as opposed to just allowing standing orders to be followed in the ED, such as having nurses administer aspirin on arrival to chest pain patients, or administer acetaminophen to a child who may be having febrile seizures," says Barbara Tomar, MBA, director of federal affairs for the American College of Emergency Physicians (ACEP) in Washington, DC. "The issue was not whether the physician must document the orders, but when. That's what they clarified, and that's what we wanted."

Pat Adamski, RN, MS, director of The Joint Commission's Standards Interpretation Group and the Office of Quality Monitoring, says, "For a long time, The Joint Commission required a patient-specific order to initiate a standing order or a protocol, and we knew this was problematic in a lot of areas, but particularly in EDs and OB units with newborns. We've been working with ACEP and the Emergency Nurses Association and other groups around this specific issue with EDs for a while."

The February 2008 memo, which reiterated the need to have a patient-specific order, "prompted us to actively work with CMS to help them understand the ramifications of requiring that kind of process out in the field," Adamski says. They had productive dialogue with CMS, she says. "Both sides learned a lot, and we are very happy with the issuance of the letter on Oct. 24 where CMS took the approach we were advocating," Adamski says.

In essence, "if the protocol had been there and was based on the approval of the hospital, and it is within the nurse's scope of practice, they can go ahead and initiate that [drug administration], and the order to initiate that action may be put on the chart after the fact," she says. The bottom line is that CMS is stating it does not wish to interfere with the expedient treatment patients might need, Adamski says. (Experts say the issue of standing orders still is not totally resolved. See story.)