CMS says yes, ED nurses can use standing orders

Patients could have been harmed

Were you concerned that your ability to use standing orders at triage was in jeopardy? A February 2008 interpretive guideline from the Centers for Medicare & Medicaid Services (CMS) alarmed emergency nurses by requiring patient-specific practitioner approval for standing orders prior to treatment.

However, an October 2008 clarification says that standing orders can be signed later by a physician. The memo states: "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 see the complete letter, go to

"We are excited that CMS has changed their stance on this issue," says Donna Mason, RN, MS, CEN, immediate past president of the Emergency Nurses Association (ENA) and senior nurse consultant with Orlando, FL-based Blue Jay Consulting, specializing in ED processes. Mason is former nurse manager of adult emergency services at Vanderbilt University Medical Center in Nashville, TN.

Many ED nurses were worried that they would have to stop using standing orders for pain medications, acetaminophen for children with fever, or aspirin for myocardial infarction patients, says Mason. "Early intervention is evidence-based. Aspirin is in the core measures for acute MI," she says. "Emergency nurses are in constant contact with physician colleagues, which is different from other areas in the hospital setting. We have those resources readily available to us."

Without the use of standing orders, there would be "needless pain and suffering" by patients, says Mason. "We want patients cared for in an efficient and timely manner with the best outcomes," she says. "We do not want to delay any treatment which could result in patients having further damage or suffering. Regulatory bodies sometimes forget patients come first."

ENA president Denise King, RN, MSN, CEN, says that before this clarification, ED nurses were "put in a difficult position. Without the ability to utilize standing orders, patients would be subject to delays in treatment," she says.

The CMS clarification came at a time when many EDs are struggling with overcrowding, notes Gayle Walker-Cillo, RN, MSN/Ed, CEN, an ED clinician at Morristown (NJ) Memorial Hospital. "The confusion over the regulations could have put nurses or patients at risk," she says. "Emergency nurses should not be in the situation of being concerned about initiating care without a physician order in a critical situation or have their hands tied when they assess a patient is in trouble."