Ambulatory Care Quarterly: Speed up orders for inpatients held in ED

What is your No. 1 obstacle to reducing delays and improving patient flow? For many emergency department (ED) managers, the culprit increasingly is inpatients being held in the ED for hours or even days.

"If we can expedite getting the patients out of the ED, of course that is best," says Jay Kaplan, MD, FACEP, medical director of the Studer Group, a Gulf Breeze, FL-based group that specializes in operational and service improvement in EDs and health care facilities.

"If we can’t, it is vital to recognize what orders need to be carried out immediately and which can wait until the patient gets to the floor," Kaplan says. "The problem, of course, is that too often you don’t have any idea how long the patient is going to be held in the ED."

Here are strategies to manage orders for inpatients held in the ED:

Determine which orders need to be carried out immediately.

You need a foolproof system to ensure that important orders are carried out while the patient is in the ED, Kaplan says. "The problem is that often this system is not set up, and thus there may be a delay in important orders being carried out," he says.

Often, inpatient order sheets are used, which fail to differentiate which orders must be done in the ED and which ones can wait, Kaplan notes. "Given the uncertainty as to how long the patient will be in the ED, there is confusion, and it must not be left up to an individual’s discretion as to which orders are carried out.

"It is equally unreasonable to expect ED nurses, with all of their other patient responsibilities, to do everything. This is problematic," he adds.

Use a protocol for inpatient orders to ensure that important orders are carried out while the patient still is in the ED, he recommends.

Resist pressure for ED physicians to write inpatient orders.

The Dallas-based American College of Emer-gency Physicians has taken a position against ED physicians writing inpatient orders, Kaplan says. "In that scenario, once the patient leaves the ED, the emergency physician is taking responsibility for the patient on the inpatient unit and before the attending physician has taken charge of the care," he explains.

"This is an untenable situation. You can’t have two captains steering the same ship." However, there often is pressure put on ED physicians to write these orders so that private attendings do not have to see patients, Kaplan says.

Create a template that includes the statement "Call Dr. ______ upon patient arrival to unit for orders," he advises.

There also should be a clear statement that once a private physician has called in orders on a patient, or house staff have come down and written orders on behalf of an attending physician, the ED physician no longer is responsible for the patient unless there is a life-threatening emergency, he says.

Use transitional orders.

At Englewood (NJ) Hospital and Medical Center, patients being held in the ED encountered a Catch-22 scenario: Inpatient units would not accept patients without orders, and the ED physicians did not want to write admitting orders because of the liability risks involved, reports Stuart M. Caplen, MD, chief of the department of emergency medicine.

As a result, patients would wait in the ED until the residents worked them up, he explains.

Caplen’s ED found an effective solution by working with the departments of medicine and nursing to develop "transitional" orders to use for inpatients being held in the ED. The orders provide for activity, diet, and first dose of pain medication or other stat medications.

The patient’s attending physician and the resident are called and notified that the patient will be sent to the floor for the admitting history, physical, and orders. A preprinted sheet is used and one of the first orders is to page the resident when the patient arrives on the floor. (See Admitted Patient Transitional Order Sheet.)

Transitional orders are used only for relatively stable patients, such as patients with infections who have gotten their first doses of antibiotics in the ED, who can safely wait one or two hours for the resident to see them on the inpatient floor, Caplen notes.

When transitional orders were first implemented, the ED agreed to wait one hour to notify the resident before using the orders to give the resident time if he or she wanted to see the patient in the ED. The one-hour waiting period has been eliminated to speed the process when the ED is busy, he says. The transitional orders have gotten patients up to the floor several hours quicker, by not having to wait for the resident to examine the patient in the ED and write admitting orders, Caplen reports.

A recent example involved an elderly patient with pneumonia who was not in acute respiratory distress, he says. The woman received the first dose of antibiotics in the ED and later went to the inpatient floor, where the resident examined the patient and did the history and physical.

"An additional bed for new ED patients opened up several hours earlier than it would have, had the transitional orders not been used," Caplen says.

[For more information, contact:

  • Stuart M. Caplen, MD, Chief, Department of Emergency Medicine, Englewood Hospital and Medical Center, 350 Engle St., Englewood, NJ 07631. Telephone: (201) 894-3527. Fax: (201) 541-2977. E-mail:
  • Jay Kaplan, MD, FACEP, Medical Director, The Studer Group, 913 Gulf Breeze Parkway, Suite Six, Gulf Breeze, FL 32561. Telephone: (602) 381-0788. Fax: (602) 381-0886. E-mail:]