CMS Reverses on Standing Orders in EDs

February 2009

By Barbara Helpren
ACEP News Contributing Writer

It took more than 9 months, but ACEP and other emergency medicine organizations persuaded the Centers for Medicare and Medicaid Services to reinstate the use of standing orders in an October 2008 ruling.

On Feb. 8, 2008, CMS unexpectedly issued an interpretive guidance of The Joint Commission regulations and terminated the longstanding practice of dispensing care under a standing order unless or until it was signed by the patient's physician. CMS reasoned that this approach better safeguarded patients and ensured complete, direct physician attention and oversight.

The February guidance prevented nurses and other health care workers from dispensing care beyond their authority or knowledge, without the watchful eye of the patient's physician. Consequently, a physician's signature was required before a standing order could be used--even to dispense an aspirin for a heart attack patient--a standard intervention.

The ruling created major hurdles, especially for busy, crowded emergency departments that relied on standing orders for more efficient triage of some cases. Worse still, many hospitals were caught unaware and were being cited and fined in their Joint Commission surveys for using unsigned standing orders.

ACEP and other emergency medicine organizations made the argument that this CMS ruling was counterintuitive and counterproductive. Rather than safeguarding patient care, it was jeopardizing patients by restricting time-tested, proven, often lifesaving interventions, and increased the backlog of patients.

In response to the CMS ruling, ACEP staff members worked diligently and collaboratively with the Emergency Nurses Association (ENA) and the American Academy of Emergency Medicine (AAEM) for months to reverse the CMS decision.

ACEP's Federal Affairs Director, Barbara Tomar, argued successfully that requiring a physician's signature before care could be dispensed might actually lead to a worse, not better, outcome. Ms. Tomar argued that it is potentially more dangerous to the patient and risky for the hospital not to provide immediate intervention via the hospital's standing orders, which are approved by the medical staff and are based on proven best practices.

"The now chronic ED crowding crisis and the needs of patients for intervention in a timely fashion necessitate a responsive method of developing standing orders to ensure prompt, proper intervention whenever possible," Ms. Tomar said.

ACEP's Chair of the Board and Immediate Past-President, Dr. Linda Lawrence, said it was exciting to work with other emergency medicine organizations and to see "that the voice of the nurses was represented" to The Joint Commission and CMS.

"In the ED we work as a team, and the use of approved standing orders allows the often solo physician to manage multiple patients simultaneously with timely care," she said.

"Some orders may seem very basic, like Tylenol for a young child with fever. However, that dose of Tylenol while in triage can prevent a febrile seizure in the waiting room and immediately help the child to feel better."

ACEP was able to give CMS concrete examples of why standing orders are so vital to patient care.

"Another situation where we were hampered was the inability to continue a nebulizer treatment started by EMS on an asthmatic patient until the emergency physician could assess the patient and order continued therapy," Dr. Lawrence explained. "The need for the nursing team to continue therapy on this new patient is an example of the dependence on teamwork to provide seamless care from field to ED."

Once CMS better understood the real-world issues, they reversed their earlier guidance. The new CMS ruling, published Oct. 24, 2008, is a return to the status quo. Hospitals may once again use preprinted or pre-approved standing orders to provide timely intervention, typically for noncritical patients. It is permissible to update the patient's record and add the physician's signature later, so as not to delay an emergency response--thus making the process less disruptive for busy ED staff. Physicians may sign the last page of the record, assuming that other critical updates are checked or initialed, as necessary.

"Reinstating the use of standing orders preserves the status quo by enabling what is a vital practice in emergency medicine, critical to rendering timely, quality care to our patients," explained Dr. Lawrence.

While pleased with this victory for ACEP members, all emergency physicians, and their patients, Ms. Tomar warned that there could be changes down the road. "When CMS reversed itself in October, their intent was to continue to conduct research and consensus building forums. Consequently, they could make a new interpretation on this at any time," she cautioned.

ACEP recommends that hospitals and emergency departments regularly review their standing orders according to their hospitals' protocols, to be sure they are consistent with best practices and that quality care is maintained. While CMS has granted some flexibility for the timing of physician signatures on verbal and written standing orders, there are still strict guidelines governing physician authorization of patient records. Pre-approved standing orders and electronic records must be duly authorized and serve as an accurate time line, and rendered unalterable after the time they were approved.

Ms. Tomar made a far-reaching suggestion in her Oct. 23, 2008, letter to CMS: "We believe that CMS could serve a useful role in providing a clearinghouse of these orders in order to assist other hospitals in reviewing the clinical literature and developing their own protocols." This centralized, archived, searchable database could fill an important function by ensuring consistent standards in patient care, and eliminate marginal practices, thereby better safeguarding patient care across the board.

Read the guidance memo at and search for "S&C-09-10."

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