Standing Order in ER

[Defineyourself]

Hello you wonderful nurses!

I'm doing a project for my CN3 - I'm trying to reduce wait times in the Emergency Room by developing some standing order sets that can be ordered by RNs jn triage. What are yours? Do they include meds like Ibuprofen? What about ultrasound? What are the categories (abd pain, CP, extremity injury..)

thanks for your input!

[Happynurse12]

I work urgent care but we have order sets. For example if an adult has a fever over 101 I can order Motrin or Tylenol. If they are sob I can order a duo and a chest X-ray. Throat swans if they have a sore throat and xray if they have an ortho injury. The orders era def move things along when wait times are bad.

[emtb2rn, BSN, RN, EMT-B]

Do a search on standing orders/protocols in this forum. We had a long detailed thread that will give you that info.

[renzlao, MSN, APRN]

In our ED we do have standing orders with 10 different complaints. For example, if a patient comes in with chest pain, triage RN can automatically order trops, ECG etc.

[nixonk86]

We can order (after specific training and in certain circumstances) extremity XRs, paracetamol (acetaminophen), paracetamol and codeine combos, oxycodone, ibuprofen, morphine (for hip fractures only), laceraine (amethocaine, lignocaine and adrenaline topically) for lacerations, intranasal fentanyl, salbutamol inhaler or neb (I think US is albuterol), ipratropium inhaler or neb. and nitrous oxide. We can also order bloods if the patient fits a pathway. We can't order chest XR or US.

[Christy1019, ASN, RN]

We can order (after specific training and in certain circumstances) extremity XRs, paracetamol (acetaminophen), paracetamol and codeine combos, oxycodone, ibuprofen, morphine (for hip fractures only), laceraine (amethocaine, lignocaine and adrenaline topically) for lacerations, intranasal fentanyl, salbutamol inhaler or neb (I think US is albuterol), ipratropium inhaler or neb. and nitrous oxide. We can also order bloods if the patient fits a pathway. We can't order chest XR or US.

I find it so interesting that you can order nitrous oxide, oxycodone, morphine and fentanyl, but not a chest xray or ultrasound. What is their reasoning on that, and are you able to order this in triage and let the people go back to the waiting room?

[nixonk86]

Oxycodone we can give in the waiting room, nitrous is usually for dislocations so we stick them in the resus bay and give them nitrous until the doctor reduces the dislocation. Morphine is only for pain due to ? fractures NOFs/hips and the pt has to be on a bed so not in the waiting room. Fentanyl is intranasal only and only for kids, it's pretty harmless stuff IN but amazingly effective. Its not like we don't know the indications for US and CXR but if the types of patients who usually need these need to be seen by a doctor before going to radiology anyway. Sometimes I'll call the doctors inside the department and tell them about a patient that needs something like that but can stay in the waiting room and order the scans as a verbal order from the doctor. It's all to do with what fits in our pathways I think, each hospital in our area has slightly different SO due to differences in size, resources and what the head of ED is happy for us to do. To give you context, I work in a 17 bed ED in Australia.

[Christy1019, ASN, RN]

Maybe Australia doesn't have the narcotic seeking problems that the U.S. has, but I can see so many people coming in, getting trusted, getting a dose of oxycodone and walking out. Its good to see that you guys can implement better pain protocols than most U.S. EDs can.

[nixonk86]

It's not a huge problem where I work, if I open up their electronic record and see that they've been in 30 times in 6 months then I usually wouldn't give it. The only oxycodone we can give via SO is 5mg Endone (don't know if you call it something else) and it's a very new SO so we'll see what happens!

[Christy1019, ASN, RN]

I have no idea what SO or endone means, but if drug seeking isn't a huge issue there, I wanna move to Australia! Lol because I am over it here!

[nixonk86]

SO = standing order, Endone is 5mg oxycodone normal release not slow release like oxycontin...don't know what your equivalent is... My hospital is in a lovely area and we share services with the closest hospital... we take kids, they take mental health and drug an alcohol... best swap ever! I'm sure drug seeking is a massive problem in other areas particularly rural and remote areas. But you are welcome to come and work in my ED... we're pretty short staffed! (And my hospital overlooks a golf course and the ocean... seriously come and check it out!)

[Christy1019, ASN, RN]

I'm packing my bags, expect me before dinner lol