Standing orders for outpatients?

SmilingBluEyes · Apr 25, 2005

This is how we do it:

We "write the order" on an order sheet to

"Admit to a clinical bed, monitor and call the doctor with status/updates". This is done prior to calling the dr.

After we call, the order is written to "d/c home with labor precautions and instructions for fetal kick counts" (and whatever else the physician may verbally order such as bed rest, medications etc.). Does this help?

JaneyW · Apr 25, 2005

I don't know if this is a silly question or not. I have worked in two small (around 300 deliveries a year) LDRP/nsy departments for the last three years. We do not have standing orders for our ob check patients who come in to rule out labor, or with other concerns about their pregnancies. I work nights and since we do not "want to bother" the doctors twice, we put them in a room, take a UA, and monitor for about an hour (possibly more) before we ever contact the doctor. Obviously, if we have a preterm labor or something we think is serious we let them know before that, but otherwise the doctor has no knowledge that his/her patient is even in the hospital until they have been there for at least an hour. Is this a common practice? I think it could have dangerous ramifications legally since we do not even have standing orders for this type of patient - we just have "tranditions" (I can not even find a hospital protocol on it.) Anyway, just wanted to know if this is a widespread thing, or just a rural Missouri one!
Thanks guys!

We do 160 to 180 deliveries a month and that's how we handle our OBOP patients. Our docs don't seem to spend much time on education and we are constantly getting people who are contracting every 20-30 minutes and just KNOW they are in labor and bring their whole family with them only for us to find they're fingertip and call the doc to send them home after an NST.

I agree that we assume a lot of liabilty when we wait to call. I think it is not really a bad practice, but we need to not get too relaxed with those patients. What we think is a UTI may turn into something different altogether. We had someone the other night with what I thought (and turned out to be) really bad heartburn, but when I called the doc he surprised me by wanting her worked up for possible gall bladder problems. Labs were fine and she went home, but it might have been something more.

I went to a perinatal legal issues class recently and was told that the doc needs to be called within one hour of the patient's arrival for standard of care to be met. It also takes some liability off of ourselves when we have informed the doc of the patient's status.

SmilingBluEyes · Apr 25, 2005

Yep, we have to meet the 1 hour rule where I work, too, Janey. It's an ACOG standard, I believe.

fourbirds4me · Apr 25, 2005

We also routinely monitor 1 hour before calling the MD. This is part of our portocol. Of course we notify sooner if needed. I believe this also agrees with emtala.

maxiebelle · Apr 26, 2005

We also routinely monitor 1 hour before calling the MD. This is part of our portocol. Of course we notify sooner if needed. I believe this also agrees with emtala.

We have had standing orders for outpatients for ten years. For example, during first 30 minutes: Admit to L&D-observation. Midstream UA, EFM, vital signs, sve if no vag.bleeding, nitrazine if indicated, pre-eclampsia assessment if indicated. Then 30-60 minutes after admission: Recheck vital signs if BP>130/80, continue EFM, call MD with UA results and pt status report. 60 minutes-discharge:(check one) discharge home, admit to L&D with routine orders, admit to 3rd floor-labor precations. If any meds, IV, etc. are ordered, we write those on a separate order form,of course. And if the pts condition needs immediate attention, we call the MD before UA results (preterm labor, non reassuring strip,hemorrhage, etc).

We also use a OB nurse evaluator form along with the standing orders--it breaks down different areas and assigns each answer a score. When the total score is above a certain number,the MD must come see the pt before discharge/admission. For example, someone with signs of pre-eclampsia, advanced dilation, hx precip delivery, no fetal heart tones, etc. would score much higher than someone with cervix closed, reactive strip, few risk factors. However, becoming a qualified nurse evaluator is a lot of paperwork--it must be approved by the staff physicians--it is almost like applying for staff privileges. A lot of work, but worth it.

Now, if it is the middle of the night, the MD doesn't always come see the pts--they usually admit them to the antepartum unit, and will see them in the AM. Hope this helps.

Littlewonder · Apr 27, 2005

Thank you so much for your replies. It does help. We do not always meet the one hour standard, so I will start using that. I think I would feel more comfortable with either a protocol or a standing order. We do use a nurse evaluator form here too, but it just requires a RN with two years OB experience to qualify.