Have Hospitals Outgrown the Holding Orders Controversy?

Gregg Miller

Gregg Miller , MD

Chief Medical Officer

Published August 09, 2017

My last ED shift was incredibly busy. The department was crowded, and the waiting room was packed. So for lack of a better option, we ended up boarding a septic 87-year-old woman who was awaiting admission on a gurney in the psychiatric pod of our ED.

The pod was noisy. Many patients were visibly intoxicated and agitated. The nurses were busy attending to behavioral outbursts.

It definitely wasn't the kind of place where I'd want my grandmother waiting around for hours. And I thought to myself, Thank goodness for holding orders.

Holding orders, also known as bridging or transition orders, allow an ED patient to move upstairs and receive basic nursing care while waiting to be seen by the admitting physician. Done right, the practice relieves ED crowding and provides a more pleasant environment for the patient.

However, holding orders remain controversial. What happens if the patient isn't seen promptly? And what if this delay results in a worse outcome?

Personally, I think the benefits of holding orders outweigh the potential risks. In today's post, I'll explain that position and share some best practices learned from our Vituity EDs.

Why Holding Orders?

For those outside the clinical world, here's a bit of background.

Let's say I need to admit a patient from the ED. As an ED provider, I don't have admitting privileges. So I need to hand the patient off to someone who does.

In the past, that was usually the patient's primary care provider or someone designated to care for unassigned patients. These days, it's more likely a hospitalist. In all of these cases, the admitting physician writes the comprehensive admission orders for the patient's care.

The bad news is, it can take quite awhile for the admitting physician to get to the ED. Medical staff bylaws allow outside physicians several hours of leeway prior to evaluating the patient. Meanwhile the patient's occupying an ED bed or waiting on a gurney.

If a patient does somehow get sent upstairs without orders, it's bad news. Without orders, the nurse can't do anything. They can't feed them, because they might be preoperative. They can't walk them to the bathroom, because they might have a broken pelvis. It's a lot of stress on everyone.

But there is a workaround for this seeming Catch-22.

How Holding Orders Work

To get a patient upstairs right away, I first call the hospitalist, present the case, and get the green light to admit. Then I write short-term holding orders covering basics like:
  • Diagnosis
  • Patient location
  • Isolation precautions
  • Diet
  • Short-term IV fluids
  • Short-term nursing orders
  • Comfort meds (for control of pain and nausea)
  • Meds/labs needed in the next few hours
These orders allow the nurses to care for the patient until the admitting physician arrives to write more comprehensive admission orders.

Holding orders can decrease ED turnaround times for both admitted and discharged patients. For example, ED providers at Maine Medical Center of Portland, Ore. increased the use of holding orders from 4 percent of eligible cases to 51 percent. In the same timeframe, turnaround times for admitted patients fell from 475 minutes to 411.

The practice also benefits discharged patients by freeing up ED resources. And shorter wait times tend to boost patient satisfaction scores for all ED patients.

So why, you may be asking, do holding orders remain controversial?

Reservations and Resistance

ACEP has cautioned members against writing holding orders. It's position: once the admitting physician gives the green light, the patient should become his or her responsibility. So the emergency physician shouldn't be muddying the accountability waters with additional orders.

The concern here is liability, which is a legitimate worry. Let's say the patient goes upstairs, isn't seen for 24 hours, decompensates, and has a worse outcome. If the emergency physician has written holding orders, they could still be viewed as bearing responsibility for that patient.

ACEP does acknowledge that holding orders may sometimes be in the patient’s best interests. And individual committee members have noted that the liability risks may be less significant than commonly believed.

I get where ACEP's coming from, but I also believe that times have changed.

More and more hospitals are using hospitalist services to handle admissions. And primary care providers are increasingly entrusting hospitalists to care for their admitted patients.

Hospitalists don't have office practices. Even when things are busy, they can usually get down the hall promptly to see the new patient. In the absolute worst-case scenario, they might be tied up for a few hours. And if the patient gets worse while waiting, the nurses know where to find the hospitalist.

So in my view, it's completely reasonable (and in fact, a best practice) to write holding orders for boarded patients who will be admitted by a hospitalist service.

Is the risk zero? Well, no. But it's probably less significant than the risks posed by ED crowding.

Creating Believers

Getting ED providers to write holding orders can be a tough sell. It's likely that some have never been trained in this practice. They may have worries about liability if there's a delay in care. And they may also feel that they're being asked to do the hospitalist's job.

Likewise, hospitalists may feel a loss of control. Seeing the patient in the ED ensures that the patient comes upstairs with an appropriate workup. If a test or study is missed in the ED, it can be a real hassle to get it later (because ED patients get priority). The consequences: a longer LOS for the patient and a ding in quality metrics for the hospitalist.

For the process to work, there has to be trust on both sides. ED physicians have to trust that their patients will be seen promptly once sent upstairs. And hospitalists have to trust that the ED physicians are conducting appropriate workups.

(This is, by the way, a major advantage of staffing the ED and hospitalist services with the same physician group.)

Here are some best practices that can help you to create believers and foster trust among the medical staff:
  • Emergency and hospital medicine should decide together which patients will be eligible for holding orders and which must first be seen by the admitting physician. Examples of the latter might include ICU, trauma, and psychiatric patients.
  • Agree together what holding orders should cover — and what they shouldn't. Create standardized templates for common diagnoses.
  • When possible, the ED provider should be the one to write holding orders, because they know the case best. (For example, does the patient need Tylenol for pain management — or opiates?)
  • Holding orders should expire after three to six hours (sooner is better).
  • Update the medical staff bylaws to reflect new agreements around holding orders.
  • Decide together how responsibility will be shared for boarded patients and when the torch of accountability officially passes from the ED to the admitting physician. Document these handoffs of responsibility in the patient's chart.
  • Track utilization of holding orders to the provider level to ensure all providers get on board with the new practice. For example, Maine Medical Center drastically increased utilization by including in pay-for-performance and publishing unblinded usage data.
  • Share successes. As ED throughput improves, include the hospitalists in celebrations and recognitions.

Foster Empathy

Finally, when creating buy-in, focus your team on what's best for the patient. Patient stories are a great way to do this.

My patient who was boarded in the psych unit is a great example. In the past, she might have spent three hours in a noisy, chaotic, worrying environment. But thanks to holding orders, we were able to quickly move her upstairs to her own room.

The patient was incredibly grateful, as was her daughter at the bedside. And I was relieved, too. It was the kind of care that I'd want for my own loved ones, which is what we strive to deliver for everyone who walks in our ED doors.

Does your hospital use holding orders? Comment below to share tips and best practices.

This post was originally published on Nov. 14, 2016.

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