Before every commercial airplane takes off from the runway, its pilot goes through a detailed checklist of switch settings, gauge readings, communication frequencies and so on. The checklist's primary purpose is the safety of the passengers and crew, and it's followed not only by new pilots but by seasoned veterans as well.

The 14 family physicians at Scott & White Clinic-College Station, Texas, have created similar “checklists” in the form of standardized admission orders for their hospitalized patients.

“You have to do the rest of the flying yourself,” says Robert Wiprud, MD, the clinic's division director for family practice and assistant professor of family and community medicine at Texas A&M University Health Science Center. “But the standard orders can get you started.”

A valuable tool

The role of standardized admit orders, according to Wiprud, is simply to remind physicians of details and to help them initiate appropriate plans of care. “In family practice, we cover such a wide variety of things, and a lot of us don't spend all of our time in the hospital where we're doing it every single day,” Wiprud explains. “I don't think it's possible for most people to remember all the little nuances and subtleties of how you want to do things.”

The standardized orders provide those needed prompts, but they also do much more, says Wiprud. They address some of the most important issues in medical practice today: variation, quality of care, cost-effectiveness and efficiency.

“I think doctors tend to do things based on how they were taught to do them in residency,” says Wiprud, “and [before creating the standard orders] I was seeing a lot of variation in how we took care of different diseases.”

While Wiprud admits that sometimes variation is of course appropriate, he believes that where high-quality, cost-effective treatments have been identified, physicians should follow them. “If we could have everybody providing up-to-date treatment, not something based on what they learned 10 years ago, we would all improve the quality of care.”

Decreasing unnecessary variation can also help with cost-containment, something the clinic is keenly aware of, given that 70 percent of its patients belong to HMOs. “When there's a lot of variation,” says Wiprud, “it's more expensive.”

In addition, the preprinted admit orders save physicians the time of having to look up information. “Sometimes it's just hard to remember at 2:00 in the morning what the dose of Mucomyst is for Tylenol overdose. You're going to have to look it up somewhere, so for me it's easier to look it up on our standard orders,” says Wiprud. “I think you're less likely to make a mistake in the middle of the night if it's already been figured out for you in the middle of the day.”

Wiprud believes the orders make life easier for nurses too. “They all follow the same format, and they have all the information the nurses want, like p.r.n. orders, diet and activity, so we're not getting calls to fill in this information,” he says.

Their creation

When Wiprud came up with the idea of developing standardized admit orders, his first step was to develop a list of conditions that family physicians encounter in the hospital. He settled on a list of about 30 (some more, some less common) and then invited his colleagues to sign up for the ones they'd like to research. The physicians took a couple of the conditions each and developed admission orders based on their research. Wiprud then edited and formatted the orders and gave them to the relevant local specialists to review for quality and cost-effectiveness. “For instance, on the GI bleed, our original order called for IV H₂-receptor blockers. Our gastroenterologist said that if the patient isn't vomiting, there's no reason to do that. It doesn't work any better, so you can give them PO, which of course in the hospital is a lot more cost-effective,” he says.

Based on those comments, Wiprud revised the orders into their final state (see "Sample admit orders"), and he worked with the hospital's information systems staff to make them accessible from the hospital computers. “We can print them out at the ER, or we can pull them up on our clinic computer and have them print out at the medicine floor, or wherever it is that we need them to be,” says Wiprud. “It's pretty handy.”

Individualized attention

Wiprud believes the standardized orders do not get in the way of treating each patient as an individual with unique needs and concerns. “I view them as guidelines and a convenience for the doctor, not something to make the doctor treat all patients the same,” he says.

The physicians are free to use the standard orders, or not. They can even edit the orders to suit a particular patient's needs. “There's a lot of leeway to add things and to cross things out and do things however you want to do them,” he says.

“And of course they're just admission orders,” says Wiprud. “You have to see how the patient does and make adjustments based on the labs the next day and all that kind of stuff, so it doesn't tell you how to treat them through their whole hospitalization. It just gets you started.”