In 1999, the 17 family physicians of the Scott & White Clinic in College Station, Texas, developed a set of standardized orders for use in admitting patients to the hospital. One year prior to this, we had started a hospital service consisting of one of our senior staff physicians working with a second-year resident from the local family medicine residency. Eventually, all of our physicians began to share this responsibility one week at a time, which left each of our doctors having a fairly intensive inpatient experience every three to four months. Because of the wide scope of family medicine, we cared for patients with a wide variety of medical conditions. Many of these patients’ problems were relatively routine, while others were less common or more complex and, therefore, more difficult for our admitting physicians to manage.

Our reasons for developing the standardized admission orders were threefold. First, we felt we could reduce unnecessary variability in physicians’ approaches to similar disease processes and thereby improve the quality of our care. Like many physicians, we were sometimes basing our care on what we learned in training or from colleagues, rather than on current evidence. Second, we felt that by reducing variability, the orders could also help contain costs. Our practice is approximately 70 percent to 75 percent capitated, so cost reduction is a significant issue for us. As we created the admission orders, we reviewed them with local specialists in the relevant fields and also with our primary hospital to help establish the most cost-effective therapies for our particular hospital practice. For example, in the treatment of UGI bleeding, many of our physicians were using IV H₂-blockers for initial management, although oral medications were as effective yet less costly in patients not actively vomiting.

Our third reason for developing the orders was simply a matter of physician convenience and efficiency. At 2 a.m., locating the correct dose of acetylcysteine for an acetaminophen overdose using our standardized orders is much easier than trying to locate it in a textbook.

The process

Once we decided which conditions we wanted to develop standard orders for, we assigned just one or two to each of our physicians to research and compose. We encouraged the physicians to take an evidence-based approach, and we sought input from appropriate specialists. The orders were then formatted using a standard template to ensure that routine issues such as diet, activity, prn medications, etc., were covered. The hospital information system staff then assisted us in making the forms easily accessible from any of the computer workstations throughout the hospital. We can also access the forms at our clinic and at our urgent care department, where many of our admissions originate. In addition, we are now working to format the orders for use on hand-held computers.

Experience

Our experience using the standard admission orders over the past two years has been very positive. We believe the orders have in fact helped us with cost, quality and convenience. It is important to realize that these orders are intended only as a framework to aid the doctors and residents as they begin the work-up and treatment of patients. We do not require the physicians or residents to use the standard orders but have found that most choose to do so. We request that the residents write their own orders for their education purpose, but we ask that they use our standard orders in the hospital for quality-control purposes. We also understand that not every patient should be treated exactly the same, and we encourage our physicians to provide individualized patient care as they deem appropriate.

Update

In April of this year, we revisited our standard orders to upgrade and update them. [The clinic’s orders were originally published in the November/December 1999 issue of FPM. See “Using Standardized Admit Orders to Improve Inpatient Care,” in page 30 of that issue.] The orders were again assigned to each of our doctors, who researched and revised them. They were edited by the clinic’s division director.

Some examples of updates made to the orders are the addition of troponin I for the evaluation of chest pain and the use of proton pump inhibitors rather than H₂-blockers for UGI bleeding. We also added the consideration for DVT prophylaxis as appropriate in patients with decreased mobility.

We hope you find these orders helpful in your practice.