As physicians, we are constantly searching for ways to reduce variability, simplify work processes and improve the quality of our services. This is especially true for family physicians because the scope of our specialty is so vast. During a typical day, it is normal for us to encounter a wide variety of patient problems, and nowhere is it as difficult – or important – for us to strive for consistency, efficiency and accuracy in our care as in the hospital setting.

In our 15-physician department of family medicine, which is part of a large multispecialty clinic, we care for our hospitalized patients with an “internal hospitalist” program. Each physician rotates as a hospitalist, caring exclusively for family medicine inpatients for one week every few months. To help decrease unnecessary variability in our care, we created a series of admission orders for common hospital admissions.

Better process, better care

When we first developed our standardized admission orders seven years ago, we chose 27 conditions that we thought would be most useful. We currently have 29 admission orders that cover the conditions our family physicians most frequently encounter in the hospital. We have found that this order set covers more than 90 percent of our hospital admissions.

Every two years, we divide the orders among the physicians in the department for updating. During the updating process, we make sure we are up-to-date with current evidence so we can incorporate the best, most cost-effective and efficient care into our admission orders. This includes reviewing certain orders with specialists in relevant fields and modifying our orders to match any standing orders issued by our primary hospital. We also update our orders based on new treatments or medications, new formulary-recommended medications, new relevant labs (e.g., troponin I, brain natriuretic peptide or D-dimer) and new technology for diagnoses (e.g., spiral CTs for pulmonary embolism and CT stone studies for ureteral calculi). During our most recent round of updates, we added new orders for congestive heart failure and pancreatitis (see "Admit orders") and made minor changes to pre-existing orders.

As I’ve mentioned in previous FPM articles, we do not view these as “written in stone” (see “Using Standardized Admit Orders to Improve Inpatient Care,” November/December 1999 and “30 Standardized Hospital Admission Orders,” October 2001). The orders are intended to provide a framework for treating patients and planning a course of care. Our physicians are not required to use orders for every admission Each patient presents with a unique situation and should be treated according to the physician’s discretion. The purpose of the orders is to get us off to a consistent start and give our patients the best possible care.

Standardized orders also help us prevent errors by giving us easy access to the information we need regarding medication doses and labs for each condition. It’s easy to imagine even the most meticulous physician making a critical error late at night after a full day of patient care. If we have a standard admit order in front of us, we are far less likely to err in our initial treatment of the patient.

Added benefits

Everyone has benefitted from the introduction of the orders to our inpatient admission process. The hospital administration and staff have been very receptive; in fact, the hospital has even designed some of its standard order sets to match ours. The orders we created are structured in a user-friendly format, and because most of them require minimal writing, the nurses don’t have to struggle to read our handwriting.

These orders have also proved excellent resources for teaching students and residents. I routinely ask students to write their own orders, which we then compare to the standard orders for discussion and teaching purposes. I can then either confirm that they remembered the necessary elements of the course of treatment or point out where they omitted something. This has become a highly effective learning technique for students.

With so many advantages to using standardized admission orders, I encourage you to incorporate them into your inpatient care. You are welcome to use the orders as we’ve created them or customize them to fit your practice’s needs.