“In the ED we work as a team, and the use of approved standing orders allows the often solo physician to manage multiple patients simultaneously with timely care,” she said.

“Some orders may seem very basic, like Tylenol for a young child with fever. However, that dose of Tylenol while in triage can prevent a febrile seizure in the waiting room and immediately help the child to feel better.”

ACEP was able to give CMS concrete examples of why standing orders are so vital to patient care.

“Another situation where we were hampered was the inability to continue a nebulizer treatment started by EMS on an asthmatic patient until the emergency physician could assess the patient and order continued therapy,” Dr. Lawrence explained. “The need for the nursing team to continue therapy on this new patient is an example of the dependence on teamwork to provide seamless care from field to ED.”

Once CMS better understood the real-world issues, they reversed their earlier guidance. The new CMS ruling, published Oct. 24, 2008, is a return to the status quo. Hospitals may once again use preprinted or pre-approved standing orders to provide timely intervention, ­typically for noncritical patients. It is ­permissible to update the patient’s record and add the physician’s signature later, so as not to delay an emergency response—thus making the process less disruptive for busy ED staff. Physicians may sign the last page of the record, assuming that other critical updates are checked or initialed, as necessary.

“Reinstating the use of standing orders preserves the status quo by enabling what is a vital practice in emergency medicine, critical to rendering timely, quality care to our patients,” explained Dr. Lawrence.

While pleased with this victory for ACEP members, all emergency physicians, and their patients, Ms. Tomar warned that there could be changes down the road. “When CMS reversed itself in October, their intent was to continue to conduct research and consensus building forums. Consequently, they could make a new interpretation on this at any time,” she cautioned.

ACEP recommends that hospitals and emergency departments regularly review their standing orders according to their hospitals’ protocols, to be sure they are consistent with best practices and that quality care is maintained. While CMS has granted some flexibility for the timing of physician signatures on verbal and written standing orders, there are still strict guidelines governing physician authorization of patient records. Pre-approved standing orders and electronic records must be duly authorized and serve as an accurate time line, and rendered unalterable after the time they were approved.