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Holding Orders: Pearls and Pitfalls

As many hospitals battle the national physician shortage, emergency physicians are increasingly being asked to write inpatient orders. These are abbreviated orders meant to facilitate the patient’s transition to the inpatient unit and are typically named “holding”, “bridge”, or “interim” orders. When faced with the question of developing this process, a few things should be addressed.

1) Purpose

It is important to be transparent about why these orders are being used. There have been studies showing that emergency department length of stay is reduced when these orders are placed by the ED physician. However, it is important to clarify why this occurs. The placement of inpatient orders is traditionally the duty of the admitting physician/team. In cases where there is a significant delay in the patient being seen by the admitting physician, the patient waits in the ED tying up a valuable resource, the ED room. In this scenario, a department and the patient will benefit from holding orders being placed to facilitate movement to the floor. But we have to acknowledge that this is occurring due to a lack of appropriate physician staffing. If physician staffing levels were sufficient, patients would be seen in a timely manner and this practice would be unnecessary. So, acknowledge that the ED is being asked to perform this task due to a lack of physician staffing (employed hospitalists, residents, rural hospitals private physicians, etc.)

2) Responsibility

Equally important is the discussion regarding when care is assumed by the admitting team. It must be understood that care is transitioned to the admitting team when the initial consultation for admission (by phone) is made. Although the ED physician may be willing and capable of writing holding orders, the patient is now under the care of the admitting physician/team and the orders should stipulate that explicitly. It is not acceptable for any admitting physician to refuse responsibility for an admitted patient solely because they have not yet seen that patient. Once the phone consultation has occurred and a request for holding orders has been made, that patient becomes the responsibility of the admitting team. If he/she is uncomfortable accepting responsibility, they should interrupt their current work and see the patient in question immediately. There are numerous examples of ED physicians being asked to manage inpatients (within the department OR on the inpatient unit) up to 24 hours after admission. This practice is inappropriate and unsafe.

3) Duration

Holding orders should have an automatic expiration. That time limit should be long enough for the admitting physician to see the patient without interrupting treatment in progress. There is no standard for this time period, but I recommend no longer than 4 hours. Since the purpose of the orders is to accommodate for short staffing, the admitting team should not be more than 4 hours behind. If they are, an examination of other options for staffing should be conducted.

4) Questions and calls.

The holding orders should note the admitting physician of record and explicitly state that questions regarding patient care should be referred to the admitting physician, not the ED physician. The ED physician can not continue to serve as the point of contact for patient care after admission. There are new patients to care for in the ED and inpatient care is not a part of an ED physician’s expertise.

5) Notification of location.

If the hospital electronic medical record does not alert an admitting physician of a patient’s location through a work list or patient list, he/she should be notified of the patient’s arrival in a room so that they can adjust their workflow and plan to see the patient in the correct location.

6) Re-evaluation. 

One of the critical reasons to define why the hold orders are being used (#1 above) is to understand if the use of these orders is meant to be temporary or permanent. If it is temporary pending recruitment of more physicians, define a timeframe for mandatory re-evaluation. Many emergency departments have found enacting this process enables house staff to delay their examination of ED patients. This creates an atmosphere of complacency regarding emergency department patients and essentially supplants the admitting physician with an emergency physician. Obviously this is not the intended purpose and a mandatory re-evaluation of the process can address this issue.

7) Liability. 

This is something that all physicians are particularly sensitive to and with good reason. Some of the liability question is addressed by defining the responsible party (#2 above). Ultimately, any poor outcome will likely result in all parties being named, but a clear stipulation of the responsible party should prevent any physician from stating they are not responsible because they never “laid eyes” on the patient. Additionally for any privately contracted groups or physicians, once the policy is written, it is wise to alert your malpractice carrier of the process and furnish then with a copy of the policy. This will insure you have coverage for these types of complaints and avoid any nasty surprises.

8) Reasons not to use them.

It should be understood that holding orders are not a mandatory step. If the patient is too complex or too ill, the admitting physician should be asked to see the patient instead and there should be an expected time frame for the response. When the patient requires admission to an intensive care unit, it is a good idea to avoid holding orders and ask the admitting physician or team to arrive in a timely manner and assume care. ICU patients are complex and transition of care is better served in person than with the holding orders process. This option should be clearly noted.

Keeping these issues in mind, it should be possible to draft a policy for the safe utilization and implementation of holding orders.

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