Pregnant People - Key Activity 5

KEY ACTIVITY #5:

Develop and Implement Standing Orders

 

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction.

 

Overview

A standing order is a preapproved provider order to perform a specific intervention for any patient who meets the criteria for the order. It is employed by a licensed (LVN, RN) or nonlicensed (MA, health educator) professional when the step in the workflow specifically requires the order of a qualified provider. Standing orders describe the action to be taken and identify who on the care team is authorized to complete the order. Standing orders are designed to enable care team members other than the primary care provider (PCP) to initiate specific clinical actions to provide timely screening and care, provided that specific criteria are met.

An important characteristic of a standing order is that all the patients who meet the criteria for the order receive the same treatment, thereby embedding equality into the clinical approach. Common standing orders include preventive measures, such as immunizations, cancer screenings and other screenings to be conducted ahead of the clinician’s time with the patient. Common standing orders in perinatal include preventive screening guidelines as well as specific testing at certain stages of pregnancy, such as initial pregnancy labs, gestational diabetes screening and group beta strep testing.

To limit the potential for errors and ensure patient safety, standing orders should be carefully designed, regularly reviewed and revised as necessary. They should be based on evidence-based recommendations and best practices, and they should have broad support from the medical director, practice manager, physicians and other staff. In addition, they should outline the criteria for initiating, modifying or discontinuing a particular course of action or treatment for a patient.[1]

Standing orders, in concert with other key activities, allow care team members to work to the full scope of their license and provide scaffolding to support care team members as they work together to support patient care. They promote practice workflow efficiency and effectiveness by standardizing routine care, thus freeing up time for the ordering clinician.

Standing orders help promote equity by ensuring that every patient who meets criteria for an intervention under the standing order is provided with appropriate services, limiting variation that could occur in interpersonal encounters. They follow clinical guidelines to ensure services for pregnant patients are provided at the right frequency based on patient age, gestational duration, pregnancy risk factors and other characteristics. Standing orders empower care team members to initiate these services within their scope and are a best practice tool that enhance the care team’s ability to close gaps in essential services.

Most EHRs have the ability to enable the creation of order sets that can be utilized to create standing orders. Order sets are particularly effective for managing a group of standard prenatal orders for a population. (See Appendix D: Guidance on Technological Interventions for more details on implementing order sets in a commercial EHR). Depending upon the health center’s workflows, these order sets can be placed on the chart by providers or can be drawn down by responsible designated staff according to protocols.

For example, a set of obstetric (OB) initial labs can be programmed into the EHR, allowing staff to check a single box to order all the recommended labs at the beginning of a pregnancy.

Relevant HIT capabilities to support this activity include prenatal care guidelines, registries, care gap reports and clinical decision support.

Effectiveness of standing orders can be tracked through registries and care quality reports.

See Appendix D: Guidance on Technological Interventions.

Action steps and roles

The steps below outline the actions required to create standing orders. They are adapted from the University of California, San Francisco (UCSF) Center for Excellence in Primary Care (CEPC).[2]

1. Review and understand the latest clinical guidelines for the required standing order and your practice’s already established protocols.

Suggested team member(s) responsible: Quality improvement lead; panel manager, data analyst, medical director or equivalent.

See the California Nursing Standardized Procedures, Protocols, Order Sets, Clinical Pathways, and Standing Orders Policy for information on California nursing standardized procedures.

Interventions specific to the perinatal care population are initiated upon the patient presenting with a positive pregnancy test and indicating they intend to continue the pregnancy. It is recommended that practices ensure access to initial and ongoing perinatal care services through the following best practices:

  • As soon as a pregnancy is identified and the patient indicates a plan to continue the pregnancy, practice staff connect the patient with perinatal service staff to initiate prenatal care services.
  • Upon notification, perinatal services staff outreach to schedule new prenatal patients for an initial intake visit and a provider visit.
  • A workflow is utilized to identify high-risk pregnancies and determine the need for referral to outside specialty obstetrics services.
    • If referred, workflow should exist to reengage the patient and new baby after delivery.
  • Practice participates in the California Prenatal Screening Program.
  • Standing orders are in place for routine prenatal and postpartum testing, including depression screening.
  • To maximize completion of postpartum depression screening, the standing order should be executed at the first postpartum visit or integrated within the first well child check with the pediatrician to complete the postpartum depression screen at any visit where the new parent presents. See The Council on Patient Safety in Women’s Health.

 

2. Translate the appropriate clinical guidelines into a standing order.

Suggested team member(s) responsible: Medical director and panel manager or data analyst.

The standing order will follow the relevant clinical guidelines and be updated whenever clinical guidelines are updated. It will generally allow the following:

  • Registered nurses (RNs) and/or medical assistants (MAs) with proper training may initiate the agreed upon standing order process when patients meet the agreed upon criteria for initiating screening, and do not have any clinical history that may require a clinician to address the concern.
  • This may include initiating an order, initiating a referral, or notifying the PCP of the need for screening and/or testing.
    In addition to the written standing order, the practice should develop a process map or update other documentation outlining how and when the standing order is to be implemented in the practice’s current workflows.

 

3. Obtain approval for standing orders from clinical leadership.

Suggested team member(s) responsible: Panel manager and/or data analyst and medical director or equivalent.

For the standing order to be valid and in effect, it must be approved by clinical leadership at the practice, signed by a designated valid signatory (e.g., medical director or other physician), and dated, and it must include the effective date for the standing order. Practices should consider including an expiration date and flagging this date in their system to help ensure that the standing order is reviewed and updated regularly. As the clinical guidelines change or other components are updated, the standing order should be signed and dated again by the appropriate party with an effective date for the revision.
 

4. Train practice staff on how to use standing orders and include this training in clinical onboarding of new staff.

Suggested team member(s) responsible: Medical director or equivalent.

It is critical that practice staff, both those directly named in the standing order and other members of the care team, receive training on the use of this standing order. Such training should include a thorough review of the written standing order and ensure that practice staff understand all of its aspects, including the associated workflow and any additional materials related to the workflow, such as patient education or instructional materials that include nuances that the care team will need to understand.

Training should be provided on each standing order at least annually, retraining should be provided before the effective date on any revisions, and the training should be part of the orientation for all new members of the practice care team.

Based on feedback from the staff, the standing order can be refined to make the instructions clearer (e.g., during training several staff members were confused by a specific instruction, indicating that the instruction needed to be revised).
 

5. Institute mechanisms to ensure the proper use of the standing order and its effectiveness.

Suggested team member(s) responsible: Clinical director or equivalent or their designee.

It is likely that one or more aspects of the standing order will not work as planned. For example, the practice’s workflow may not fully support the standing order, the wording may be confusing to one or more staff members, or the standing order’s protocol may not be regularly followed exactly (e.g., staff are using workarounds). The practice should routinely check for these and other common challenges and revise and update the standing order as needed to ensure that it works for the practice and meets all applicable regulations and guidelines.
 

FIGURE 11: COMMON PREGNANCY-RELATED STANDING ORDERS


Standing Order
Notes

Initial OB labs
Typically includes complete blood count (CBC), blood type,
Rh factor, rubella immunity, rubeola and varicella immunity, hepatitis B, hepatitis
C, sexually transmitted infection (STI) testing (HIV, syphilis, gonorrhea and
chlamydia), tuberculosis (if high-risk population), early glucose screening
(if high-risk population), and urine culture.

Depression and anxiety screening
For prenatal care, patient health questionnaire (PHQ)-2/PHQ-9
is frequently utilized. Screening is often completed at the initial prenatal
visit.
 
Edinburgh Postnatal Depression Scale (EPDS) is frequently used
for postpartum patients.

Genetic testing and nuchal translucency
For more information on the California Prenatal Screening
Program: Prenatal Care Providers.  Available from: https://www.cdph.ca.gov/Programs/CFH/DGDS/Pages/pns/healthcareprovider.aspx.

Gestational diabetes screening
Typically completed between 24 to 28 weeks of gestation.

Vaccinations
Tetanus,
diphtheria, acellular pertussis vaccine (Tdap): Offered after 28 weeks
of gestation with each pregnancy.
 
Influenza: Offered throughout flu season.
 
Respiratory
syncytial virus (RSV) vaccination (Abrysvo): Offered at 32 to 36 (or
37) weeks.

Group B streptococcus (GBS)
screening
If not
previously identified in urine culture, rectovaginal swab collected between 36
and 37 weeks of gestation.

Implementation tips

  • The same basic workflow for other standing orders that your practice already has in place can be used as a jumping-off point when developing a new standing order. Before beginning work on a new standing order, determine whether your practice has existing standing orders that you can draw from as you develop this one.
  • Verify if carrying out standing orders falls within the legal scope of practice for the supportive clinical staff intended to carry them out. California has very specific guidelines for standing orders for different healthcare professionals, including medical assistants, registered nurses (RNs) and advanced practice clinicians (APCs).
  • The first two to four weeks of implementing a specific standing order should be used to test and refine it. We recommend that the practice start with small-scale tests (e.g., test for one day), study the successes and challenges (including errors) of the test, refine the standing order and/or training on it as needed, and then test again, increasing the scale of the test as it results in fewer challenges or errors.
  • Common pitfalls of standing orders:
    • Standing orders are not updated when screening guidelines are revised and reflect an outdated practice. The remedy is to assign the task of updating the protocols to a member of the team who is responsible for at least annual review and modification.
    • New staff are not instructed on the clinical protocols. The remedy is to include review of standing orders as a core element of orientation for all roles named in the standing order.
    • Standing orders include the signature of a clinician who is no longer with the practice. Review standing orders at least annually and any time a clinician responsible for setting the order has changed roles.

Endnotes

  1. Leubner J, Wild S. Developing Standing Orders to Help Your Team Work to the Highest Level. Fam Pract Manag. 2018 May/Jun;25(3):13-16. PMID: 29989776. 
  2. https://cepc.ucsf.edu/standing-orders