POLICY and PROCEDURE

TITLE: Emergency Department Standing Orders

Number: 11914

Version: 11914.6

Type: Patient Care

Author:

Effective Date: 6/12/2013

Original Date: 1/1/2010

Approval Date: 5/23/2013

Deactivation Date:

Facility: System
Population (Define): All Employees and Patients
Replaces:
Approved by: ED Clinical Consensus Group; BH System Practice Oversight Team; Care Management Operations
Council

TITLE: Emergency Department Standing Orders

I.

Purpose/Expected Outcome:
A. To provide a pathway of timely, coordinated care for patients with specific symptoms, determined
through assessment by an RN that correspond to a specific standing order delegated by a medical
provider to reduce delays in medical treatment and care.
B. To provide a set of Standing Orders that the Hospital Emergency Department Registered Nurse
(RN) can initiate to address urgent/emergent medical condition(s) of patients presenting to the
Emergency Department.
C. To provide direction to the Hospital Emergency Department Registered Nurse (RN) to address
injuries and/or medical problems ranging from critical and life threatening to minor and self
limiting and establishing a layer of safety for patients presenting to the Emergency Department
while determining appropriate treatment in a timely manner.

II.

Definitions:
A. Standing Order (SO): an order approved by the applicable Medical Executive Committee that
may be executed prior to an individual provider order. Standing Orders are limited to a subset of
orders in regards to a patient condition or circumstance that are necessary for timely and efficient
care.

III.

Policy:
A. Prior to implementation at a facility, these Emergency Department (ED) Standing Orders must be
approved by the applicable Medical Executive Committee who may choose to utilize any or all of
these Standing Orders. These Standing Order sets are not intended to replace more detailed
department specific clinically based emergency response order sets such as Code Blue protocols.
B. The ED Registered Nurse (RN) will initiate orders off the Standing Order sets if the patient
assessment findings warrant the Standing Order intervention within their scope of competency and
within the resources of the applicable Emergency Department.
1. These Standing Order sets are complaint specific and were developed to be within the critical
thinking skill set of a bedside emergency department RN.
2. The RN may not alter the content of any Standing Order.
3. A Standing Order set(s) does not need to be implemented in its entirety. The RN should
implement applicable section(s) of the Standing Order set based on patient assessment and
established criteria.
4. More than one Standing Order set may be used for a patient as appropriate per patient need
and RN assessment. For example: A patient presenting with a laceration may require both the

May not be current policy once printed

Print Date: 7/30/2013

Policy Title: Emergency Department Standing Orders

C.
D.
E.
F.

IV.

Standing Order for Tetanus and an order for radiologic testing depending on patients
presentation.
The RN will consult with an on-duty ED physician/provider if clarification is needed in initiating a
Standing Order(s).
The RN is accountable and responsible for the delegation of any intervention in the Standing
Order set.
The RN must document assessment findings, interventions, and outcomes per this policy.
Emergency Department Standing Orders must be entered into the patients medical record and
authenticated by the responsible provider for the patient according to the facility/department
specific order authentication process.

Procedure/Interventions:
A. Patient presents to the ED with specific symptoms that align with a current ED Standing Order set
B. RN assessment confirms symptom(s) or condition that warrants initiation of Standing Order set
C. RN initiates corresponding SO and consults with medical provider if additional clarification is
needed
D. Standing Order Sets:

1. Applicable to all adult/pediatric patients experiencing the following conditions:

a. SO ED - Abdominal pain
b. SO ED - Chest Pain Adult
c. SO ED Diarrhea
d. SO ED Dyspnea
e. SO ED Dysuria
f. SO ED - Eye Problems
g. SO ED Fever
h. SO ED - Flank Pain
i. SO ED - GI Bleeding
j. SO ED Hemoptysis
k. SO ED Laceration
l. SO ED - Medical Imaging
m. SO ED - Musculoskeletal Pain
n. SO ED - Nausea & Vomiting
o. SO ED - Seizure
p. SO ED Shortness of Breath
q. SO ED Syncope
r. SO ED Vaginal Bleeding
B.

V.

See Appendix A for details on associated orders specific to the outlined conditions.

Procedural Documentation:
A. N/A

VI.

Additional Information:
A. Centers for Medicare & Medicaid Services, Conditions of Participation Section 482.23 (c) (2)
The use of standing orders must be documented as an order in the patients medical record and authenticated by
the practitioner responsible for the care of the patient, as the regulations at 42 CFR 482.23(c) (2) and
482.24(c) (1) require, but the timing of such documentation should not be a barrier to effective emergency
response, timely and necessary care, or other patient safety advances. We would expect to see that the standing
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Policy Title: Emergency Department Standing Orders

order had been entered into the order entry section of the patient's medical record as soon as possible after
implementation of the order (much like a verbal order would be entered), with authentication by the patient's
physician

VII. References:
Centers for Medicare & Medicaid Services, Conditions of Participation Section 482.23 (c) (2)

VIII. Other Related Policies/Procedures:

A.
B.
C.
D.

IX.

Keywords and Keyword Phrases:

A.
B.
C.
D.
E.
F.

X.

Provider Hospital Orders-Standing Orders Development and Approval Policy

Nursing Assessment Policy
Medication Administration Policy
Nursing Standards of Practice guidelines

Standing Orders- Emergency Department

Standing Orders
ED
Emergency Department
Nursing Assessment
Medication Administration

Appendix:
A. Appendix A: Emergency Department Standing Orders.

Policy Title: Emergency Department Standing Orders

Appendix A:
------------------------------------------------------------------------------------------------------------------------------------Table 1 Emergency Department Standing Orders
SO ED ABDOMINAL PAIN
Nursing

Saline Lock IV

DIET

NPO (except medications)

NPO (including medications)

Laboratory

CBC w/Diff [cs]

UR UA.
CMP
POC for nursing (urine dipstick)

Epigastric or RUQ Pain Add:

Lipase Serum
With Jaundice and/or on Warfarin Add:
PT(includes INR)
If Female of Menstruating Age and No Hysterectomy Add:
UR HCG Qual
POC for nursing (urine HCG POC Nursing)
Quick Qualitative Urine Pregnancy (HCGKITU)
HCG Qual Serum
HCG Quant, Serum
Possible Cardiac Component or Upper Abdominal Pain > 40 years old, Add:
Troponin I Assay
POC Troponin
DIAGNOSTIC TESTING

EKG

SO ED Chest Pain Adult

NURSING
Suspect Cardiac Origin:

LABORATORY

Saline Lock IV (Antecubital)

Cardiac Monitoring
RSP Oximeter Continuous
RSP Oxygen- 2L /min Nasal Cannula titrate to keep O2 Sat > 90% T:N
CBC w/Diff [cs]
CMP
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Policy Title: Emergency Department Standing Orders

Troponin I Assay
POC Troponin
If on Warfarin Add:
DIAGNOSTIC TESTING
MEDICAL IMAGING

MEDICATIONS

PT(includes INR)
EKG
Chest Single View Adult Portable
Chest PA + Lat
Aspirin initial 324 mg. PO chew tab

SO ED Diarrhea
Nursing

Saline Lock IV

LABORATORY
Elderly Patients with Orthostatic Changes, or Any Patient with Suspected Volume Deficit:
CBC w/Diff [cs]
CMP
Nurse Communication: Collect & save stool specimen if possible
UR UA
POC for nursing (urine dipstick POC Nursing)
Urine Culture (UR Culture Urine) if indicated

SO ED Dyspnea

NURSING
RNs may use their clinical judgment to initiate an SVN (small volume nebulizer) based on signs and symptoms including:
-Dyspnea and/or wheezing
- Oxygen saturation <90%
For patients ages 1 year- 17 years old, RNs may initiate the ED Pediatric Asthma protocol based on an Asthma Respiratory
Severity Score (RSS) as applicable
For patients ages 0- 24 months old, RNs may initiate the Pediatric Bronchiolitis protocol as applicable including
performing a Bronchiolitis Respiratory Severity Score (BRS)
Call / request Respiratory to respond
RSP Oximeter Continuous
RSP Suction- age appropriate suction bulb or BBG nasal aspirator (Reserve deep suction for
airway obstruction causing significant respiratory compromise)
RSP Oxygen- 2L /min Nasal Cannula titrate to keep O2 Sat > 90% T:N (or blow by for infants)
RSP SVN - Albuterol 2.5 mg SVN, Soln, 1 x ONLY Shortness of Breath or wheezing
RSP Peak Flow Measurement 2 times- Perform Peak Expiratory Flow Rate (PEFR) before and
after treatment if able (Exception infants and small children)
For patients under 11 years old presenting with sudden onset loud barking cough, Pediatric trained RNs may initiate the
following (available only at Certified Pediatric Emergency Departments)
Mild: Barky Cough
MEDICATION
Dexamethasone (Decadron) 0.6mg/kg po, not to exceed 10 mg, 1 x only
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Policy Title: Emergency Department Standing Orders

Moderate/Severe: Barky Cough with active stridor, retractions at rest, retractions with severe respiratory distress,
hypoxia, or cyanosis
If child is under 6 months of age:
RSP SVN-Racemic epinephrine 0.3ml of 2.25% solution diluted in 3mL NS SVN, 1x ONLY
If child is 6 months of age or older:
RSP SVN-Racemic epinephrine 0.5mL of 2.25% solution diluted in 3 mL NS SVN, 1x ONLY
If child is no longer moderate/severe:
Medication
dexamethasone (Decadron) 0.6mg/kg po, not to exceed 10 mg, 1 x ONLY
dexamethasone (Decadron) 0.6mg/kg IM, not to exceed 10 mg, 1 x ONLY. For use only if patient vomits oral dose.
Document patient assessment and notify provider as soon as possible after treatment has begun
Repeated SVNs are given only after the provider has been consulted or per ED Pediatric Asthma protocol

SO ED Dysuria
LABORATORY

UR UA
Urine Culture (UR Culture Urine) if indicated
POC for nursing (urine dipstick POC Nursing)

If Female of Menstruating Age and No Hysterectomy Add:

HCG Urine Qual
POC for nursing (urine HCG POC Nursing)
Quick Qualitative Urine Pregnancy (HCGKITU)
HCG Quant, Serum
HCG Qual Serum

SO ED Eye Problems

MEDICATIONS
FOR SEVERE PAIN DUE TO POSSIBLE CORNEAL ABRASION OR FOREIGN BODY
CONSIDERATION: Do NOT use topical anesthetic (tetracaine or proparacaine) if there is a possible globe perforation.
tetracaine ophthalmic 1 drop, 1x ONLY
proparacaine ophthalmic 1 drop, 1 x ONLY
NURSING
Visual Acuity Evaluation
CHEMICAL SPLASH TO THE EYE(s) Check pH, but do not delay irrigation
CONSIDERATION: Do NOT use topical anesthetic (tetracaine or proparacaine) if there is a possible globe perforation, if not
contraindicated:
tetracaine ophthalmic 1 drop, 1x ONLY
proparacaine ophthalmic 1 drop, 1x ONLY
S-Sol Irrigation Sodium Chloride 1L (S-Solution Irrign NaCl 0.9 1L), use ocular irrigation set
NURSING

Visual Acuity Evaluation

SO ED Fever
Nursing

Saline Lock IV

LABORATORY
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Policy Title: Emergency Department Standing Orders

Toxic appearance:

CBC w/Diff [cs]

CMP
Lactic Acid
Blood Culturex2
UR UA
POC for nursing (urine dipstick POC Nursing)
Nurse Communication: urinalysis clean catch or catheter

MEDICATION
Consider Acetaminophen when: 1. the child's temperature is 38.0 C or higher 2. The child was under dosed according to
weight guidelines 3. Or the last dose was vomited regardless of the time it was given. Consider Ibuprofen when
Acetaminophen was given within the last 4 hours and if the childs temperature to 38.0 C or greater.
14 years and younger: 15mg/kg
Acetaminophen PO or rectal
For children age 6 months to 14 years: 10mg/kg
Ibuprofen PO
If Neonatal Fever:

IV Saline Lock
Straight Catheter Insert NEO
UR UA catheterize
UR Culture - catheterize
Blood Culture x 1
Draw red top to hold
Lidocaine 4% cream (LMX /Ela-max)- apply up to 5 gm to lumbar spine area

SO ED Flank Pain
NURSING

Saline Lock IV

LABORATORY
Basic Labs:

CBC w/Diff [cs]

Comprehensive Metabolic Panel
UR UA
Urine Culture (UR Culture Urine) if indicated
POC for nursing (urine dipstick POC Nursing)
If Female of Menstruating Age and No Hysterectomy Add:
HCG Urine Qual
POC for nursing (urine HCG POC Nursing)
Quick Qualitative Urine Pregnancy (HCGKITU)
HCG Quant, Serum
HCG Qual Serum

SO ED GI Bleeding
Nursing

Saline Lock IV

LABORATORY
Apply Blood Band ID to all specimens
CBC w/Diff [cs]
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Policy Title: Emergency Department Standing Orders

Comprehensive Metabolic Panel

PT(includes INR)
Hold Clot
If Patient on Heparin or Hemophiliac Add:
PTT (APTT)
If Hemodynamically Unstable, add:
Type and Screen
If Chest Pain, see SO ED Chest Pain

SO ED Hemoptysis
Nursing

Mask

Medical Imaging

Chest X-ray PA/Lat

SO ED Laceration

MEDICATION
If last tetanus immunization greater than 5 years or unknown, and no history of adverse reaction to tetanus (IF CHILD IS
UNDER 10 YEARS OF AGE, CONTACT PROVIDER)
diphtheria/pertussis, acel/tetanus adult (diphtheria/pertussis/tetanus) 0.5mL IM 1X ONLY
For topical anesthetic use at laceration site (DO NOT USE for fingers, toes, nose, or ears)
LET topical anesthetic solution- apply up to 3 mL to an open wound for 20-30 minutes
For patients under 18 years old presenting with pain associated with minor closed head injury and/or laceration
(available only at Certified Pediatric Emergency Departments)
Consider Acetaminophen for pain: If the child was not already given acetaminophen
Consider Ibuprofen for pain when child is over 6-months-of-age AND Acetaminophen was given within the last 4 hours
or the child is allergic to acetaminophen
Acetaminophen 15mg/kg PO, not to exceed 1000mg, 1 x ONLY
Ibuprofen 10mg/kg PO, not to exceed 800mg, 1 x ONLY

SO ED Medical Imaging

PRIOR TO ORDERING
1. Nurse may order one site (all views) for x-rays. Consult with physician if more than one site (all views) needs to be ordered,
unless special instructions are noted in WHAT TO ORDER
2. Question patient for possible pregnancy
3. Examine injured area and initiate ice, immobilization and elevation
4. Request analgesia ASAP as needed
5. Always palpate joints above and below injury to assess for other injuries
INDICATIONS:
1. Injury confined to extremities
2. Presence of deformity, instability, crepitus, point tenderness, ecchymosis, swelling or pain
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Policy Title: Emergency Department Standing Orders

3. Patient request which meets above criteria

4. History significant for probable fracture
PROVIDER CONSULTATION NEEDED:
1. Any time multiple sites may need to be taken
2. Any doubts the nurse has on which films to order, i.e. unable to localize injury
3. All patients possibly pregnant
4. Any associated injury to head, neck or trunk
5. Any evidence of neurovascular compromise
WHAT TO ORDER
"Heard a pop", inversion or eversion ankle injury; swelling at malleoli. Palpate fifth metatarsal and if pain present, order a
foot x-ray also. Ankle film does not visualize the metatarsals well.
Ankle 3 Or More Views Lt
Ankle 3 Or More Views Rt
Post traumatic pain if associated with decrease or loss of supination, pronation, flexion or extension.
** In a child of 5 years or less with unexplained loss of arm function and no apparent soft tissue swelling, a radial head
subluxation must be considered and x-rays should not be obtained prior to physician evaluation.
Elbow 3 Or More Views Lt
Elbow 3 Or More Views Rt
If swelling or pain on top of foot.
Foot 3 Or More Views Lt
Foot 3 Or More Views Rt
Clear hand injury distal to wrist
Hand 3 Or More Views Lt
Hand 3 Or More Views Rt
Order special calcaneal films if fracture suspected
Calcaneus [Heel] Lt
Calcaneus [Heel] Rt
1. Inability to stand or walk with localized knee pain
2. Post traumatic joint effusion
3. A fall or blow to the kneepatellar area with subsequent inability to flex or extend the knee fully. If pain over patellar area,
add order for sunrise (patellar) view
Knee 3 View Lt
Knee 3 View Rt
Tenderness above the shoulder or on top of the shoulder; may or may not have swelling/deformity.
Shoulder 2 Or More Views Lt
Shoulder 2 Or More Views Rt
1. Fall on an outstretched hand with swelling and tenderness to the wrist
2. If snuffbox tenderness, a comment of "navicular view" in the order comments.
Wrist 3 Or More Views Lt
Wrist 3 Or More Views Rt
Post traumatic pain in hip area if associated with rotated and shortened leg
Hip 2 Or More Views Lt
Hip 2 Or More Views Rt
Pelvis 1 or more views
Post traumatic pain in thigh area with swelling or pain to thigh area
Femur 2 Or More Views Lt
Femur 2 Or More Views Rt

Policy Title: Emergency Department Standing Orders

SO ED Musculoskeletal Pain
Nurse Communication: Provider comfort measures i.e. Ice, pillow, elevation and consult MD for pain medication
MEDICATION
For patients under 18 years old presenting with pain associated with minor closed head injury and/or musculoskeletal
injury (available only at Certified Pediatric Emergency Departments)
Consider Ibuprofen for pain when child is over 6-months-of-age: 1. If the child was not already given ibuprofen
Consider acetaminophen for pain if: 1. Ibuprofen was given within the last 6 hours, 2. the child is allergic to ibuprofen,
3. The child is under 6-months-of age
Ibuprofen 10mg/kg PO, not to exceed 800mg, 1 x ONLY
Acetaminophen 15mg/kg PO, not to exceed 1000mg, 1 x ONLY

SO ED Nausea and Vomiting

Nursing

Saline Lock IV
For pediatric patients greater than 6 months old, may start Oral Rehydration Therapy (ORT) per
protocol as applicable

LABORATORY

UR UA
POC for nursing (urine dipstick POC Nursing)
CMP
CBC w/Diff [cs]
If Female of Menstruating Age and No Hysterectomy Add:
UR HCG Qual
Quick Qualitative Urine Pregnancy (HCGKITU)
POC for nursing (urine HCG POC Nursing)
HCG Qual Serum
HCG Quant, Serum
MEDICATIONS

2 mg for weight from 8 to 16 kg

4 mg for weight >16 kg

Ondansetron (Zofran ) ________ mg PO DIS (Disintegrating) Tablet or liquid now

If Abdominal pain follow SO ED Abdominal pain careset

SO ED Seizure
Nursing

LABORATORY

Saline Lock IV
Nurse Communication, place seizure pads around patient.
Glucose Point-of-Care (Finger-Stick Glucose)

With Prior Seizure History and On One Of These Medications Add:

Carbamazepine (Tegretol) Level
Dilantin Level
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Policy Title: Emergency Department Standing Orders

Valproic Acid (Depakane) Level

Phenobarbitol Level
If Fever or Obtunded Add:

Blood Culturex2
UR UA
POC for nursing (urine dipstick POC Nursing)
Urine Culture (UR Culture Urine) if indicated
CBC w/Diff [cs]
Comprehensive Metabolic Panel

If Female of Menstruating Age and No Hysterectomy Add:

UR HCG Qual
POC for nursing (urine HCG POC Nursing)
Quick Qualitative Urine Pregnancy (HCGKITU)
HCG Qual Serum
HCG Quant, Serum

SO ED Shortness of Breath

Does Not Apply to Uncomplicated Asthma in a Young Patient, see SO ED Dyspnea

NURSING

Saline Lock IV
RSP Oximeter Continuous
RSP Oxygen- 2L /min Nasal Cannula titrate to keep O2 Sat > 90% T:N

LABORATORY

CBC w/Diff [cs]

CMP

If Cardiac Origin Add:

BNP
Troponin I Assay
POC Troponin

DIAGNOSTIC TESTING

EKG

MEDICAL IMAGING

Chest Single View Adult Portable

Chest PA + Lat

SO ED Syncope
NURSING

Notify Physician if Hemodynamically unstable

Orthostatic vitals
Saline Lock IV

LABORATORY
Draw Extra Tubes for Possible Cardiac Enzymes, PT, INR, PTT, Toxicology Studies, Type and Screen
CBC w/Diff [cs]
CMP
UR UA
POC for nursing (urine dipstick POC Nursing)
If Female of Menstruating Age and No Hysterectomy Add:
Urine HCG Qual
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Policy Title: Emergency Department Standing Orders

POC for nursing (urine HCG POC Nursing)

Quick Qualitative Urine Pregnancy (HCGKITU)
HCG Qual Serum
HCG Quant, Serum
Apply Blood Band ID to Specimens
DIAGNOSTIC TESTING

EKG

SO ED Vaginal Bleeding
LABORATORY

UR UA
POC for nursing (urine dipstick POC Nursing)
CBC w/Diff [cs]

If Female of Menstruating Age and No Hysterectomy Add:

UR HCG Qual
POC for nursing (urine HCG POC Nursing)
Quick Qualitative Urine Pregnancy (HCGKITU)
HCG Qual Serum
If Patient Reports a Positive Pregnancy Test or has a Positive Pregnancy Test Add:
Rh Only
HCG Quant, Serum
If on Warfarin Add:

PT(includes INR)

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