It took more than 9 months, but ACEP and other emergency medicine organizations persuaded the Centers for Medicare and Medicaid Services to reinstate the use of standing orders in an October 2008 ruling.

On Feb. 8, 2008, CMS unexpectedly issued an interpretive guidance of The Joint Commission regulations and terminated the longstanding practice of dispensing care under a standing order unless or until it was signed by the patient’s physician. CMS reasoned that this approach better safeguarded patients and ensured complete, direct physician attention and oversight.

The February guidance prevented nurses and other health care workers from dispensing care beyond their authority or knowledge, without the watchful eye of the patient’s physician. Consequently, a physician’s signature was required before a standing order could be used—even to dispense an aspirin for a heart attack patient—a standard intervention.

The ruling created major hurdles, especially for busy, crowded emergency departments that relied on standing orders for more efficient triage of some cases. Worse still, many hospitals were caught unaware and were being cited and fined in their Joint Commission surveys for using unsigned standing orders.

ACEP and other emergency medicine organizations made the argument that this CMS ruling was counterintuitive and counterproductive. Rather than safeguarding patient care, it was jeopardizing patients by restricting time-tested, proven, often lifesaving interventions, and increased the backlog of patients.

In response to the CMS ruling, ACEP staff members worked diligently and collaboratively with the Emergency Nurses Association (ENA) and the American Academy of Emergency Medicine (AAEM) for months to reverse the CMS decision.

ACEP’s Federal Affairs Director, Barbara Tomar, argued successfully that requiring a physician’s signature before care could be dispensed might actually lead to a worse, not better, outcome. Ms. Tomar argued that it is potentially more dangerous to the patient and risky for the hospital not to provide immediate intervention via the hospital’s standing orders, which are approved by the medical staff and are based on proven best practices.

“The now chronic ED crowding crisis and the needs of patients for intervention in a timely fashion necessitate a responsive method of developing standing orders to ensure prompt, proper intervention whenever possible,” Ms. Tomar said.

ACEP’s Chair of the Board and Immediate Past-President, Dr. Linda Lawrence, said it was exciting to work with other emergency medicine organizations and to see “that the voice of the nurses was represented” to The Joint Commission and CMS.