Mount Sinai Hospital is a core urban hospital in Toronto that sees about 65,000 patients a year of whom 20% are >65.
We have easy access to an interdisciplinary assessment team (physiotherapist, occupational therapist, social work) but only during business hours. So we frequently hold people overnight in the ED after they have been fully medically assessed specifically to see the assessment, frequently leading to discharge. However we were having a lot of complaints/comments from the team as well as patients that things were going wrong during that holding period: regular medications like BP meds or anti-Parkinson’s meds or bed-time sedatives – were not being given; inappropriate medications like benzodiazepines were being given at 0400 for sedation leaving the person too sleepy for assessment; patient was left “NPO” for 16 hours and so was hungry, weak, and dehydrated by morning; by next day, after two shift changes, no one knew exactly what the original plan was!
Our GEM nurse and unit manager and a physician developed an order set (the “Extended Orders for Hold Overnight” set) to bring some uniformity to managing these patients. It requires the physician initiating the hold, to make clear that all medical investigations are complete (and their outcomes); to establish a clear plan (e.g. “medically stable for discharge after mobility and functional assessment complete”); to promote mobility by discontinuing any tethers (IVs, monitors, catheters, etc.); to ensure diet, hydration, and weight-bearing were clarified; to record orders for all standing orders; and variable medications usually for analgesia.You can download the order set here:
You can download the order set here: Extended Orders for Hold Overnight – DOWNLOAD
The Challenges and Drivers
It’s an extra piece of paper or computer screen to interact with so staff needed to be convinced that filling it out was not only good for the patient – but made their lives easier too. Nurses were certainly early adopters because they quickly saw that their job was clearer and fewer things were going wrong. It also addressed doctors’ reluctance to accept handovers as there was a form that clarified what had been done, what needed to be done, and who was responsible. Within three months “Are the Hold Overnight Orders complete?” became a standard question at each handover!
Cost? Administrative time (3-4 hours to create the form); some staff in-service time.
More uniform care for our most complex patients; fewer missed medications; less delirium; more awareness among staff of the importance of mobilizing and “de-medicalizing” patients; more successful and more expeditious assessments (e.g. clarity around weight-bearing status for physios; more effective analgesia allowing better functional assessment)
You can download our Hold Overnight Orders for use in your ED.
More information: Contact Don Melady at firstname.lastname@example.org