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Friday, March 25, 2011

Order sets are stupid, IMO

Based on my experience as a departmental representative at various administrative committees, I am privy to some wisdom not available to the general public. For instance, many hospitals have order sets that are hidden under the guise as protocols.

No, they are not protocols. Protocols increase personal accountability and responsibility. Protocols increase personal thought and intellectuality. Protocols preach individuality.

Yet order sets, while started with the intention of doing what is best by best practice medicine, generally make it so each patient is treated the same. Order sets take away personal accountability, individual thought, personal accountability and responsibility.

Protocols improve morale, and order set decrease morale. Order sets decrease morale because all we do is a bunch of procedures not because they are needed, or even because a doctor wanted them, but just because. Order sets are cook book medicine.

Order sets (which, again, go under the guise as protocols and guidelines) not only result in decreased morale, they increase the cost of medicine because, ahem, someone has to pay for all of this impractical medicine.

CMS only pays a flat fee (because of DRGs), and those obtaining CMS services get free healthcare (well, free to them anyway. We have to pay for their free). Therefore, the one's who will pay are those of us who pay premiums for health insurance.

We will pay more. This goes along with the premium hikes we will now have to pay because Obama care provisions to force insurance companies to pay for dependents until they are 25, and previous medical conditions (liabilities).

Consider the following:

1. Of the 20 EKGs I did today, only 15 were needed. All were ordered not by a doctor but by an order set.

2. Of the five ABGs I did today, none were needed. All were ordered not by a doctor but by an order set.

3. Of the 30 breathing treatments I did today 28 were not needed. All 28 were ordered not by a doctor but by an order set.

4. Of the six stress tests completed in my department today, none were needed. All were ordered as a result of an order set.

Order sets wouldn't be so bad in and of themselves, but most of the items on them are pre-checked, at least at my institution. To not order something, the doctor has to scratch out the item and sign. And then risk a lecture by the Quality Review lady. So it's easier for them not to bother.
If order sets were as they were initially intended, a list of all possible procedures the doctor might want to order, then order sets wouldn't be so bad. And balanced by good protocols to eliminate ordered procedures that aren't needed, order sets would also be good.  Yet that's not how it is when you resign yours institution to cook book medicine.

Thus, most items on order sets are ordered whether needed or not. Common sense is not the result of an order set. Common sense and individual thought are down the drain.

The following are unintended consequences of order sets:
  • Lots of not needed procedures
  • Wasted money
  • Increased workload for RTs
  • Increased burnout
  • Loss of confidence due to loss of ability to decide what patients need
  • Loss of morale due to inability to use common sense
  • Poor attitude at bedside because after the umpteenth not needed EKG or treatment you get irritated by it all. It becomes a job rather than a profession, like working an assembly line at a factory
  • Poor patient care due to low morale and in a hurry to get all the procedures done
  • Feeling of irritation by RTs because we're doing a bunch of BS
  • Increased apathy
  • RTs develop RATS, which isn't good for the institution (and I'm not talking about the creepy little critters either.)
In the ideal world order sets are counterbalanced by protocols.  But in the real world idealism in merely a pipe dream. 

Yes, there are some advantages to order sets. Yet the disadvantages are way more than the advantages. There's an old saying: Something is worth the investment only when the advantages out weight the disadvantages.

And in this case, the few recommending these order sets (mainly people sitting at a desk in Lansing or Washington) have a clue of the negative consequences. Or do they? Perhaps the intent is to collapse the health care system. Perhaps that's the intent. If it's not, I have a hard time justifying it.


1 comment:

kscottrichey said...


I enjoyed reading your perspective on order sets; I as well agree that poorly written order sets allow for the implementation of unnecessary or non-indicated procedures, therapies, and medications.

I can see these being very problematic in regards to the newer physician, when seeing all the choices provided they feel they should select them all thinking it is more beneficial to the patient.

What ever happened to the “Hippocratic Oath” in medicine, “First Do No Harm”?

Conversely, I have seen a few (~3) well written order sets, that were designed by a multi-disciplinary team (Respiratory Therapy Included).

- Evidence based medicine on antibiotic administration.
- Sepsis order set which uses the “Rivers Protocol” & Respiratory Therapy to implement lung protective strategies & limit plateau pressures.
- An order set that the default is for Respiratory Therapy to manage the ventilator, if the physician does not want this they would have to write all the orders them self.
- An order set that the default is Respiratory Therapy to consult or the physician has to write in everything.

These order sets are very rare, and the only thing that will change the standard is a dedicated & supportive medical director, RT Manager, and RT staff willing to set on a few committees which will bring the evidence base to the table.