An “order to admit” is defined as a dated and timed order from a licensed independent practitioner (LIP) with appropriate privileges.  The order to admit serves to notify hospital registration, health information management, and case management of the admission and the desired location of the patient within the hospital.  These are within the scope of practice for an emergency physician, and require only four elements – the admitting physician’s name and service, diagnosis, location and clinical status.  They do not, however, constitute admission orders.

“Admission orders,” on the other hand, are a set of orders individualized to the clinical condition of the patient. They are written in a timely manner following the order to admit by an LIP with admission privileges; the hospital must define the acceptable timeframe for the LIP to provide admission orders (usually based on the patient’s acuity level, or clinical condition and location within the hospital); hospitals should monitor compliance with these rules and policies.

"Transition orders" fall somewhere in between.  They are time-limited orders that facilitate the transfer of care between the ED and inpatient setting; provide continuation of essential measures begun in the ED and those immediately necessary for the acute care of the patient; and they are a “handoff of care” communication (in that they are a real-time, interactive process of passing patient-specific information from one caregiver or team to another for the purpose of ensuring the continuity and safety of the patient’s care) – but they do not replace admission orders.

Before you implement bridge order protocols, there are many things to be considered, such as whether ED physicians have privileges to admit patients to inpatient or observation status, and who has the ultimate responsibility for the patient when transition orders are executed. Consider also whether using transition orders will delay attending physician response time or increase the amount of time a patient spends waiting to be transferred to the inpatient unit.  Above all, are transfer orders in the best interest of your patients or staff? Will they expose the ED physician to unnecessary additional risk or will supporting transition orders place the ED physician at odds with his own professional organization?

The American College of Emergency Physicians (ACEP) believes that the best patient care occurs when there is no ambiguity as to who the responsible physician is for the patient.  Medical orders establish which physician is in charge of a patient’s care. ED physicians generally are not credentialed or insured to provide continuing inpatient care. Therefore, ACEP endorses the following principles:

·       The ED physician should not be compelled to write any orders that extend, or appear to extend, control and responsibility for the patient beyond treatment in the ED to the inpatient setting.

·        Hospital and ED policies should clearly delineate responsibility for writing admission orders.  Policies should also guarantee that the patient be seen in a “timely manner.”

·        Hospital policies and procedures should clearly delineate that once an admitting physician has accepted a patient, that admitting physician has assumed responsibility for the patient, regardless of the patient’s physical location within the hospital.

Keep the following points in mind, from a risk management perspective:

·        The best patient care occurs when admitting physicians take immediate or early responsibility for patient care.  Therefore, having the admitting physician write admission orders at the time the order to admit is written provides the highest quality and safest care, minimizes exposure to liability for the emergency physician, and is probably most compatible with the ACEP policy statement, “Writing Admission and Transition Orders.”[1]

·        When this is not possible, or when an attending physician asks an ED physician to write admission orders, and if the ED physician is permitted to do so under the hospital’s bylaws, transition orders may be a reasonable alternative to a lapse in care, in that they “bridge” the gap in care until the attending physician takes over (between an order to admit and actual admission orders.) These should be time-limited orders, and close communication between the attending physician and ED physician must be maintained.

Click here to download our handy list of guidelines for implementing a transition order policy.