2.7 Protocol and order set development

10.1055/b-0038-164262

2.7 Protocol and order set development

Stephen L Kates, Joseph A Nicholas

To access the References, please follow the URL link

1 Introduction

High-performing geriatric fracture centers report the institution of protocols and order sets as one of the major tools to improve outcomes. These attempts at standardization of care are often focused on many different members of the care team, including providers, nursing, ancillary services, and administrative staff responsible for arranging safe and timely surgery.

Standardization of care is an essential part of providing optimal care for fragility fracture patients (FFPs). Order sets, protocols, and care plans are tools that can help organize safe and efficient care, and avoid errors due to inappropriate variation. These tools are the centerpiece of fracture programs that yield significant gains in safety and reductions in harm.

This chapter will discuss the rationale for increased standardization of care, as well as issues to consider in the development, adoption, and maintenance of these tools.

2 Why are standard protocols and order sets needed?

The primary concept is to create a standard work flow for a specific diagnosis. The concept of standard work is ubiquitous in industry dating back to the early 20th century in the automotive industry [1]. Standard order sets offer a lot of benefits, as the following list and Table 2.7-1 show:

**Table 2.7-1**: Areas to address in a standardized program.
Area	Benefit	Example	Team members
Emergency department order sets	Rapid admission Avoid unnecessary tests and x-rays	Emergency department order set	Surgeon Medical doctor Nurses Pharmacist Emergency physician
Admission orders	Optimize patient Appropriate tests Avoid bad medications	Admission order set for hip fractures	Surgeon Geriatrician Nurses Pharmacist Social worker Therapists Mid-level providers
Postoperative orders	Streamlined postoperative care Appropriate medications ordered Avoid unnecessary tests Early discharge Avoid delirium	Postoperative hip fracture order set	Surgeon Geriatrician Nurses Pharmacist Social worker Therapists Mid-level providers
Consultation form	Standard assessment for preoperative patient Risk stratification Avoid unnecessary consultations	Preoperative geriatric fracture consultation form	Geriatrician Surgeon Anesthesiologist
Surgical choices	Develop decision tree based on radiographic pattern for evidence-based correct hip fracture fixation Goal is stable fixation that allows immediate weight bearing	Hip fracture poster to hang in surgical area	Surgeon champion
Metabolic bone workup	Standardized assessment for osteoporosis, primary or secondary	Set of orders, including vitamin D level, PTH level, TSH level, calcium	Surgeon and medical physicians Mid-level providers
Transfer protocol	Standard method for streamlined acceptance of transfers from other facilities	Transfer protocol and poster	Surgeon Medical physician Mid-level providers Hospital administration
Direct admission	Standard method for streamlined acceptance of direct admission to the orthopedic floor from other facilities	Direct admission protocol	Surgeon Medical physician Mid-level providers Hospital administration
Nursing care	Plan that follows each step of the standard order sets Everyone is on the same page	Nursing care map	Surgeon Medical physician Nursing leaders
Discharge process	Early hospital discharge	Standardized social work assessment done prior to surgery after admission	Social worker Surgeon and medical champion
Consent forms	Preprinted procedure-specific consent forms	Expedite consent process with legible complete form Avoid liability issues	Surgeon champion
Outcomes report	Collect standard outcome measures for hip fracture patients	Monitor program performance	Surgeon and medical champions Hospital administration
Comorbidity scoring	Score patients with a standard score that predicts outcomes	Helps to risk-stratify patients For outcomes, and understand patient comorbidity severity	Surgeon and medical champion Hospital quality department and information technology personnel
Abbreviations: PTH, parathyroid hormone; TSH, thyroid-stimulating hormone.

They may help to reduce unnecessary variations [2–6]. This avoids what is referred to as “inappropriate creativity” by the physician when writing orders and devising treatment plans.
They ensure that patient care follows a predetermined pathway that has been shown to be effective and hopefully is based on evidence-based best practices [7].
When all patients are managed using standard protocols and order sets, outcomes can be better assessed and compared. When an order or pathway is changed, it is considerably easier to assess the effects of the change.
An unspoken benefit of standard protocols and order sets is that all members of the care team come to accept them as being the norm, and recognize potentially harmful deviations. When there is a variation from the norm, the team members will question why, often avoiding harm or an adverse event. Use of standard order sets offers the opportunity for significant cost savings by reducing the use of “physician preference” medications and other variations. This results in measurable cost savings and offers the opportunity to avoid medication errors.