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Nurse Initiated Orders

  • 1.  Nurse Initiated Orders

    Posted 08-02-2023 19:13
    Edited by Mallory Stroup 10-14-2025 15:43

    I am wondering if anyone else is using Nurse Initiated Orders for basic preventative care orders (mammogram, influenza vaccine, etc) in their clinics? If so, what is your workflow for using them and what types of orders are nurses placing?



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    Mallory McConnaha, BSN, RN, AMB-BC

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  • 2.  RE: Nurse Initiated Orders

    Posted 08-03-2023 06:43

    Hi Mallory,

    I am an ambulatory CNES and work closely with our director of compliance to build a robust library of standing orders for situations like these. We have a Standing Orders committee with nursing, MD, and pharma representation to vet the orders through. Once approved they are good for a year. They come up for review annually and are revised to reflect current EBP. The standing orders advise on who falls within scope to enter the orders, what patients are included or excluded, and an exact step-by-step of how to enter the orders. This eliminates the need for nursing judgment because the order already states who is within scope and which patients are applicable.



    ------------------------------
    Torie Bonnet MSN, OCN, RN, NE-BC
    Clinical Nurse Education Specialist, Ambulatory Care
    UNC Health
    Raleigh NC

    torie.bonnet@unchealth.unc.edu
    ------------------------------

    Original Message


  • 3.  RE: Nurse Initiated Orders

    Posted 08-03-2023 08:08

    Hi Mallory,

    Our process is similar to Torie's at UNC Health.  We have a myriad of Nurse Standing Orders for preventative services that have been vetted and approved by an authorizing provider, and can be activated by an RN/LPN.



    ------------------------------
    Philidah Seda DNP, MSN, RN
    Sr. Director of Nursing
    Kaiser Permanente
    Kennesaw GA
    (470)373-9724
    ------------------------------

    Original Message


  • 4.  RE: Nurse Initiated Orders

    Posted 08-03-2023 08:23

    Once again, I agree with Torie! 

    We have different sets of standing orders, depending on the patient population (pediatrics, general medicine, women's, urology, cardiology). The orders are based off of best practices, commonly ordered tests, published vaccine standing orders, and for population health specific items the US Preventative Task Force standards. Commonly ordered tests have clear indications on when it can be used (ex: rapid strep can be performed if the patient is presenting with acute onset of sore throat with fever). 

    The goal for all of these is to have a standard that requires no critical thinking or medical judgement. 



    ------------------------------
    Andrea Kelly MSN, RN, NPD-BC
    Director, Population Health
    ECU Health Physicians (formerly Vidant Medical Group)
    Greenville NC
    (252)847-3930
    ------------------------------

    Original Message


  • 5.  RE: Nurse Initiated Orders

    Posted 08-04-2023 08:45
    Good morning, 
    I think there is a time and a place for standing orders. I have some concerns and like to approach problems from a position of knowledge and understanding. 

    The first question: 
    What problem are we trying to solve? Why does the problem exist and how long has it been a problem? What are the risks to this problem? 
    What are ALL the potential solutions with pro's & con's? Etcetera. 

    Until we completely understand the problem, any solution we find and attempt to implement may increase the likelihood of unintended consequences. For those who are creating standing orders I'd like to hear more about the problem you are experiencing that leads you to believe this is the best solution. What pitfalls have you mitigated? What unintended consequences have you found? 

    I worry that simply have a standing order doesn't address the root cause of a problem, and, creates the potential for more problems. Creating a standing order that automates, limits, or eliminates clinical judgement seems, on the surface, to be a time saving process enhancer. However, we are dealing with real people with real concerns, feelings, preferences, and conditions. Is one-size-fit-all really the right way to go? Additionally, if an LPN has a directed scope of practice, can an LPN initiate a standing order independently? Is that potentially a NPA violation?  

    While I have a number of additional questions and concerns, I will leave my comments with this: if the standing order is "the" way to go to fix your problem, what prevents you from having an ordering kiosk where the patient can self select their "order". If no or limited clinical judgement is needed (i.e. no assessment) why is a nurse needed? 

    Maria Burke 

    --
    Maria
    Maria S. Burke, BSN, RN-BC, AE-C
    District 1199NM
    505-948-2043




    Original Message


  • 6.  RE: Nurse Initiated Orders

    Posted 08-04-2023 15:17

    Hi Maria-

     

    All great points!

    Our nurse driven protocols have inclusion and exclusion criteria; therefore does not eliminate clinical judgement.

    Any outliers must be pended to a provider, who ultimately has the final say on whether an order is appropriate for a patient.

    These protocols are designed to support routine care in disease management, health maintenance and specialty areas. Individual patient needs would exclude then from the protocol and require the RN to triage and route as appropriate.

    Our LPNs use clinical practice guidelines, with the same inclusion/exclusion criteria- but all orders must be pended to a provider, as their clinical scope is limited compared to RN.

     

    Lisa

    _____________________

    Lisa C. Dutton, MSN, RN, AMB-BC, NE-BC

    Professional Development Manager, BWH Department of Ambulatory Nursing 

    Clinical Director, MGB Nurse Hotline

    Operations Lead, MGB COVID Outpatient Therapies

     

     

    Brigham and Women's Hospital

    75 Francis Street, Boston, MA 02115

    M: 603-479-7468 T: 617-525-7789

    brighamandwomens.org

     

     

     

    The information in this e-mail is intended only for the person to whom it is addressed.  If you believe this e-mail was sent to you in error and the e-mail contains patient information, please contact the Mass General Brigham Compliance HelpLine at https://www.massgeneralbrigham.org/complianceline .


    Please note that this e-mail is not secure (encrypted).  If you do not wish to continue communication over unencrypted e-mail, please notify the sender of this message immediately.  Continuing to send or respond to e-mail after receiving this message means you understand and accept this risk and wish to continue to communicate over unencrypted e-mail. 




    Original Message


  • 7.  RE: Nurse Initiated Orders

    Posted 08-03-2023 08:26
    Mallory,

    We have a fairly robust list of both RN/LPN and MA driven protocols, one of our most used is the Preventive Health Orders Protocol. In addition to orders for mammograms, A1C, Diabetes screening labs, we also have an accompanying protocol for caccines including childhood, Flu and COVID.

    If you’re interested, I’d be happy to hop on a call to discuss our process for development, review/approval and implementation and/or share our current preventive health protocol .

    Just let me know!

    Sarah L. Kundrat RN, MSN, NEA-BC
    Associate Chief Nursing Officer
    Executive Director, Ambulatory Nursing
    UChicago Medicine

    Sent from my iPhone


    Original Message


  • 8.  RE: Nurse Initiated Orders

    Posted 08-03-2023 09:00

    Hi there, 

    We use them in our specialty clinic and there are other delegated protocols that we have access to used in broader ambulatory. These protocols are heavily vetted through our department and in our hospital. 

    For us, we use them for ordering labs for defined circumstances and dx. Our delegation protocols contain including/excluding criteria and are very specific. We heavily document when using them and will enter an additional attachment to the order where we will need to reference the specific protocol what we are using. It is so helpful in giving uninterrupted care. 



    ------------------------------
    Rachel Tomlinson
    OHSU
    Eugene OR
    ------------------------------

    Original Message


  • 9.  RE: Nurse Initiated Orders

    Posted 08-03-2023 09:42

    Hi Mallory-

     

    We have developed Nurse Driven Protocols for Chronic Disease management that allows a nurse to place an order using the order mode "Per protocol-cosign required"  (EPIC platform) which activates the order versus pending to a provider. There is inclusion and exclusion criteria guidance built into the protocol. A provider ultimately has to sign the order, but these protocols allow nurses to practice top of their licenses and reduces delaying care.  Happy to share if this is what you are looking for.

    Best,

     

    Lisa

    _____________________

    Lisa C. Dutton, MSN, RN, AMB-BC, NE-BC

    Clinical Director, MGB Nurse Hotline

    Operations Lead, MGB COVID Outpatient Therapies

    Professional Development Manager, BWH Department of Ambulatory Nursing 

     

    Brigham and Women's Hospital

    75 Francis Street, Boston, MA 02115

    M: 603-479-7468 T: 617-525-7789

    brighamandwomens.org

     

     

     

    The information in this e-mail is intended only for the person to whom it is addressed.  If you believe this e-mail was sent to you in error and the e-mail contains patient information, please contact the Mass General Brigham Compliance HelpLine at https://www.massgeneralbrigham.org/complianceline .


    Please note that this e-mail is not secure (encrypted).  If you do not wish to continue communication over unencrypted e-mail, please notify the sender of this message immediately.  Continuing to send or respond to e-mail after receiving this message means you understand and accept this risk and wish to continue to communicate over unencrypted e-mail. 




    Original Message


  • 10.  RE: Nurse Initiated Orders

    Posted 08-03-2023 09:50

    Lisa, I would love to see what you have developed.  My email is Erin.Nicol@ohiohealth.com

    Thank You!



    ------------------------------
    Erin Nicol LPN
    OhioHealth
    Columbus OH
    (740)503-0420
    ------------------------------

    Original Message


  • 11.  RE: Nurse Initiated Orders

    Posted 08-03-2023 12:15

    Lisa, 

    I also would love to see what you have developed.  We are also on an Epic platform and are starting to develop protocols for health maintenance.  Do you have an example of one you could share?  My email is Lstapleton@skagitregionalhealth.org

    Thank You

    Leighanne Stapleton, MSN, BSN, RN 

    Clinical Service Director

    Skagit Regional Health

    Skagit Regional Clinics

    Office: 360-814-6570

    lstapleton@skagitregionalhealth.org



    ------------------------------
    Leighanne Stapleton MSN
    Clinical Service Director
    Skagit Regional Health
    Marysville WA
    (360)814-6570
    ------------------------------

    Original Message


  • 12.  RE: Nurse Initiated Orders

    Posted 08-03-2023 15:55
    Edited by Mallory Stroup 10-14-2025 15:43

    Hi Lisa, 

    I would be very interested in seeing what you have. Would it be possible to email me at mmcconnaha@kh.org? I appreciate your help!



    ------------------------------
    Mallory McConnaha, BSN, RN, AMB-BC

    ------------------------------

    Original Message


  • 13.  RE: Nurse Initiated Orders

    Posted 08-04-2023 06:34

    Hi Lisa - I would love if you could share what you have developed as well.  My email is emily.newbury@gundersenhealth.org.  

    Thank you!



    ------------------------------
    Emily Newbury
    Gundersen Health System
    Tomah WI
    ------------------------------

    Original Message


  • 14.  RE: Nurse Initiated Orders

    Posted 08-03-2023 10:19
    Mallory,
    We have a fairly robust list of both RN/LPN and MA driven protocols, one of our most used is the Preventive Health Orders Protocol. In addition to orders for mammograms, A1C, Diabetes screening labs, we also have an accompanying protocol for vaccines including childhood, Flu and COVID. We also have a number of specialty specific protocols including things like STI and UTI treatment, HTN Medication Management, etc. to help support our Population Health nurses.
    If you're interested, I'd be happy to hop on a call to discuss our process for development, review/approval and implementation and/or share our current preventive health protocol .  
    Just let me know!
    Sarah L. Kundrat RN, MSN, NEA-BC
    Associate Chief Nursing Officer
    Executive Director, Ambulatory Nursing
    UChicago Medicine



    ------------------------------
    Sarah Kundrat MSN RN NEA-BC
    Exe Dir & Assoc Chief Nursing Officer, AMB Nursing
    UChicago Medicine
    ------------------------------

    Original Message


  • 15.  RE: Nurse Initiated Orders

    Posted 08-03-2023 10:30

    Sarah-

     

    We have many similar protocols and guidelines for RNs and LPNs/MAs both for chronic disease management and Health maintenance.

    Happy to join you in the call and discussion if appropriate.

    Our specialty protocols include ones for STI, Immunizations, Advanced Heart Disease, Renal patient management, Derm, Cardiology, Allergy, and even some for our infusion dept.

     

    Have a great day all!

    Lisa

    _____________________

    Lisa C. Dutton, MSN, RN, AMB-BC, NE-BC

    Clinical Director, MGB Nurse Hotline

    Operations Lead, MGB COVID Outpatient Therapies

    Professional Development Manager, BWH Department of Ambulatory Nursing 

     

    Brigham and Women's Hospital

    75 Francis Street, Boston, MA 02115

    M: 603-479-7468 T: 617-525-7789

    brighamandwomens.org

     

     

     

    The information in this e-mail is intended only for the person to whom it is addressed.  If you believe this e-mail was sent to you in error and the e-mail contains patient information, please contact the Mass General Brigham Compliance HelpLine at https://www.massgeneralbrigham.org/complianceline .


    Please note that this e-mail is not secure (encrypted).  If you do not wish to continue communication over unencrypted e-mail, please notify the sender of this message immediately.  Continuing to send or respond to e-mail after receiving this message means you understand and accept this risk and wish to continue to communicate over unencrypted e-mail. 




    Original Message


  • 16.  RE: Nurse Initiated Orders

    Posted 08-06-2023 17:51

    Hi Lisa,

    I too am interested in learning about the RN chronic disease protocol. My email address is gmcgilberry@christianacare.org

    Thanks!

    Gloria McGilberry MSN, RN AMB-BC



    ------------------------------
    Gloria McGilberry MSN RN
    Manager
    Medical Group of Christiana Care
    New Castle DE
    (302)367-5484
    ------------------------------

    Original Message


  • 17.  RE: Nurse Initiated Orders

    Posted 08-08-2023 19:06

    I'd also be interested in learning more about RN initiated orders. You can reach me at jess.cline@protonmail.com, or Jessica.m.cline@kp.org.

     

    Thanks!  

     

    Jessica Cline, BSN, RN, CMSRN (she/they)

    Nurse Advice Line

    UFCW Local 7 Union Steward

    P: 303-388-4545 | E: Jessica.M.Cline@kp.org

     

     

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    Original Message


  • 18.  RE: Nurse Initiated Orders

    Posted 08-03-2023 16:00
    Edited by Mallory Stroup 10-14-2025 15:42

    Hi Sarah,

    I am very interested in talking with you. What you have sounds exactly like what I am looking for. Would you possibly email me so we can set up a time for a phone call? My email is mmcconnaha@kh.org. Thank you so much!



    ------------------------------
    Mallory McConnaha, BSN, RN, AMB-BC


    Original Message


  • 19.  RE: Nurse Initiated Orders

    Posted 08-04-2023 08:25

    Good morning Mallory,

    Throughout Johns Hopkins Medicine we have made use of two types of protocol orders, Non-provider Initiated Patient (Protocol) Orders (NIPOs) and Protocols.  They are built similar to other organizations.  Algorithmically designed, policy based, and broad in their execution.  We have attempted to harmonize the process to the best of our ability.  Addressing your second part, we have used them extensively for health maintenance needs (mammography, lab orders, simple procedures, etc).  The tools have helped our nurses work to the top of their scope and helped to expedite care.

    Best-



    ------------------------------
    Bryan Barshick DNP RN
    Sr Dir of Nursing, Ambulatory Svcs
    Johns Hopkins Health System
    (443)287-2355
    ------------------------------

    Original Message


  • 20.  RE: Nurse Initiated Orders

    Posted 08-04-2023 10:23

    I am following along and interested to see how many people are using nurse initiated orders for heart failure patients.  Please share your process.

    Margaret Jones, BSN, RN-BC

    Ross ACC Heart Failure

    The Ohio State University Wexner Medical Center



    ------------------------------
    Margaret Jones
    Registered Nurse
    Ohio State University Ross Heart Hospital
    Grove City
    (614)205-5725
    ------------------------------

    Original Message


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