ORCHID Tips for ED Up/Downgrades, Abx, IS, NPO after MN, Holding Meds

To Upgrade or Downgrade While the Patient is Boarding in the ED:

Do not use the Transfer Order! Explanation: Transfer Orders with an ED or ED Boarder location means transfer to another facility.

Do place a new Request for Admit and Admit to Inpatient order with the new level of care.  Both orders must agree on the level of care.  The nurse and bed control will follow the most recent orders.  Again, this applies to patients boarding in the ED.


If the patient is already on the ward or unit, continue to use the Transfer Patient order to change the level of care.


To Order Restricted Antibiotics:

For Restricted Antibiotics (refer to the cream-colored antibiotic card), if the antibiotic has a pre-approved indication, specify that in the Indication detail field.  If you have received verbal or written approval from the ID Fellow or Attending, specify the Indication and the Approving Consultant.


Restricted Antibiotics with pre-approved indications at OVMC: Amikacin, Ampicillin/Sulbactam (Unasyn), Cefepime, Piperacillin/Tazobactam (Zosyn), and Vancomycin (oral and intravenous)

Fully Restricted Antibiotics requiring ID approval at OVMC: Aztreonam, Amphotericin B Liposomal, Ceftazidime, Cidofovir, Colistin, Dalfopristin/Quinupristin, Daptomycin, Foscarnet, Ganciclovir, HIV antiretrovirals, Isavuconazole, Linezolid, Meropenem, Moxifloxacin, Micafungin, Oritavancin, Posaconazole, Tigecycline, Voriconazole

icon-pharmacy-reject If you see this icon, it means the Pharmacy has rejected your order (e.g. incorrect order, unapproved indication, etc).  If you have not already been paged by Pharmacy, please speak to the inpatient pharmacist regarding your order.


To Hold a Dose of Medication:

The safest approach to “hold” a medication is to discontinue the medication and then re-order it when you are ready to restart the med or specify an appropriate First Dose Date/Time.  Avoid using Communication orders alone to “hold” a medication.

Explanation: Discontinuing a medication takes it off the MAR, so the nurse and pharmacy will not dispense or administer the medication. Communication orders are unreliable because although it may alert the nurse, no alert goes to pharmacy to hold the medication.  Direct verbal communication is also very helpful (e.g. holding a dose of enoxaparin before a procedure).


To Order NPO after Midnight:

The best practice is to both modify the previous diet order with a specific Stop Date/Time and add the new NPO order with a specific Start Date/Time.


Your orders will look similar to the following:


Please note, if there are two concurrent diet orders (e.g. the times on the diet orders overlap), Dietary Services will follow the most restrictive diet order.


To Order Incentive Spirometry:

Place both Incentive Spirometry Nursing and Incentive Spirometry Instruct orders.


Explanation: The instruction order will go to RT to provide the patient initial instructions on using IS.  The nursing order will go to the Nurse to document IS, but will not task the nurse with providing IS instruction.