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Telephone orders in the emergency department
POSITION STATEMENT telephone orders, emergency department
Telephone Orders in the Emergency Department [This position statement was developed by the ACEP Professional Liability Committee and approved by the Board of Directors on September 8, 1989. American College of Emergency Physicians: Telephone orders in the emergency departroent. Ann Emerg Med May 1990;19:601.] Telephone orders dictated by physicians from outside the emergency dep a r t m e n t for patients who are currently in the department can result in serious lapses in the quality of medical care a patient receives. Therefore, the A m e r i c a n College of Emergency P h y s i c i a n s endorses the following principles: Emergency d e p a r t m e n t patients should be examined and evaluated by a physician i n the emergency department prior to carrying out telephone orders.
American College of Emergency Physicians Dallas, Texas Address for reprints: American College of Emergency Physicians, PO Box 619911, Dallas, Texas 75261-9911.
Hospital and emergency department policies should specify the criteria for dictating and accepting telephone orders. Drug Enforcement A d m i n i s t r a t i o n regulations prohibit dispensing controlled substances from emergency d e p a r t m e n t stocks for t r e a t m e n t of patients by telephone order. Hospital and emergency department policies should prohibit telephone orders for medications on the controlled substances list. SECTION 829, US CODE OF PHARMACEUTICALS Prescriptions Schedule II substances (a) Except when dispensed directly by a practitioner, other than a pharmacist, to an ultimate user, no controlled substance in schedule Ii, which is a prescription drag as determined tinder the Federal Food, Drug, and Cosmetic Act, may be dispensed without the written prescription of a practitioner, except that in emergency situations, as prescribed by the Secretary by regulation after consultation with the Attorney General, such drug may be dispensed upon oral prescription in accordance with section 503(b) of that Act. Prescriptions shall be retained in conformity with the requirements of section 827 of this title. No prescription for a controlled substance in schedule II may be refilled. Schedule III and IV substances (b) Except when dispensed directly by a practitioner, other than a pharmacist, to an ultimate user, no controlled substance in schedule III or IV, which is a prescription drug as determined under the Federal Food, Drag, and Cosmetic Act, may be dispensed without a written or oral prescription in conformity with section 503(b) of that Act. Such prescriptions may not be filled or refilled more than six months after the date thereof or be refilled more than five times after the date of the prescription unless renewed by the practitioner. Schedule V substances (c) No controlled substance in schedule V which is a drug may be distributed or dispensed other than for a medical purpose. Non-prescription drugs with abuse potential (d) Whenever it appears to the Attorney General that a drug not considered to be a prescription drug under the Federal Food, Drug, and Cosmetic Act should be so considered because of its abuse potential, he shall so advise the Secretary and furnish to him all available data relevant thereto. (Pub.L. 91-513, Title II, § 309, Oct. 27, 1970, 84 Stat. 1260.)
19:5 May 1990
Annals of Emergency Medicine
601/155
EDITORIAL NOTES References in Text. Schedules II, III, IV, and V, referred to in text, are set out in section 812(c) of this title. The Federal Food, Drug, and Cosmetic Act, referred to in subsecs. (a), (b), and (d), is Act June 25, 1938, c. 675, 52 Stat. 1040, as amended, which is classified generally to chapter 9 (section 301 et seq.) of Title 21 U.S.C.A., Food and Drugs. Section 503(b) of that Act is classified to section 353(b) of Title 21.
Code of Federal Regulations Prescription requirements, see 21 CFR 1306.01 et seq.
phone and proceed to call the emergency room and order the administration of a stocked controlled substance upon the patient's arrival at the emergency facility. Section 829 of the US Code provides that prescriptions m u s t be utilized, except w h e n controlled substances are dispensed directly by a practitioner, other than a pharmacist, to an ultimate user. It follows, of course, that only pharmacists can fill prescriptions. Hence, a physician cannot make an "order" or a prescription and expect it to be honored by hospital emergency rooms. The stock of the emergency room is part of the hospital stock and cannot be construed to be pharmacy stock.
Response from the Houston Field Office of the Drug Enforcement Administration. The following information in this letter is written in response to inquiries concerning the ordering of controlled drugs for emergency room stocks by physicians' "orders" into the emergency room: T h e stock of drugs m a i n t a i n e d i n h o s p i t a l e m e r g e n c y rooms or outpatient facilities is kept for use by or at the direction of physicians in the emergency room. Therefore, in order to receive such medication, a p a t i e n t m u s t be examined by a physician in the emergency room or outpatient facility, and the need for a p a r t i c u l a r controlled substance determined. It is not possible, under federal requirements, for a physician to see a p a t i e n t outside the emergency room setting or talk to h i m or her on the tele-
156/602
The options of a physician, in a case of this type, are as follows: 1. Administer or dispense drugs to the patient from his or her drug supplies. 2. Write a prescription to be filled by a pharmacy (including a hospital pharmacy) w h i c h is separate and distinct from the hospital emergency room stocks. 3. Send the patient to the emergency room for examination and the possible obtaining of whatever drugs that exa m i n a t i o n indicates from the emergency room stocks. It is hoped that the above discussion clarifies the federal requirements in this area.
Annals of Emergency Medicine
19:5 May 1990
Telephone Orders in the Emergency Department [This position statement was developed by the ACEP Professional Liability Committee and approved by the Board of Directors on September 8, 1989. American College of Emergency Physicians: Telephone orders in the emergency departroent. Ann Emerg Med May 1990;19:601.] Telephone orders dictated by physicians from outside the emergency dep a r t m e n t for patients who are currently in the department can result in serious lapses in the quality of medical care a patient receives. Therefore, the A m e r i c a n College of Emergency P h y s i c i a n s endorses the following principles: Emergency d e p a r t m e n t patients should be examined and evaluated by a physician i n the emergency department prior to carrying out telephone orders.
American College of Emergency Physicians Dallas, Texas Address for reprints: American College of Emergency Physicians, PO Box 619911, Dallas, Texas 75261-9911.
Hospital and emergency department policies should specify the criteria for dictating and accepting telephone orders. Drug Enforcement A d m i n i s t r a t i o n regulations prohibit dispensing controlled substances from emergency d e p a r t m e n t stocks for t r e a t m e n t of patients by telephone order. Hospital and emergency department policies should prohibit telephone orders for medications on the controlled substances list. SECTION 829, US CODE OF PHARMACEUTICALS Prescriptions Schedule II substances (a) Except when dispensed directly by a practitioner, other than a pharmacist, to an ultimate user, no controlled substance in schedule Ii, which is a prescription drag as determined tinder the Federal Food, Drug, and Cosmetic Act, may be dispensed without the written prescription of a practitioner, except that in emergency situations, as prescribed by the Secretary by regulation after consultation with the Attorney General, such drug may be dispensed upon oral prescription in accordance with section 503(b) of that Act. Prescriptions shall be retained in conformity with the requirements of section 827 of this title. No prescription for a controlled substance in schedule II may be refilled. Schedule III and IV substances (b) Except when dispensed directly by a practitioner, other than a pharmacist, to an ultimate user, no controlled substance in schedule III or IV, which is a prescription drug as determined under the Federal Food, Drag, and Cosmetic Act, may be dispensed without a written or oral prescription in conformity with section 503(b) of that Act. Such prescriptions may not be filled or refilled more than six months after the date thereof or be refilled more than five times after the date of the prescription unless renewed by the practitioner. Schedule V substances (c) No controlled substance in schedule V which is a drug may be distributed or dispensed other than for a medical purpose. Non-prescription drugs with abuse potential (d) Whenever it appears to the Attorney General that a drug not considered to be a prescription drug under the Federal Food, Drug, and Cosmetic Act should be so considered because of its abuse potential, he shall so advise the Secretary and furnish to him all available data relevant thereto. (Pub.L. 91-513, Title II, § 309, Oct. 27, 1970, 84 Stat. 1260.)
19:5 May 1990
Annals of Emergency Medicine
601/155
EDITORIAL NOTES References in Text. Schedules II, III, IV, and V, referred to in text, are set out in section 812(c) of this title. The Federal Food, Drug, and Cosmetic Act, referred to in subsecs. (a), (b), and (d), is Act June 25, 1938, c. 675, 52 Stat. 1040, as amended, which is classified generally to chapter 9 (section 301 et seq.) of Title 21 U.S.C.A., Food and Drugs. Section 503(b) of that Act is classified to section 353(b) of Title 21.
Code of Federal Regulations Prescription requirements, see 21 CFR 1306.01 et seq.
phone and proceed to call the emergency room and order the administration of a stocked controlled substance upon the patient's arrival at the emergency facility. Section 829 of the US Code provides that prescriptions m u s t be utilized, except w h e n controlled substances are dispensed directly by a practitioner, other than a pharmacist, to an ultimate user. It follows, of course, that only pharmacists can fill prescriptions. Hence, a physician cannot make an "order" or a prescription and expect it to be honored by hospital emergency rooms. The stock of the emergency room is part of the hospital stock and cannot be construed to be pharmacy stock.
Response from the Houston Field Office of the Drug Enforcement Administration. The following information in this letter is written in response to inquiries concerning the ordering of controlled drugs for emergency room stocks by physicians' "orders" into the emergency room: T h e stock of drugs m a i n t a i n e d i n h o s p i t a l e m e r g e n c y rooms or outpatient facilities is kept for use by or at the direction of physicians in the emergency room. Therefore, in order to receive such medication, a p a t i e n t m u s t be examined by a physician in the emergency room or outpatient facility, and the need for a p a r t i c u l a r controlled substance determined. It is not possible, under federal requirements, for a physician to see a p a t i e n t outside the emergency room setting or talk to h i m or her on the tele-
156/602
The options of a physician, in a case of this type, are as follows: 1. Administer or dispense drugs to the patient from his or her drug supplies. 2. Write a prescription to be filled by a pharmacy (including a hospital pharmacy) w h i c h is separate and distinct from the hospital emergency room stocks. 3. Send the patient to the emergency room for examination and the possible obtaining of whatever drugs that exa m i n a t i o n indicates from the emergency room stocks. It is hoped that the above discussion clarifies the federal requirements in this area.
Annals of Emergency Medicine
19:5 May 1990