Infusion rate for blood products

[clmergen]

This is the following that was cited by Joint Commission at one of the hospitals in my system:

MM (1 EP)

bFinding: Orders for blood products did not include a rate of administration

This is the first JC since we have been on an EMR with physician order entry. We are considering putting in a default comment of "transfuse 150mL per hour, not to exceed 4 hours unless otherwise indicated" for the blood products. Any ideas on if this will work or any other suggestions? This caught us by complete surprise as this we have never required this before. When the physicians were handwriting they sometimes put how long to transfuse the unit but not always.

[tbostock]

I've never heard of this, that the rate of administration had to be included in the physician's order. Do you have the number for the specific regulation that they are citing?

We have suggested rates of admin in our nursing transfusion policy.

In your suggestion above for the default, I would recommend that "not to exceed 4 hours" should come AFTER "unless otherwise indicated". The way it is written, it could be interpreted as the physician has the ability to extend it past 4 hours.

[L106]

Our nursing procedure states "Start the transfusion at a rate of 120cc/hour. After the first 15 minutes and with no signs of a reaction, the rate of infusion can be increased to 240cc/hour. Physician orders or nursing judgment may be used to determine if the transfusion should be infused at a more desirable rate. Maximum duration of transfusion is 4 hours."

Joint Commission has never had a problem with this at our institution.

[clmergen]

We have something similiar written into our procedure but this JC team didn't like that. And the same team will be inspecting a second hospital by the end of the month. My understanding is that they did not cite a specific regulation or standard but we still have to "fix" it.

After nursing, Transfusion, and IT discussed the "comment" the decision was that we weren't the people to solve the issue. They tried to pawn the entire problem on my Medical Director but I promptly deflected that. My MD can "advise" but not override a physician so I think the problem needs to be addressed by the Medical Staff. Our EMR team has a Physicians Advisory Group (PAG). The problem is being presented to the Vice President of Medical Affairs (VPMA) of the hospital who can then consult with the VPMAs of the other hospitals and they can consult with the TS MD. And then the PAG can decide how they want to fix the EMR nursing order set.

[L106]

Maddening, isn't it? What one inspection team thinks is "great", another inspection team thinks the same thing is "inadequate."

Would it be any easier for you to state the standard rates for infusion in the nursing procedure, then on the Physician Order Entry Screen there two boxes (& they have to check one of the two boxes.) One box says "Standard Rate" and the other box says "Other Rate (Specify): _______" ? (Just trying to think what would be the easiest.)

[clmergen]

I just found out that we are challenging the RFI so we shall have to wait to see what happens.