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KKidd

Physician's entering BB orders in the computer

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Within the next year our physicians will be entering their own orders into the computer system. Currently only the ED is doing it and they tend to order transfusions. We'll do a type and screen and the ED will call 1 hour later to ask if the blood is ready. Sorry, no order.

I am interested in hearing from others that work at facilities where physicians put the orders in on in-patients. Are the correct? Do they get ordered too early if the patient is for surgery? What kind of queries must be answered?

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Can't help with the inpatients. Our ED physicians went live with physician ordering within the last year. Sounds like we are in the same boat as you are. They just don't understand all of the ins and outs of the system they are using and it causes no end to the problems.

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Can't help with the inpatients. Our ED physicians went live with physician ordering within the last year. Sounds like we are in the same boat as you are. They just don't understand all of the ins and outs of the system they are using and it causes no end to the problems.

THanks, Denny

I'm curious as to what computer system you are blessed with. We have Meditech.

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We have been phasing in CPOE for inpatients over about the last 6 months. Before the physicians started ordering blood bank stuff, there was an order entry set put together to help them with that process. I don't know who was involved in putting that original set together other than an Oncologist and the nursing folks who were building the order set, but I can tell you who was NOT involved. Do you want to guess???? The first our medical director knew about it was at the med staff meeting where is was brought up and approved in about 2 minutes. After we had a chance to look at the order set, I made suggestions, which the medical director approved and she took it back to med staff. They approved our suggestions and it was put in place.

The order set lists the common tests - T&S, crossmatch, blood type, DAT (though we have to call it D Coombs). It explains what tests are included in the T&S and crossmatch and also states that blood must actually be CROSSMATCHED prior to transfusion. The second section lists the blood products available and gives them a place to say how many units they want. As a part of that we included information to help them get the platelet dose right, as we only have apheresis platelets here (6 units of random donor platelets = 1 apheresis platelet). We also included boxes to check off for irradiated and CMV neg. I took a few phone calls in the beginning from some of the docs who wanted to make sure they were getting what they thought they were ordering but everything seems to be going smoothly now. I think the key was giving them limited choices on the order set (which covers 95% of the patients) and giving them some guidance as to what they were getting when they ordered something. If they want something outside of that, they can still write it and that will be entered by a ward clerk or nurse with help from blood bank if needed.

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Our LIS is SCC and works well. The ED is using Allscripts. There are issues between the two still to be addressed. Similar to AMcCord there are limited order sets to try to guide the physicians the correct direction, and thankfully a ward clerk handles the paperwork necessary for blood bank. This minimizes the mistakes as they must get the correct order from the physician to complete the paperwork. Our biggest issue seems to be when a physician from ED attempts to place a timed order following their initial order. It frequently attaches to the original order and shows up as STAT with the only indication of it having a specific draw time is whatever comment the physician may have entered. I think part of the problem is an understanding of how the program is designed from the physician standpoint. Still a work in progress.

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We face the same issues. We have been live for about 6 mos, and we are plagued with duplicate orders, red cell orders with no T&S, and orders to only transfuse, which we do not see:) Is anyone having "transfusion orders" flying into the Bank? We have SoftBank & SCM Order Entry

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We have Epic EMR and the physicians order there. I agree with everyone above: try to set up an order set that is as "foolproof" as you can get it. They are limited to what they can order and what criteria they can use to justify it. They order a "prepare order"...a wish list, which we mostly ignore. :rolleyes: Then they order a "transfuse order" which is what is actually to be given. These orders print in the Blood Bank.

One of our biggest issues now is that the physicians don't see the warning about the Type and Screen being valid for 3 days, and they order a new TS every time they order blood, which drives us crazy, and occasionally ends up with patients redrawn unnecessarily.

Spend the time up front to really test this order set before "go live" to get it the way you need it to work for the Blood Bank.

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Is there a place in EPIC to select an indication for transfusion?

Is EPIC transfusion module cleared by FDA/510K?

We built a mandatory question for justification, with a list of our criteria that they have to pick from.

No, it does not have FDA 510K, so we elected not to use it.

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[ATTACH]587[/ATTACH]

We use Epic (and Sunquest LIS). When a "transfusion order" is placed into Epic, an order prints in the blood bank. I've attached a copy of an order, with the patient and ordering practitioner's info blacked out.

The first three order questions (see middle section of form) are required. The next six questions are optional and help us place the patient on the required protocol (irradiated, CMV, etc). The patient weight auto-fills from Epic. The order comment is also optional and is free texted by the practitioner with any additional info requested.

The system works well and ensures that we have all of the required information prior to filling any blood product order. The only problem is if we have any kind of print server problems/downtime. Our IS team would like us to go to an electronic order list of some kind, rather than a paper print-out, but we are quite a ways away from that at this time.

One other thing to consider... our transfusion orders are handled like lab orders, however we have since implementation wondered why they weren't set up like medication orders. That may be something else you wish to explore. Good luck! :)

Stephanie Townsend, MT(ASCP) SBB

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We use EPIC EHR and we have been working over one year on tweaking BB ordering. Order sets are the way to go, but each service has different rules and requires unique order sets. It is a lot of work but worth it. We get a printout of the prepare order not the transfused order. This is beneficial for pre-op patients.

EPIC has a duplicate order screen pop-up that is large and obnoxious for duplicate type and screen orders. It has helped some but we still get duplicate orders. We are hoping this will continue to decrease as physicians are familiar with the system.

We are also using medication style orders for derivatives and Rh Immune Globulin.

We meet once a week with EPIC IS, nursing clinical services, various physician services, hospital IS, BB med director, and myself as Manager of Transfusion Service. It is well worth the time investment.

For downtime, we use a back-up multi-copy requisition that is later scanned into EHR. It works well.

Nursing is required to enter the collection date and time as well as the collector in the EPIC system for each BB specimen collection. If a lab phlebotomist collects, nurse can enter generic lab phleb as collector, and we collect phleb name in our BB system. The collection information stays on the nurse's worklist to remind them to complete the information. We have had problems with nurses defaulting their name instead of entering correct collector. It is a massive education issue. We are a large, metropolitan, level 1 trauma center so we have a lot of staff to educate.

We are also trying to use EPIC to record transfusion data (vitals, rx evidence, etc). Is there anyone else with experience in this area?

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JLF: looks like you are facing some of the same frustrations as us, especially the duplicate Type and Screens.

Totally agree with you about spending a lot of time building, validating, educating, etc, the blood order set. Well worth it when it works correctly.

As far as entering any transfusion data, we chose not to. Epic does not have 510K approval for their blood administration module, which is required. It is NOT required for ordering, so we do that part in Epic. We (unfortunately) had to remain on paper for documentation of all blood admin data, but hope in the future to go to a handheld module that is FDA approved.

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Hi,

I work at a Meditech Magic blood bank and would love help with the order sets and whatever else is needed for POM and duplicate orders. Our biggest problem as of now is there is no way for the Dr. to tell the nurse to give the LRBC unless they order it again...

Please help.

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We are in Phase 1 testing of Eclipsys (now Allscipts) SCM. It is it set up so all the physician will order is the blood product transfusion and date/time needed. The system will check for a current Type & Screen sample (within 3 days prior to transfusion for red cells or once per admission for non-red cell products). If there isn't one, the physician will get a pop-up message and in one click the Type & Screen is ordered. A reason for transfusion will be required for all products. Indication for irradiation (or no irradiation needed) will be required for red cells and platelets. Their order screen lists all the indications for irradation so they have to either pick one or select "irradiation not indicated". All product orders will print a requisition in Blood Bank. Red Cell orders will NOT populate our LIS (Softbank) but the other product orders will. I insisted on that to prevent duplicate red cell orders when red cells may already be available.

We just started integrated testing last week so I am sure there will be tweaks to get things to work. As the Order Set stands now, there is no way to request products to be on hold. It has not even come up for phase I.

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bmarotto: Our hospital also uses SCM and we get all the printouts in BB. Believe it or not, our blood bank is still "manual" but we are in progress of bringing SoftBank live this year. How is your experience with SoftBank?

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We love Softbank! We were on another system for 16 years before moving to Softbank in 2008. We are much happier with Soft.

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We have Meditech and our ED physicians put their own orderd in the computer. Thed hardest thing to get across is they must order the blood(2 RBC, etec) ubn the BB before they order the transfusion in the nursing module. We have gotten quite a few calls from the ED asking is blood was ready on a patient and there was no order for us. Things are getting better. When we built the BB orders we kept it simple. They just order the component and number of units. If we have any questions, we'll call them.

Unfortunately, I wasn't involved in the build. Good Luck!!!!!!!!!!!

:eyepoppin

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Hi,

Our problem is not just ER but all over the hospital. Do you have any info on your Order Sets? How does a Doc tell a nurse to give a unit that was set up yesterday?

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Hi,

Our problem is not just ER but all over the hospital. Do you have any info on your Order Sets? How does a Doc tell a nurse to give a unit that was set up yesterday?

Sorry I cannot give you more specific info. We have started with the ED and have not moved to in-patients yet. If it is set up the same way, I think that the order is put into the nursing module along with any other orders for the day.

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It isn't pretty! Basically, they don't really care about trying to do it correctly; they know the Lab and Nursing will "fix" things for them. In my last place, we spend so much time every day; cancelling duplicate orders, calling to ask Nursing to Order a Type and Screen because the MD only ordered crossmatches; etc. Could the Physicians have "seen" what was done and what needed to be done? Absolutely! I even offered to make a little "cheat sheet" to place by every Nursing station computer for Physicians to use; was told (by my Medical Director) that they would not bother to look at that either. Very frustrating; wasted our time, the Nurses time, the phlebotomist's time.

In my current place, they created different "rules" in their Hospital computer system such that Physicians are 'forced" to do things more appropriately. Problem is, it is restricting the Lab in some ways so may need to be changed.

I know, not what you wanted to hear!

Brenda Hutson, CLS(ASCP)SBB

Within the next year our physicians will be entering their own orders into the computer system. Currently only the ED is doing it and they tend to order transfusions. We'll do a type and screen and the ED will call 1 hour later to ask if the blood is ready. Sorry, no order.

I am interested in hearing from others that work at facilities where physicians put the orders in on in-patients. Are the correct? Do they get ordered too early if the patient is for surgery? What kind of queries must be answered?

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bmarotto: Our hospital also uses SCM and we get all the printouts in BB. Believe it or not, our blood bank is still "manual" but we are in progress of bringing SoftBank live this year. How is your experience with SoftBank?

We went live with SoftBank a year ago. We LOVE it. It's a great system.

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