Addenda: Mar. 8 & 31, 2009

Experience in using electronic medical records for ordering and documenting blood transfusions

Two colleagues in the United States were interested in learning about the experience of others with regards to electronic medical records and the ordering and documenting of blood transfusions.

1. A colleague in Southern California wants to know what experience others have had with computer order entry systems for ordering of blood products, including the use of 'electronic' signatures by the physician who is prescribing the transfusion. The Californian is of the understanding that some hospitals allow nurses and clerks to input orders for blood products into a hospital information system, provided the orders have been 'written' by a physician.
2. A colleague in Florida reports that his health system will be opening a new "paperless" hospital in February 2005. The hospital will have an electronic medical record, physician computer order entry, wireless handheld devices for recording vital signs, drug administration, etc. In the short run the Floridian does not see any way around printing unit tags to label components for transfusion, even though there will be no patient chart on which to place a completed unit tag! Scanning a handwritten completed unit tag and placing a digital image into the patient's electronic record is an option until their Information Systems team can develop an electronic form to capture all of the information that is normally recorded on a completed unit tag. The Floridian would be interested to learn from the experience of any transfusion service that has already developed an electronic blood administration record, and how they went about this. Key issues for discussion would be forms design, data fields, electronic signatures, as well as the actual logistics/process for nursing to complete the forms, the transfusion service to monitor completion, reporting of reactions, etc.

The following replies were submitted in response to the above:

1. The Editor suggests that the information at:
   • CBER Guidance for Industry - Part 11, Electronic Records; Electronic Signatures - Scope and Application. August 2003, Pharmaceutical CGMPs
   • CDER Guidance for Industry - Part 11, Electronic Records; Electronic Signatures - Scope and Application. August 2003, Pharmaceutical CGMPs
   and the e-Network Forum discussions:
   • The effect of handwritten vs computer-generated labels on the rate of misidentified samples received for compatibility testing
   • Maintenance, storage and retrieval of transfusion service records
   may be germane to the present discussion.

2. A colleague in Wyoming reports that in October their hospital will begin using an electronic medical record. Their goal is to be paperless. The inquiring colleague wonders if other institutions would share their experience with how they document in an electronic medical record the steps at the bedside of starting a transfusion. Critical steps would include matching information on the patient's ID band with the transfusion tag, capturing the blood product unit number, unit blood type, identity of the transfusionists, etc. As much detail as possible would be appreciated.

3. A colleague at a large medical center in Illinois reports that they use three separate electronic orders pertaining to the preparation and dispensing of blood products for transfusion: 1 - An electronic order 'Blood Product Set-Up' for the blood bank lab to set-up blood products for eventual dispensing. This order contains all the required information necessary to set-up blood products (similar to a manual lab requisition). The blood bank 'Blood Product Set-U'’ order is not an order to transfuse/give the product to the patient. 2 - An electronic order 'Transfuse Blood Product, Nurse Care' for nursing to transfuse/give the blood products to the patient. The nursing order to transfuse has specific instructions for the transfusionist to follow, such as the rate of administration and the need to administer pre-transfusion medications. They have had multiple occasions when physicians order a 'blood product set-up' order for the blood bank to fill BUT eventually do not transfuse the product. 3 – An electronic order 'Issue Blood Products' for the blood bank lab to dispense the product to the requested location within the institution.
   
   All three orders: 'Blood Product Set-Up', 'Transfuse Blood Product, Nurse Care' and'‘Issue Blood Products' are entered in the patient's electronic medical record (EMR) by the physician or by the nurse taking written or verbal orders from the Physician (i.e., if he/she is off-site). The 'blood product set-up' order will print on the blood bank lab printer prompting the blood bank staff to set up the product. The nursing order is routed electronically to the "Nursing Task List" for the nurse who is taking care of the patient within the patient's EMR. The 'Issue Blood Products' order is usually entered in the patient’s EMR when the transfusionist is ready to transfuse/give the product to the patient. This order will also print on the blood bank lab printer that will prompt the blood bank staff to dispense the product. The 'Issue Blood Products' order is very specific as to what product is requested for dispensing, the number of units or doses, the special requirements, the pneumatic tube station number where the product is to be sent, and etc.
   
   At the Illinois hospital they created several transfusion order sets and logics or rules within the EMR that will help the physicians and nurses. Examples: Order Set - One order set contains all three orders 'Blood Product Set-Up', 'Transfuse Blood Product, Nurse Care' and 'Issue Blood Products' that simultaneously orders the three orders when the need for product is urgent. The blood bank staff will set-up the requested product and dispenses the product immediately after preparation. Rule/Logic - The 'Issue Blood Products' order cannot be entered in the patient's EMR when there is no 'blood product set-up' previously ordered within a certain time frame. The nurse cannot request for the blood bank to dispense a dose of platelets when there is no order to set-up platelets. Similarly, the 'Issue Blood Products' order cannot be placed in the patient’s EMR when there is no 'Transfuse Blood Product, Nurse Care' order to transfuse platelets. This prevents products sitting on the "Nursing Stations" waiting an order to transfuse from the physician. If a certain order is missing based on a defined rule, the reasoning will pop-up on the screen explaining the scenario and gives the patient caregiver the option to order or enter the missing order.

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Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator

W. Tait Stevens, MD
CBBS e-Network Forum Assistant Editor & Moderator