Mercy-Orders-DEM-BAPET.txt Mercy Hospital of Pittsburgh DEM BAPET (Brain Attack) Orders Change List 2/13/07 The Owner of this Standing Order is Bruce MacLeod, M.D., Chair, DEM. Suggestions for changes should be emailed to both of Dr. MacLeod's Delegates for this Standing Order: Keith Conover, M.D. John Whiteford, M.D. Change List started 11/25/06 Most recent changes or proposed changes at top. See also Mercy-Orders-Template.txt and Mercy-Orders-Signature- Template.txt for additional notes of changes that apply to all orders. Proposed changes from version 2.0 (7/11/06) to version 2.1: - Changed Platelet Suppression Assay to Aspirin Response Test, and added "Green is the Medical Records original copy. Please retain." at the bottom. Based on suggestions from Lennie (PCA). - The Rapid Response Team (RRT) that responds to emergencies on the floor would like to use the DEM Brain Attack and related orders on the floor. Received a request from AJ Pinevich via Donna Gurcak in the Pharmacy for this. Per the DEM meeting 2/13/07, decided the following: a) The DEM is pleased that our work in making easy-to-use orders is appreciated by the RRT. b) The DEM would be pleased to make a version of specific DEM orders that are specific to the RRT, making modifications as appropriate. c) However, the DEM wants to keep the DEM and RRT orders separate. For example, the signature block at the bottom of the orders is DEM- specific, and we can replace this with a signature block more appropriate for the RRT. d) Dr. Conover will work with Dr. Mohan (or whoever will represent the RRT in this) to develop these orders. e) The DEM will have new versions of many of its orders in the near future and this will soon be posted and available for the RRT to review. - spelling of ticlopidine fixed. - On the first page it says "Patient on aspirin, clopidogrel (PLAVIX), ticlopidine (TICLID), or aspirin/dipyridamole (AGGRENOX)?" and has yes/no checkbox-radio-buttons, with the second, "yes" checkbox- radio-button having an arrow to a pre-checked checkbox with "Platelet Suppression Assay." This worked fine for the doctors completing the orders (they checked yes and no appropriately), it resulted in errors when the secretary was entering the orders. If their eye runs down the right side of the page and sees a checked checkbox with "Platelet Suppression Assay" then they order it, regardless of whether the "yes" was checked or not. Therefore, this should be changed to say "order Platelet Suppression Assay" with "order" in italics to indicate it is a hint to the doctor (consistent with italics for hints on dosages to order elsewhere in the orders). - Changed PT/PTT to "Bedside PT / PTT" to indicate the need for a "POC" (Point of Care) PT, though the term "Bedside" based on informal interviews in the DEM suggest the term "Bedside" will be better understood than "POC" or "Point of Care" and thus less likely to result in error. - Added urine HCG (UCG seems to be universally understood as appropriate notation for this in a quick survey in the ED) for females < 50 years old. - Changed Nipride to nicardipine for BP control: better agent in many ways. Left labetaolol as an option, as many physicians are more familiar with labetalol and is a reasonable agent. - Tammy Outly suggested that, for diabetic patients, we add a HgA1C to the order set. While this sounds reasonable, should it be on the DEM orders or the admitting orders? It will not contribute to the management in the DEM, and sometimes it isn't clear whether the patient is diabetic at time of presentation, but it should be clear by the time of admission. Changes prior to version 2.0: ---- - changed the insulin drip to be weight-based - Added, for certain subsets, CT angio head\neck and CT perfusion of head. - Decided that, on the initial BAPET orders, only need one IV; but if we start thrombolytics, then we need three IVs. - Decided that, on the initial BAPET orders, we can do just a type and screen, and on the ICH or Thrombolytic orders, we can add FFP or type and cross as appropriate. - fixed typo where rectal Tylenol dosage hint said "PO" instead of "PR." - for NIHSS 1-3, and NOHSS 4-22 with sx > 8 hours, added "consider CT angio if NIHSS 0-3, Cr normal, no DM" as a parenthetical note to physicians. Changes from version 1.2 (10/12/05) to 2.0 (7/11/06) - Decided to change platelet suppression assay to an option. "I think the first test on a Mercy patient was done last Thursday. The current test is an "aspirin reponse test". It measures aspirin response units (ARU). If the ARU is 0-549 there is platelet dysfunction indicating aspirin is working. If ARU is 550 or greater then there is no platelet dysfunction and aspirin is not working. A "clopidogrel response test" and "GIIbIIIa response test" should be available soon. My understanding the cost to the hospital for the test is about $18. The assay takes about 5 minutes to perform." "I do not think it is currently necessary to put the aspirin reponse test in the initial order set. If the patient is on antiplatelet agents and there is a hemorrhage on CT then it can be considered. This would be similar to our discussion on the urine toxicology screen. If a patient is having multiple ischemic TIA/strokes while on aspirin it also could be considered as they may be a nonresponder to aspirin. This aspirin nonresponder group may be as large as 20%." (John Baker) - As far as glycemic control, and as regards that NEJM article we passed around recently, Mike Trimmer suggested we nix the sliding scale suggestion--useless in the ED anyway--and just go with an insulin drip. Agreed and coordinated with Dr. Jann Johnston of endocrinology on the best way to do this. - multiple changes to the formatting of the criteria for CT angio to make them easier to fill out without error ("user-friendly"). Based these on analysis of actual errors and user interviews as users were completing orders on actual patients, which was a significant problem. The new version seems to be working much better. - Changed this and all DEM orders to read "Department of Emergency Medicine" at top. - Split off NIH Stroke Scale as a separate document, with an additional NIHSS Worksheet for those not familiar with the NIHSS. Working more successfully this way. Changes prior to version 1.2: - added platelet suppression assay: "We should probably have some sort of reminder regarding ordering the new aspirin suppresion assay on patients who presents on aspirin. The residents are not remembering to consider ordering this test when indicated. There are some caveat's with respect to test utility if the patient is are already on taking other antiplatelet medications which we could also add to make more clear to those ordering the assay." (Kaveh Ilkhanipour) - added bedside INR and type and screen, so patient can be quickly transfused with platelets or FFP if has an ICH and this is needed. - added bedside urinalysis, as this is a standard part of preop labs (need to know if patient has UTI), and we think it's a good idea to do standard preop labs on any and all CVA-type patients, as they might have an intracranial hemorrage, and we'd like to have all the preop labs done soon after we know that there is an ICH and thus the patient can get to the OR fast but with preop labs done. - Changed to make the IV order "R arm preferred" - "I've been thinking that I've been wasting entirely too much time on this orders business (also working on a new format for all the hospital's standing orders). But then the article in JAMA showing how a poor computer-based order-entry system (and theirs was really quite bad) can cause significant medical errors made me rethink. Forms design and computer interface design (or "user interaction design" to use the "in" term) are more art than science, but I think that time spent on giid desugb will reduce error and therefore are worth the #@$% frustrations involved in designing them. "It would be interesting to, at some point, compare using a carefully- designed PDF for data entry vs. a standard web-based (or worse, mainframe-based) order system for practitioner order entry. "Bet we could elminate most of those errors in the JAMA article with good design." (Keith Conover) - Moved the glucose and temperature management (initially found in both ICH and CVA orders) to the Brain Attack orders. - As these are orders for nurses, and although suggestions for doctors may appear parenthetically, changed to eliminate a dosage range for antihypertensive medication (i.e., 40-80 mg) to a specific dose (40 mg)