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Barbara Tinsley
Standing orders

Does any one in an oupt infusion center have standing orders for individual patients.  Ex:  you have a stable pt who has been getting IVIG for 2 yrs, is on a stable monthly dose.  Do you allow the MD to write one order that covers more than one month.  What meds whould you consider this for and under what conditions.  Anybody have and evidence base for this. 

Also does anyone have a flow sheet that they use for peripheral chemo.  One that includes the needed blood return checks and perhaps a diagram or other information for location of PIV.

Trying to update our PP, will trade for other PP or pt education tools you may need.

Kathleen M. Wilson
Standing orders, infusion center.

Hi, we allow orders for one year. They are considered expired at that point. Examples for us: Solumedrol, Avonex, Bisphosphonates, Therapeutic Phlebotomy, Remicade.

When you ask, under what conditions, I am not sure exactly what you mean. But, I can say we follow any manufacturers guidelines, such as Creatinine Clearance prior to Bisphosphonate infuion. Or, on the phlebotomy, each pt's order defines the lab value parameters that dictate whether or not the procedure will be performed. We also notify the Dr. about the visit.

 

Personally, I think a key to safety in executing standing orders is excellent nursing assessment in these scenarios. The reason for this is that if they come in every three months for their treatment, they may NOT have seen their ordering Dr. in that interim. Part of our job is to assess how the last tx went, where there any side effects or problems after they went home?  And, what is their health status today? ie if they are getting Remicade, are they sick today? If they are getting Avonex, is there mobility this week the same as last week?

 

Hope this helps,

 

Kathleen Wilson

Kathleen Wilson, CRNI

Elizabeth.Raucci
Standing orders

We do the same as described above, with the exception of REMICADE:  we were cited two years ago, as Remicade is a weight based medication.  It requires new orders for each visit so the MD can weigh, reassess and redose if there is a change in weight.  Now we treat the patient, fax the MD the date of the next Rx and expect another set of orders for the future visit.  IVIG is also weight based and same holds true here, with the addition of the fact that in order areas Medicare requires office notes from the MD (including, ht/wt/VS/visit info and any test results related to Dx) for each treatment in order to consider reimbursement, therefore, the MD has to see patient monthly in order to be able to do that.  ALL CHEMOTHERAPY IS WEIGHT BASED and also requires a new order for each treatment/cycle - we were cited for that along with the Remicade, as we were allowing the orders for the Herceptin/5 FU/weekly Taxol, etc to be for a month's worth of treatments but that did not fly with the regulatry agency.  Hope this helps.

 

We have a flowsheet for Chemotherapy....if you give me you email - I will forward.

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Kathleen M. Wilson
I agree. I didn't mention the

I agree. I didn't mention the weight on Remicade. We do this every time and the pharmacist calculates the dose based on the order. Thanks!

Kathleen Wilson, CRNI

Kathleen M. Wilson
Remicade

Elizabeth,

Our orders for Remicade are based on weight, but the Dr's order is mg/kg. So, each time we get the weight, and inform pharmacy. They do the calc. based on the order. In your experience with Medicare, do you know if that would work or do we need to consider revision?

Thank you!

 

 

 

Kathleen Wilson, CRNI

Elizabeth.Raucci
REmicade Reimbursement

Our order is also mg/kg, however the MD's must do the calculation also.  Pharmacy does not do any calculating.  I believe your process is acceptable.  What got us cited was the fact that we had no correspondence from the MD and the patient was not seeing the MD between visits, only our assessment of the patient.  Their rationale was that because weight would go up or down, if we kept a standing order we could be under or over dosing the patient, as our process is not to do weights on our patients.

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Kathleen M. Wilson
Thanks very much.

Thanks very much.

Kathleen Wilson, CRNI

gmccarter
We do yearly orders as well.

We do yearly orders as well. We do this for all drugs that the doc wants to. I am going to have to look into the Medicare rules a bit - thaks for tht tip.

We do an asssesment and a lot of patient teaching before each dose is given, including checking labs as needed. We are a small unit - one nurse at a time. When te nurse decides that the patient is ok for the dose we chat briefly with the pharmacist - and if they agree with us we give the drug. If not- we call the MD. The system seems to work well for us.

 

 

Gail McCarter, BSN,CRNI

Franklin, NH

gmccarter
Medicare rules

I looked up the Medicare rules today, just to check. Medicare rules vary depending on the state and/or area you are in. I go to Centers for Medicare and Medicaid Services and look for the LCD or local coverage determination. For NH, when you give IVIG it depends on the diagnosis if the patient needs to be seen by the MD between doses or not. I am still looking into the one for Remicade.

If you have any problems looking for the LCD - the person who does your coding should be able to help you.

 

Gail McCarter, BSN,CRNI

Franklin, NH

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