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Nursing station order entry for hospital computers.

Tired of illegible labels, unlabeled specimens, and frantic phone calls asking what happened to specimens? This lab was and devised a system to allow test ordering and label printing from nurse stations.

ARE YOU TIRED of devoting a significant amount of your time to resolving dilemmas created by unlabeled blood specimens and illegible labels? Are you tired of having laboratory assistants spend most of their time reentering specimen orders that were incorrectly entered by the nursing staff? While planning the acquisition of our new hospital information system-laboratory information system (HIS/LIS), we decided that we were not going to continue putting up with laboratory entry of test requests any longer.

As members of the committee that planned for the new information system, we added to the request for proposal a statement that the accepted system must provide order entry from terminals on the floors and must use bar codes to identify specimens. To accomplish this, we devised a step-by-step procedure that allowed test ordering at nurses' stations and the printing of labels for blood and other specimens that were obtained by ward or clinic personnel. The bids were made and received; a vendor was selected. This article details what we got and discusses its many advantages.

* Teaching hospital. Harbor-UCLA Medical Center is a 650-bed primary care hospital owned by the County of Los Angeles. The 250 persons who constitute the senior medical faculty for the hospital all have teaching appointments with the University of California, Los Angeles (UCLA). In addition, there are about 180 members of the house staff.

The hospital is a major trauma center with a very active OB service. We have a series of follow-up clinics, both in the hospital and in outlying buildings. Most of the faculty have active basic and/or clinical research programs. We are used as a teaching hospital both by the medical schools of UCLA and by the University of California, Riverside.

* Lots of data. We needed a system that could accommodate and transmit quickly a great deal of data, and allow the review of previous studies on patients, not only for patient care purposes, but for teaching and research purposes as well.

To make the system work, we placed at least one computer terminal at every nursing station. Each station also was given its own heavy-duty bar code printer. One terminal was positioned near the OR suite and another was placed near the delivery room. Several others were put in the ER and outpatient areas. These terminals (more than 90 in all) display each patient's demographics and a menu of available tests.

* Ordering protocol. The physician uses the standard order form in the patient's chart to make the written request for a laboratory test (or drug or other order). The ward clerk or nurse then selects the appropriate test from the on-line menu and enters the order. The computer immediately displays the order on the patient's screen.

If the test is requested as Stat or ASAP or is a non-blood specimen, the printer at the nursing station immediately generates a bar code label. The ward clerk or nurse attaches it to the specimen container prior to drawing. If the order is for a routine blood, however, the information is stored and the labels are batch printed the next morning before the phlebotomist makes his or her rounds.

Each label lists the patient's name, the medical record number, the tests to be performed, the type of container required, any special instructions, and the bar code that identifies the specimen. The clerk or nurse attaches the label to the container, then identifies the patient and obtains the specimen. The specimen is then brought to the laboratory. No order slip is needed at that point, since the computer has already been notified that the test is coming.

* Scanned into lab. Once the container is in the laboratory's central receiving area, a scanner reads the bar code specimen number. The computer already has the test information, so only the specimen number needs to be read.

In the case of a timed draw, the phlebotomist initials the label and writes on it the time of drawing. A laboratory assistant keys in that information. Upon inquiry, the computer displays the time and date that the specimen arrived in the lab. (We do not get many timed draws.)

The specimens are then delivered to the analytical areas. If a specimen needs to be divided, bar code printers in the receiving area produce the additional labels that are affixed to the aliquot tubes.

* Bidirectional interfacing. The specimens, most of which are in their original tubes, are placed in automated analyzers. All of our major instruments are bidirectional; consequently, the ordered test information is sent from the HIS to the instruments, which perform the tests and forward verified results back to the point of origin.

After technologists verify the results, they are released, along with the date and time the test was completed, to the main computer to be displayed on terminals at the nursing stations or clinics. Results are thus available almost immediately after the test has been performed and verified.

A nurse who requires a hard copy of a result can get one by printing the screen at her terminal. The printout will appear at a nearby printer. This capability is hardly used in our facility.

* Daily summaries. At first, daily summaries of laboratory results were printed and placed in the patient's chart. At the end of a 5-day activity cycle, or upon the patient's discharge, a summary of all laboratory studies made during the intervening days was printed. The daily reports were then removed from the chart at the end of 5 days or when the patient was discharged (whichever came first) and replaced by a cumulative, 5-day summary.

This practice resulted in too few or too many summaries being removed from the chart. The problem was brought to our clinical laboratory committee, which consists of members of the laboratory staff, the clinical faculty, and the medical house staff. The members felt that, because current results could be viewed on a terminal, only the 5-day summary was needed. The daily summaries were discontinued.

In the year and a half that has elapsed since the new system went on-line for order entry, we have had only two complaints from physicians about the unavailability of daily printed results. Before those two physicians start their rounds, the nurses on the ward now print out and hand them the daily results.

* Identifying trauma patients. The admission of trauma patients to our system is somewhat unique. A series of prepared "trauma packages" are available in the ER. These contain wrist bands, patient information, and necessary forms.

Each trauma patient who meets the standard criteria is given the name TRAUMA, PT. 93XXXXX. The 93 signifies the current year and the five Xs represent an ascending set of preassigned hospital identification numbers that have been reserved for that year. (Because our facility admits several hundred trauma patients each week, the names Jane or John Doe are never used.)

When the patient's name is finally discovered, the fictitious name TRAUMA, PT. is removed by Medical Records and the true name of the patient is appended to the preassigned number, which remains the same.

* Many advantages. What are the benefits of our nursing station entry system?

Telephone calls asking about the progress of specimens have been greatly reduced. The nursing station knows that the test was ordered and that the specimen was submitted. If there is any doubt, the status of each test can be called up and viewed on screen. The abatement in phone calls has created a relative quiet in the laboratory that never was present before.

Mislabeled or illegible slips exist no more because there are no order slips (except for special cases, which are usually handled with greater care anyway). The bar coded label and the computer do it all.

Nonexistent orders no longer come into the lab. Because bar coding offers positive patient ID, spelling errors no longer gum up the works. If the test is done, it is shown on the order screen.

Nursing knows that the test is pending since it was a nurse or a ward clerk who entered the order on a screen. The patient can be prepared appropriately.

Quality assurance data and other information are printed at the time of test performance and saved for the management staff. For example, turnaround time reports for Stats are generated weekly.

Abnormal results are summarized and printed, which allows the appropriate clinical specialists to review the records and verify that the patients are correctly treated.

Edited results are noted and the number of errors that occur are accumulated as a separate report. All of these reports are required by the QA committee for its assessment and review of error production.

* A few kinks. Of course, nothing is perfect. What would we like to have changed?

Downtime requests are special forms used with the new system when the computer is inoperative. The forms must be filled out manually and sent with the specimen. The laboratory staff keys in the information on the computer when the system comes back up.

To simplify the downtime procedure, we have ordered an automatic card reader. When the equipment arrives, the request form will be converted to a bubble card and the tests blackened in on it by ordering physicians or nurses. The card can then be read by the reader, eliminating the need for manual entry by the laboratory staff.

Outpatient requests and tests performed for other hospitals under the shared laboratory program must be hand-entered into the system. We hope to adapt these tests to the same type of automatic card reader so that manual entry by members of the laboratory staff can be completely avoided.

* Plan ahead. We also learned several things from the installation of our new system, and offer them as advice:

Choose a vendor that is flexible enough to design what you want. If they say they can't do it, check to see if someone else can.

Be firm on what you need. Visualize the workflow. Consult with all the prospective users. Think about how the data should be handled, then design the software specifications to achieve it. Don't settle for what was done in the past.

Finally, encourage teamwork with your software vendor. Tell them what you want. Listen to their problems. Then work out the best compromise.

In summary, we love our hospital information system with its capability for nursing station order entry. It pains us to look back and remember how we got along without it.

Myhre is professor of pathology and chief of clinical pathology at the Harbor-UCLA Medical Center in Torrance, Calif., where Clonts is associate administrator and chief information officer, Colson is administrative coordinator of pathology, and Hostetler is acting assistant director of information systems.
COPYRIGHT 1993 Nelson Publishing
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Copyright 1993 Gale, Cengage Learning. All rights reserved.

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Author:Myhre, Byron A.; Clonts, Ron; Colson, Rebecca; Hostetler, Karen
Publication:Medical Laboratory Observer
Date:Aug 1, 1993
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