(P-QU-8) Using Quality Improvement to Improve Nurse Completion of Transfusion Orders

Background/Case Studies: In our tertiary care pediatric hospital, providers order blood products in mLs/kilogram or units depending on the patient's weight. In the electronic health record (EHR), when the transfusion order is in mLs, our organization defaulted the quantity of potential transfuse occurrences as 20 to accommodates large orders for plasma exchange. However, most blood product orders in mLs are for single aliquots. Once transfused, orders in mLs require the registered nurse (RN) to perform additional steps to complete the order in a dedicated blood administration navigator within the EHR. This navigator is separate from worklist tasks and flowsheet documentation. When RNs fail to finalize all actions for a transfuse order, a list of orders remains available for release and possible administration. The risk is a future unintended transfusion or administration for the incorrect volume.

Study

Design/Methods: A quality improvement project aimed to reduce incomplete transfusion orders using a series of plan-do-study-act (PDSA) cycles. The outcomes measured were the rate of worklist task and order completion. Each PDSA cycle tested the effects of worklist tasks manually added to the EHR. The tasks targeted incomplete orders of products prescribed in mLs and included instructions: "Complete Transfusion Task" and location in EHR for completing the order. The cycles occurred with or without education explaining the steps needed to complete transfusion orders. The PDSA cycles included transfusions in the Cancer, Pediatric Intensive, and Neonatal Intensive care units (Unit #1, #2, and #3, respectively).

Results/Findings: For all units, worklist task completion occurred nearly 100% of the time (see Figure A), but order completion was variable. RNs in unit #1 received education before the first PDSA cycle, and order completion was 80%. Unit #1's rate of completed transfusion orders declined with subsequent PDSA cycles. Unit #2 first PDSA cycle had 40% of orders completed, which improved as they received education after this first cycle. Unit #2 order completion increased to 100% with the subsequent PDSA cycles. Unit #3, included in the last PDSA cycle, received no education, and order completion rates were 100%.

Conclusions: PDSA cycles inform the feasibility of an intervention without the risk of implementing a new process affecting all EHR orders. Early learnings from these initial cycles show worklist tasks need to be actionable: linking to order completion vs. relying on the user navigating the EHR to complete the order. Requiring RNs to complete tasks in more than one action, such as opening a chart and accessing orders in different locations of the EHR, likely explains why tasks and order completion rates were not equal. The plan is to implement a transfusion order-generated worklist task that links to order completion.

Importance of research: Using plan-do-study-act (PDSA) cycles for quality improvement can provide insight if an electronic health record (EHR) solution solves a problem. A quality improvement project focused on improving incomplete transfusion orders, a problem unique to blood products ordered in milliliters, demonstrates how PDSA cycles provide data about the feasibility of an intervention without the risk of implementing a new process that would affect all blood product orders in an EHR.