State specific laws allow RNs to administer immunizations with or without standing orders given by a physician under CDC guidelines and with adequate competencies. CPOE can improve the delivery of care, but should be implemented with existing information systems to be effective. CMS is not holding physicians responsible for documenting existing Stage III and Stage IV pressure ulcers upon admission.
Standing Orders, Computerized Order Entry, & Admission Pressure Ulcers
Standing orders are non-patient specific orders written by a physician or a nurse practitioner (Primer on standing orders for immunizations and emergency treatment of anaphylaxis, n.d.). New York RNs can administer certain immunizations with a standing order and protocols. Implications have come from designing workflows in the computerized order entry systems if not properly fitted with the existing information systems. Physicians are now responsible to assess, document, and treat present on admission pressure ulcers.
In the state of New York, RNs must be CPR certified with American Red Cross, American Heart Association, or other equivalent organization to administer immunization agents with a standing order and protocol. For adults, 18 or older, authorized agents include Hepatitis A, Hepatitis B, Influenza, Pneumococcus, Meningococcus, Diphtheria, Tetanus, Measles, Mumps, Rubella, Varicella, Inactivated Polio, and any additional approved by the Board of Regents. For children, under 18 years, authorizing immunization agents include Diphtheria, Tetanus, Acellular Pertussis, Measles, Mumps, Rubella, Varicella, Haemphilus Influenza Type b (HIB), Inactivated Polio, Hepatitis B, and any additional approved by the Board of Regents. RNs are also authorized when the immunization program is instituted as an epidemic declared by a health official.
The RNs must follow all non-patient specific standing orders and protocols and must maintain a copy of the standing order and protocols that authorizes them to administer the immunizations. The standing orders must be written in language that the RNs to administer the immunizations and contain names and license number of the RNs or the entity that is legally authorized to employ or contract RNs and contain a statement that RNs not named individually cannot administer immunizations outside of employment or contract. The standing order must also contain specific immunization agents allowed, the period of time the order is effective, protocol in accordance with the standing order, and the name, license number, and signature of the prescribing physician or CNP.
The authorization of administration of immunizations by RNs is state specific. RNs in California may administer immunizations without a standing order (the BRN Report, 14(1), 2001). The RNs must possess knowledge, skills, and abilities to do so competently using CDC guidelines. Agency policies and procedures may require a physician order, but it is not required by state law.
"Computerization of ordering can dramatically affect the care delivery process as patterns of communication, cooperation, and collaborative work must shift to accommodate technology" (Campbell, 2009). Computerized Provider Order Entry (CPOE) can cause contentions for computers in busy workstations, software design issues cause some work processes to be awkward, and there is often not enough space for free text entry. The CPOE often does not smoothly handle transactions in level or location, causes rigid scheduling of tests and medications (schedules from time of order entry instead of time needed), and causes difficulty in altering timing of doses when medications cannot be given on schedule. It may not fully support staff workflow activities, can cause loss of situational awareness between nursing staff and physicians, and may create difficulties when standards are hard to implement and interpret.
CPOE systems are tools to support and improve the delivery of care, but do not resolve all clinical practice problems. Workflow problems can be mitigated by altering workflow and CPOE to a comfortable fit based on organizational needs. Proven usability design needs to be used to avoid systems that violate basic principles. Improvement with CPOE comes through interoperability with and access to other clinical information systems. The roles of all staff should be considered in the design process, especially nursing, clerical, pharmacy, and other ancillary staff. Situational awareness is improved through functionality that integrates with other systems and displays information from other systems in a single location as well as maintaining a level of consistency. Clinical decision support tools alert clinicians to potential problems not otherwise detected. Work practices should be mandated in CPOE and rigorously tested.
The Centers for Medicare and Medicaid Services (CMS) has implemented new guidelines for present on admission pressure ulcers (Lyder, Oct 2009). When patients are admitted with a Stage III or Stage IV pressure, the physician is now responsible to assess and document the pressure ulcer in the medical record. CMS defines physician as "MD" or other qualified practitioner legally accountable for establishing a patient's diagnosis. The physician must document the location, stage of the pressure ulcer, and the treatment prescribed.
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