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Dome - One Protocol Fits All

Dome October 2014

One Protocol Fits All

Date: October 6, 2014

Electronic order sets standardize outpatient care and clarify nurses' scope of practice.


Eppie with blackboard

Back when treatment protocols were on paper, a provider may have signed off on 50 or more individual orders for one lung transplant candidate. It was a time-consuming and inefficient process that forced transplant nurses to constantly track down physicians for signatures on diagnostic and lab orders, hindering their ability to do their job.

Epic has put an end to that laborious process in several ambulatory settings across The Johns Hopkins Hospital, where a single, standardized clinical protocol for multiple orders has replaced sheaves of individual paper orders.

“When you put Epic in the mix, it clarifies who should be doing what and how,” says Renay Tyler, senior director of nursing for ambulatory services at The Johns Hopkins Hospital. Working together, Tyler and other ambulatory leaders harnessed the power of the new electronic medical record system to create the new protocol’s order entry lists.

Under the new protocol, in the hospital’s lung transplant program, for example, a provider will consult with a transplant nurse coordinator on outpatients who are potential candidates. If the care team decides to move forward with the transplant evaluation process, the provider will sign off once on dozens of diagnostic and lab orders that are bundled together in the electronic medical record system. The nurse coordinator can then place multiple orders on her own without running back and forth to the provider.

The result is more efficient, consistent, patient-centered care, says Michelle D’Alessandro, assistant director of nursing for transplant programs. “I would rather a transplant surgeon sign five new orders for five patients than 55 orders for five patients who each need a chest X-ray, a mammogram and the same list of other tests.”

What’s more, the one-stop approval process has freed up nurses to work to the full scope of their training. “Overall, nurses feel a little more autonomous,” D’Alessandro says. “They can order appropriately, and the protocol expedites care.”

The electronic protocol is currently used in the heart, lung, liver and kidney transplant programs and in oncology. Tyler has approached other departments that can benefit from the protocol. “If I see 25 or more orders from the same nurse in the same week for the same procedure, I know we could create a protocol for that.”  

Tyler has also helped to establish Epic-based guidelines for nonprescriber-initiated patient orders that permit nurses and other nonclinical staff to administer flu vaccines and basic procedures, such as urine and blood tests. The prescriber will later receive an electronic reminder to cosign the order.

Take, for example, routine orders for gynecology and obstetrics patients who suspect they’re pregnant. Rather than wait for a provider’s signature for each pregnancy test and other orders, Tyler says, “You may as well create a protocol.”

 —Stephanie Shapiro