Topics: Restrictions to Editing Chemo Orders Changing Chemo Orders in an Oncology Protocol Editing Chemo Orders Before Activation Defining Approval and Authorization Activating Chemo Orders Activation Dates and Expiration of Inpatient Chemo Orders Ordering, Activation, and Expiration of Chemo Pre-Admission Orders Activation Dates and Expiration of Ambulatory Chemo Orders Expiration of Active Chemo Orders Handling Orders Across Treatment Locations |
Awaiting activation—New Inpatient Chemo Orders (NICO), Pre-Admission orders, and Ambulatory Chemo orders are not active on sign-off. This includes edits to active chemo orders. In the inpatient setting, orders cannot be transcribed or reviewed by an RN while they are awaiting activation. They can be discarded without becoming part of the permanent patient record. These orders must be manually activated when needed. See Activating Orders Containing Chemotherapy Agents Order status of patients with orders awaiting activation:
Activation for unregistered ambulatory patients—In ambulatory units, if the patient isn't registered for the visit on arrival, the sessions are preceded by an asterisk (*). You will be notified that the patient is unregistered when you click activate. At present, this message is the only result.. Split sessions, non-chemo session #1 and chemotherapy session #2 and #3—When an order session contains chemotherapy medications, the session is split in two, with both parts listed separately in the Pre-Admit/NICO Sessions list. In the list of sessions awaiting activation, each session is labeled with the session type (Pre-Admit, NICO, or Ambulatory), treatment date, session split (non-chemo session #1, chemo session #2, chemo session #3, blood product session #3), and the name of the treatment regimen or protocol. Each must be activated, one at a time. Split sessions for non-RN activation, chemotherapy #3—If one or more of the chemo agents in a session has been defined to allow activation by clinicians other than an RN, a third session is split out for those orders. Chemotherapy Session #3 splits for every day of administration, so if the agent in session #3 is scheduled for days 1, 2, and 5, it will split into three (3) separate sessions for activation on the scheduled days. Separate sessions by different order times—Orders are handled as separate sessions whenever a provider orders chemo via the Write or Pre-Admission options, even if the regimen or protocol is the same and the treatment date is the same. Split session for DFCI only—Blood products and premedications ordered using the Transfuse form are split into a separate session for activation at all Dana Farber (DFCI) locations. This is alongside the non-chemo session #1 and the chemo sessions #2 and #3 if applicable. Sets of sessions split by week—In addition to splitting chemo and non-chemo orders, separate sets of sessions are created for every week that chemo is to be given. For example, if chemo is scheduled for days 1, 8, and 15, three (3) sets of sessions are created. Any chemo session #3 (RN not required to activate) with scheduled days that fall within that week is included in the set. The first, as a pre-admission session, carries the admission date as entered; the second is dated one week later, and the third, two weeks later. The orders to be activated after admission are NICO (new inpatient chemotherapy orders) sessions. Splitting sessions for a treatment that starts on Day 0 (zero)—Chemo orders using a day 0 (zero) for the first day of treatment split a little differently. Day 0 orders are split into a separate set of sessions for activation. If the schedule following day 0 spans more than one week, the remaining orders split into groups for weekly activation. Treatments with negative days (inpatient only)—There is an exception to the rule of splitting orders into weekly groups for activation. If the treatment includes negative days—that is, if there are orders scheduled for administration before day zero—the orders are simply divided into the non-chemo session #1, chemo session #2 (RN activation only), and if applicable, chemo session #3 (provider activation). If the schedule spans more than one week, the orders do NOT split into groups for weekly activation. Approval/Authorization Pending—Chemo pre-admission or NICO Session #2 and/or #3—Chemotherapy awaiting attending/NP approval or exception authorization cannot be activated until signed off. The sessions do not split until they are approved/authorized. Desensitization—Chemotherapy order sessions containing orders that still await submission of the desensitization worksheet are flagged Pending Desens; chemo sessions with a desensitization worksheet awaiting attending allergist approval are flagged Pending DesensApr. The order session cannot be activated until the desensitization orders are submitted (and approved if needed). Once any desensitization pending flags are cleared, the session status progresses to Pending (activation). The orders then follow standard chemotherapy activation rules. Activation order—Sets of sessions must be activated in order:
Discarding sessions—If sessions awaiting activation are expired, an RN can discard the expired non-chemo session. Only an MD, NP, or PA can discard the session containing chemotherapy medications. See Discarding Pre-Admit/NICO Orders Awaiting Activation and Discarding Pending Ambulatory Orders. Changing the treatment date—If a chemo session has expired, the treatment date can be changed to reset the status to awaiting activation, within limits. For details, see the overviews on activation and expiration for inpatient, pre-admission, and ambulatory sessions (links to left). Also, sthe treatment date can be changed to reset the status to awaiting activation. See Changing the Dates or Cycle for Chemo. Who can activate—The chemo pre-admission or NICO chemotherapy session #2 can only be activated by the following clinicians:
Chemotherapy attendings, fellow, nurse partitions, and physician assistants can activate chemo session #3 so long as they are not the clinicians who signed to orders. Any authorized clinician can activate the non-chemo session #1. Pharmacy Activation—At DFCI only, pharmacists can activate orders for chemotherapy. However, pharmacy cannot activate via the Edit/View Inactive function on the UCM (patient list); pharmacists must access the orders via the Activate button. This prevents the possibility of activating the orders twice (once by pharmacy, and again by the administering RN). Laboratory Results—Laboratory results are displayed beneath the orders list. These are results that have been reported in the previous 21 days, which are defined as relevant to the chemo medications for the current regiment or protocol. Today’s results are bold and underlined. Results outside of the reporting lab's reference range are flagged in red followed by H (high) or L (low). If no results are displayed, check the Results viewer by clicking Results in the CAS toolbar on the left. (See Checking Last Known Values for Lab Results.) Recalculation of Dosing—The clinician activating chemo orders is prompted to verify the patient's weight and height, and the most recent serum creatinine level if AUC dosing is used. Dosing based on the patient's weight, BSA, or creatinine (for AUC dosing) is recalculated at activation unless the treatment is defined to prevent it, or clinician ordering chemo indicates that this should not be done. See Preventing Recalculation On Activation (Writing or Editing Chemo). Approval requirements after activation:
Printing at MGH Ambulatory and DFCI—Clinicians activating chemo orders are prompted to print a paper copy if needed. At MGH ambulatory and DFCI sites, orders for the treatment of hypersensitivity reactions are suppressed from printing on activation of the orders in session #1. If the patient is having a reaction, print the hypersensitivity orders from the active orders View, or by using the Reprint feature:
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