Purpose—Links between orders in the chemo builder are designed to set up administration instructions for chemotherapy orders that can be interpreted by the pharmacy system and the electronic medications administration record (eMAR) for scheduling. Orders that can be linked include chemotherapy medications, IV fluids, and non-chemo medications.
Types of links—There can only be one type of link between the same two orders, but an order can be linked to more than one other order. There are four (4) types of links:
Mutually exclusive—A group of two or more orders with only one, and not more than one, that can be administered. The administering RN chooses which order to administer. The ordering clinician is not required to select any or all orders in the group. Medications with range dosing cannot be linked to a mutually exclusive set. While PRN (as needed) medications can be grouped as mutually exclusive, PRN medications cannot be linked to non-PRN medication orders. PRN medications can be linked if they have different interval (Q2H, Q8H, etc.) frequencies, but not if they have different non-interval (QD, BID, etc.) frequencies. An example would be two orders for the same medication, written for different routes, the second to be given only if the first is not possible: Ondansetron PO, with Ondansetron IV ordered in case the patient cannot take oral medications at administration time.
Mix together—Two or more orders that should be mixed together for administration. Mix together orders must be have the start time and date, the same frequency, and the same administration route. The same order cannot be linked in two separate mix together groups for the same day. Mix together orders cannot be mutually exclusive, and none can be ordered as PRN (as needed). Orders that are already linked in a sequence or time offset cannot be added to a mix together group. A linked mix together group of orders can be linked altogether to be mutually exclusive, in sequence, or time offset with orders that are not part of the mix together group. Multiple intrathecal (IT) medications administered in the same syringe is an example of mix together orders.
Sequential—Two order more orders that must be administered in specific sequence, with no defined time between administrations. The first and final orders of a set of sequentially linked orders can be linked to a group of orders linked with a time offset. PRN (as needed) medications cannot be included in a sequence.
Time offset—Two or more orders that must be administered in a specific sequence with a defined time lapse between the start of the first and the start of the next administration. Time offset links are defined in pairs; more than one pair of orders can be linked in the same sequence. The start times of time offset orders cannot be the same. PRN (as needed) medications cannot be included in a time offset group. The time intervals for offset are whole or half hours, including zero hours for orders that are given together but not mixed in the same container for administration. The group of orders in a time offset can be linked to the first or final orders of a sequentially linked group. An example is MESNA given 30 minutes before administration of a chemo agent, with three additional infusions of MESNA started at three, six, and nine hours after the start of the chemo agent. This results in four pairs of links: MESNA 0.5 hours before chemo, chemo 3 hours before MESNA, chemo 6 hours before MESNA, and chemo 9 hours before MESNA.
Linking based on the patient's condition will not be available from the linking tool. Such orders will continue to rely on pharmacy to nursing communication.
Scheduled days—When links are established between orders with scheduled treatment days (numbered from the start date of the treatment episode), the links are valid for the scheduled days that are the same for each linked order.
Copying order sets—Links are duplicated when orders that have links are copied. This includes copying an entire regimen or protocol from production, as well as copying any folder—regimen, protocol, branch point, yellow folder, or order set—in chemo maintenance. After copying in the builder, the linking tool establishes links between the new orders in the copy. The copied orders are not linked to the originals.
Linking, pre-selected orders, and order selections by clinicians—Linked orders can be pre-selected or left to the ordering clinician to select. The state of the orders that are linked does not have to match: none, one, or all can be pre-selected. The instructions for linked orders are only valid for those that are selected when the clinician writes orders.
Deleting linked orders—Deleting an order in an order set (in the chemo builder) invalidates the links to that order. If the deleted order is part of a group of more than two orders, the links between the remaining orders are maintained.
Inactivating and editing links—Links between orders can be edited or inactivated in the linking tool.