Emergency Department Medication Standing Orders
People with bleeding disorders may present to the Canberra Hospital Emergency Department (ED) for treatment, for example, when a serious bleed occurs or when the Canberra Hospital Haemophilia Treatment Centre (HTC) is closed. Medication Standing Orders (MSOs) for the administration of factor replacement in the ED have been developed by the HTC in consultation with the ED specialist clinicians. It is important that patients are aware of these MSOs, as they may facilitate timely infusion of factor replacement.
Importantly, the existence of these MSOs are to help expedite the quick factor administration within 30 minutes of presenting at the ED but do not guarantee it Subsequently, patient evaluation by a medical professional remains essential for appropriate dosing in line with the type of bleed. Furthermore, it is crucial that first aid, including Rest, Ice, Compression and Elevation be administered IMMEDIATELY after a suspected bleed.
What do the MSOs do?
The MSOs are medication administration instructions that empower ED doctors and nurses to administer recombinant and plasma-derived factor concentrated at a specified dose to patients with a diagnosed bleeding disorder that present to the ED with a bleeding-related injury.
As at July 2018 there are three MSO's relating to the administration of recombinant and plasma-derived factor concentrate:
- Administration of recombinant factor VIII.
- Administration of recombinant factor IX.
- Administration of von Willebrand factor using plasma derived Biostate.
The MSOs mean that nurses and doctors can administer factor to patients without the need for an individual prescription from the treating specialist. This can expedite administration of factor upon presentation to the ED. The ‘referral criteria’ listed in the MSO notes that ‘factor replacement is always a priority’. This supports best practice in case of a suspected bleed: infusing first before other diagnostic tests (e.g. scans, x-rays, etc) are carried out.
The MSOs were designed in order to reduce the time between a patient’s presentation at the ED and the administration of factor. They provide medical staff with guidance to administer factor quickly and accurately.
The MSOs do not replace clinical judgment on the part of the treating clinician. Medication Standing Orders are a guideline only and can be overruled by ED staff. In this situation, open communication between patient and medical staff is paramount. The patient or their family need to contact the HTC after this presentation to ED.
How can a patient assist staff in relation to use of the MSOs in the ED?
Most ED doctors and nurses should be aware of the existence of MSOs however, casual, fill-in and new staff are constantly joining the ED team and may not be aware of them. When presenting to the ED triage nurse, patients or their carers should mention their diagnosis of a bleeding disorder, and show any letter they have from their haematologist as well as their My ABDR card. This will reinforce to ED staff that the patient has a diagnosis and a treating haematologist. During this primary assessment it is worthwhile mentioning that there are specific MSOs for the administration of factor.
What if ED staff are not aware of or cannot find the MSO?
MSOs are not a substitute for clinical judgment. ED staff are highly trained to deal with any emergency situation and will provide the best possible care. Patients can also facilitate the process of timely administration of factor by bringing relevant documentation relating to their diagnosis when they present to the ED.
Patient’s MyABDR Card and access to the latest version of MyABDR on their smartphone will provide identical guidance on factor administration as appears in the MSOs to ED staff.
The MSOs are located on the ACT Health intranet within the “hospital policy” section, which is accessible to all ED staff. All staff should be aware of this policy section even if they are not specifically aware of the bleeding disorders MSOs. Searching this database for the word “haemophilia” will result in all relevant MSOs.
The MSO's are also available to the public on the ACT Health website in their Policy and Plans section: http://www.health.act.gov.au/research-data-and-publications/policy-and-plans-0.
The direct links for each of the three MSO's, in Adobe PDF format, are provided below:
These then provide ED staff with guidance on administration, including dosage.
How do I find out more information or seek support?
Please contact the Haemophilia Treatment Centre on 0481 013 323 or 62442286 or via email (firstname.lastname@example.org) for more information on the MSOs, MyABDR and ED procedures. The Haemophilia Counsellor can also offer support in relation to your treatment and care experiences (email: email@example.com).
Things to remember
- Timely first aid (Rest, Ice, Compression and Elevation) can be as crucial as timely clotting factor administration.
- Regular reviews with your haematologist are vital to ensure your records are up to date and will assist in timely delivery and ongoing care in the event of an emergency.
- Report all bleeds to the HTC (no matter how minor) or enter them yourself into MyABDR. This will assist with treatment decisions in both emergency and non-emergency situations.