From: Andrea Rawn, Coordinator Evidence-Based Care Program
Chair GBHN Order Set Committee
Date: April 2011
RE: January/March Report 2011 OSOS Meeting to Apr/May Committees
Please note that all Order Sets developed MUST have a clear physician/department based
stakeholder(s) list. Protocols may be developed, but are not limited to, different disciplines outlining
their scope of practice, with the understanding that ALL protocols must have a physician order to
initiate them and that the contents cannot be altered. All physicians are required to know the content of
the protocols before initiating them.
NEW ORDER SETS AND PROTOCOLS RELEASED FOR USE:
New: GBHS – OS only – Family Planning Clinic Post Op Order Set
Chief Stakeholders: WCCU
This order set will be used in a selective group of patients post op family planning / surgical
New: GBHS – OS only - Methotrexate Injection for Termination of Pregnancy
Chief Stakeholders: WCCU
This order set will be used in a selective group of patients who pass strict criteria for use as
outlined in the guidelines.
New: Intravenous Immune Globulin Order Set
Chief Stakeholders: Oncology/Laboratory;
This is a new order set to assist in the decision making and dosing of IVIG throughout the
GBHN network. It is available to all who are qualified to order IVIG in a clinical setting and
where the product is available for use. This order set includes a new feature in that it links the
order set electronically to Transfusion Ontario for indications of use and dosing.
PLEASE NOTE: Dosing is based on Ideal Body Weight (IBW) as is best practice and not body
weight alone. There is a significant difference in the total dosing and thereby the cost.
New: IVIG Nursing Guidelines/Worksheet Protocol
Chief Stakeholders: Oncology/Laboratory/Nursing
This protocol is a best practice administration guide and recording sheet for Nursing to monitor
and administer the IVIG in the safest manner. By including a Nursing Protocol the IVIG Order
Set has been made significantly smaller and pertinent to the physician.
New: Misoprostol Alone for Termination of Pregnancy
Chief Stakeholders: WCCU
This order set will be for use across the network with consultation if required. Strict criteria are
laid out in the guidelines. Instructional material also included as well as follow up.
MODIFIED ORDER SETS AND PROTOCOLS THROUGH CHANGE REQUEST FORMS:
Continuous Bladder Irrigation Protocol – language changes around size of irrigation bag as not all sites have
three litre sizes. Wording changed to Normal Saline. Approved.
Enteral Feeding Order Set – clarification of wording and added addition of the Tiger2 feeding tube and the follow
up care associated with this. Approved. Discussion around availability of the Tiger 2 at other
sites resulted in a concensus that if the tube is not available, it will not be used and the
traditional tubes will continue which are also covered in the order set. The order set covers all
selection of feeding tubes.
PCNL & Retrograde PCNL Post Op – Type of CT scan clarified on both order sets. Approved. Discussion with
Urology the 2 sets being similar in content and this is correct and will continue as two sets.
Speech/Language Pathology Consult Protocol – Clarification of language as submitted by the Registered
Dietitian group and Dietary in discussion with the S/LP. Approved.
Ischemic/Hemorrhagic Stroke Order Set – Rehab Stage – Addition of swabs for MRSA and VRE as is routine
Cardiac Cath Prep Order Set LHSC – LHSC forwarded requested changes to their process and this is reflected
in the Order Set. Approved.
C-Section Postpartum/VB Postpartum – Preselected Bladder Management Protocol added for urinary retention
as is best practice.
Enteral Feeding – Feeding types changed, clarification of wording and addition of the Tiger 2 feeding tubes.
GBHS – OS Site only – Drotrecogin (Activated Protien C) – Infusion charts updated, clarification of mixing
instructions; new documentation coming from pharmacy as to how much drug has been
dispensed and when (this is a pharmacy controlled document). Associated documents reflect
GBHS – OS Site only – Intensivist Led Unit Admission Order Set – Changes to remove duplication of
Ischemic Stroke Thrombo and Non-Thrombo Order Sets – Changes to reflect updated guidelines and improve
consistency across this spectrum.
Discussion centered around membership and meeting times that would enable as many as possible to attend.
Reporting structure will be as follow;
EBCP reports to Katrina Wilson CEO and President of HDH as the Lead of the Network EBC Program
OSOS is a subgroup of EBCP
OSOS will continue to retain absolute approval rights for order sets/protocols with stakeholder input.
OSOS will report to the Clinical VP’s as outlined in previous reporting structures.
OSOS will send a written report to Professional Practice x3 and MAC x3 bimonthly with approved changes and
the OSOS chair will become an ad hoc member of all; attending as requested and to educate
Ann Fleming – retiring and will need replacement for GBHS
Dr. Roth passing off to Dr. Duwyn for SBGHC
Dr. Montag – able to come back to committee from HDH
May need to changes date/time of meetings to accommodate physicians attendance as many have Wed
Andrea is requesting that Melissa Comyn be invited to become a member of the committee as a SBGHC
representative and application specialist with HIS. She will be educating power plans and order sets at
At this point meetings will continue to be bimonthly, the 2nd Wednesday in the month at 1400.
Rise in POC glucose testing;
- The number of POC glucose specific orders has been increasing and has been reflected to the order
set format. It needs to be stressed that the Order Sets are physician based and the ordering comes directly
from that group. The POC is not preselected and must be specifically ordered when the order set is
-recommendations have been received from a coroner’s report to add a limited number to the ventolin
inhalations on the Community Acquired Pneumonia Order Set. Although there is no direct correlation to this
case it was listed as a remote consideration for contributing factors.
ORDER SETS/PROTOCOLS ON HOLD:
Obstructive Sleep Apnea Order Set remains on hold pending stakeholder discussion.
Liver Biopsy Order Set remains on hold pending stakeholder discussion.
Lung Biopsy Order Set remains on hold pending stakeholder discussion.
Orthopedic Day Surgery Post Op Order Set remains on hold pending review of relevant content. Dr Henning –
GBHS Orthopedic Surgeon, has suggested an alternative content review with one supported by
Markdale site. This is under review and other suggestions welcomed.
REQUESTS FOR NEW AND UNDER DISCUSSION:
Smoking Cessation Order Set
Insulin Drip/ Dose Adjustment Order Set/Protocol (outside of Critical Care)
C – Diff Recurrence Order Set
Diabetic Ketoacidosis Order Set
Octaplex Order Set / Protocol
DVT Prophylaxis Order Set / Protocol
ALC Order Set / Protocol