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PAU

-many of you received abnormal/critical value alerts on your phones/iPads for patients who have gone through the PAU.  This was immediately resolved and there should be NO messages regarding abnormal results in your mailbox.

-going forward, the nurse in PAU will be receiving a report that flags patients who have abnormal lab results.  The RN will then alert the anesthesiologist(s) in the unit by messaging said result to the respective inbox.

-see WIKI or Anesthesia Learning Home dashboard for document titled, “Abnormal Lab Results in the PAU” in the PAU workflow folder

 

-we are still using labels for all billing at this point.  The status of the addressographs seems to be fluid.  Supposedly, they should be remaining for a few weeks.  In the absence of an addressograph, you can kindly ask the clerk to print a label for you.

- see WIKI or Anesthesia Learning Home dashboard for document titled, “Printing a label” in the PAU workflow folder

 

-the Pre-Eval note is designed to link in the narrative on any diagnostic imaging.  This seems to be an issue in that some of the narratives are quite extensive.  In other situations, you will be receiving the initial and any addended report.  You may also see reports which are titled in such a way that ********precede and follow******* the name of the report.  *** asterisks are WILD CARDS in EPIC.  This means EPIC wants you to replace the *** with free text.  You cannot sign a note until the *** are resolved.  Therefore, if a report contains asterisks, you must erase them.  We can look at the value of continuing to link this information during optimization. 

 

Main OR

-first shock will be lining up at the Omnicell.  Despite being told otherwise, all generic OR locations seem to be gone.  You must withdraw your meds against a patient name.  Until otherwise informed, the plan would be to withdraw all drugs for the day under your first patient.  Continue to use a narcotic control sheet to reconcile drug administration.  Return any unused drugs against the patient you initially withdrew from.

 

-the event, “Start Data Collection” will pull up a screen which will prompt you to insure you are documenting on the correct patient.  Scanners are mounted on all machines.  Experience on the w/e was spotty with regard to correct reconciliation.  Give the system a chance to process the scan.  If no problems, continue.  If it tells you it is not reconciling against the open record, then obviously make sure you have the correct chart open and the correct patient on the table.  As per your shadow charting, you must document a reason as to why you did not scan.

 

-please keep an eye on physiologic variables coming from the monitors.  A problem on the weekend with display of art line values on the graph has been resolved.  Insure you are receiving vent data such as gas, ETC02, volumes.  There is currently an issue with some variables that will be corrected.  Lack of any variable means the monitor was not configured by Biomed.  Inform a super user of this problem.  A ticket needs to be created.  If you are faced with this situation, you will have to create a memo documenting ballpark values throughout the case.  Alternatively, you can enter important information manually by hitting the “All Data” icon. 

-if a patient is coming from the floor

·         remember that any currently running IV’s will be found under the ACTIVE tab of the Meds section.

·         and you plan to place the patient on APS in the postop period, you MUST go to the “Active” tab of the ORDERS section and delete all drugs that you will be prescribing for the APS phase of care. This would include Acetaminophen, NSAID’s, narcotics, sleeping aids, etc.  You then need to include these drugs on your APS orders.  If you do not initially cancel these drugs, you will have a hard time ordering APS meds and/or there may be duplicate orders.

-if a patient is coming from SDA

·         as per above, there can be no narcotic orders by the surgeon for the postoperative period.  Whoever writes the narcotic orders first trumps everyone else.  If you want to place APS orders, remind the surgeon not to write any orders containing the class of drugs noted above.  You will need to order all these drugs.

·         The surgeon may have already ordered Cefazolin for the patient.  This will be fournd in the Active order section.

 

Blood administration-we ran into major problems on the w/e due to the Cerner interface (controlling the lab/blood) not communicating properly with EPIC.  As a result, it was impossible to reconcile/scan the blood or blood products arriving in the OR.  We simply documented the admin of these products in a note.  As a result, any product or volume was not truly accounted for in EPIC.

 

A fix was introduced.  Under “Blood”, you will see the addition of “PRBC-Unmatched”.

In an elective situation, try reconciling your unit using the “RBC” icon.  If this doesn’t work, then you will be forced to use the “PRBC-Unmatched” icon.  Don’t worry about the terminology.  Just use the icon that works.  You should then be able to scan the blood.

 



 

At this writing on June 2, the team was working on a similar flow for platelets,

FFP and Cryo.  If the fix is in, you should also see tabs for the “unmatched” blood products.  If not, you WILL HAVE TO WRITE A MEMO to document the units and volumes.

 

 

 

 

 

 

NB.  If you are in a “massive transfusion protocol” ALWAYS USE THE “ UNMATCHED ” selection.

 

Remember that if you can’t find something in the drug room or in your anesthesia cart, you need to ORDER it.  This morning, we required fibrinogen concentrate.  You will NOT find this product in our Meds tab as per above.

Go to the “ORDERS” tab.  Under “Manage Orders”, place the order for fibrinogen.

 

 

If you look closely, three instances of fibrinogen appear but these are “Lab” requests to measure fibrinogen level.  One of these selections will not order your fibrinogen.  Notice also that the system defaults to a “preference list”.  Fibrinogen is not in this preference list.  If you can’t find what you need under the “preference list”, go to the facility list.

 

 

 

 

 

Mobile Cart-Civic Campus

-we were expecting a new computer but not yet delivered.  EPIC will run on the clunky laptop but will require a lot of scrolling.  I’m told to expect a new computer next week.

 

 

Labor and Delivery

-remember that you must retrieve your own Ropi/Fent syringes and epidural bag from the Omnicell against a patient’s name. 

-remember that you must complete the “Birthing unit Epidural Analgesic” orders before trying to complete your epidural procedure.  Otherwise, you will not find your Ropi/Fent syringes under the Active tab of Meds.

 

see WIKI or Anesthesia Learning Home dashboard for document titled, “Initiating an Epidural” in the Labour and Delivery workflow folder.

 

 

-OXYTOCIN infusion can be found in the OB/GYN section of Meds. Right now, there are a couple of issues:

·        The mixture components will only allow 1000 ml of fluid.  Standard at the Civic (?General) is 20u in 500 ml NS.  As you can’t select 500 ml, you need to adapt and say you have 40u in 1L to get the same concentration

·        The rate of oxytocin delivery is in milli-units/min.  We want to run it in ml/hr.  I have requested a change to allow us to do this.  However, if you want to chart oxytocin, you need to do some math: if there are 40u/L and you run at 75 ml/hr.

o      You have 0.040 u/ml running at 75 ml/hr = 3 u/hr

o      3 u/hr = 3000 mu/hr = 50 mu/min (if I’ve done my math correctly)

o      If you don’t want to do this, then write a memo stating your mix and your infusion rate.

 

 

 

Consults

-problem on the weekend with consults not showing up in the Anesthesia Consult folder.  This has been resolved.

 

APS

-seems to be going well.  Issue is collecting labels on everyone, an obvious pain.

We are waiting on the crystal report that will allow us to track the billing in EPIC.  It is very important to bill correctly so that the business groups can reconcile the paper to the electronic billing.  Once convinced that EPIC is producing a believable report, we can default to EPIC to provide us with a flat file.

 

see WIKI or Anesthesia Learning Home dashboard for document titled, “APS from start to finish” in the APS workflow folder

 

 

 

 

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