June 9 issues/tip
rules governing the ordering of drugs while on the APS created some serious challenges in the first week of GoLive. Post op PACU/APS orders needed to be written in a particular order. Our colleagues on the floor experienced issues in their workflows due to the “hard” stops while on the APS phase of care. They quickly worked around this by unilaterally discontinuing patients from the APS.
By Friday afternoon, an alteration to the rules governing the APS was put into place. For anesthesia, you should be able to place your orders for postop care in the order you choose. The Department should no longer be receiving phone calls from other care givers complaining about their inability to perform tasks due to APS oversight. Non-Anesthesia providers will receive a warning message when ordering meds restricted to the APS phase of care. They will have to provide an override reason as to why the order is required. We will be able to audit this activity. Only Anesthesiologists/APS RN’s are now able to discontinue a patient from the APS. (as of this writing, I am informed that anesthesia residents are also receiving a warning-this will be rectified as residents were not placed on the exemption list when this was released on Friday).
One Click or Two
I have created a document titled, “One Click or Two” which will be I recently uploaded to the WIKI. It explains the subtleties of this common practice. There are a lot of areas in EPIC where the traditional double click will take you to where you want to go. However, highlighting with a single click is nearly full proof.
Ordering a mixture
We share a common medication database with our Cardiac colleagues. It has become clear during GoLive that they mix some of their medications in a different default concentration than the main OR. As such, the default mixes will be removed. When ordering a medication that you prepare by placing mass into volume (eg. most of our CVS drugs), you need to make sure you specify the mix. In the end, this is probably a safer practice.
If a patient has been cancelled AFTER you have opened a patient’s chart but before the anesthetic has commenced, you will use an event called, “
Cancelled in Pre
”. You will find this under “Events”.
This is important because once the chart has been opened, you will need to resolve all the “close encounter” rules. The chart will be considered incomplete. Clearly, many of these do not apply in a cancelled case. Once you have cancelled the case, then close encounter rules change to recommended. This satisfies the system and your case will no longer be considered open/incomplete.
Deleting a Procedure
-If you have created a stand-alone Procedure in error, this is how you flag for deletion.
In the example below, you are called to the floor for an intubation. You identify the patient on the list.
You select “
” as the Px you want to create a note for.
You proceed as per the event prompts/reminders and you document your Px. You then realize that you have documented this procedure on the incorrect patient. If you recognize this error while the Px note is still open, you can skip the next step.
Navigate to “
” and locate the Event. Double click to open the Px note.
Go to the “
” tab and select “
Mark for Deletion
Searching for a Patient
-if you haven’t noticed by now, searching
by MRN will not work.
Notice the body of the message. It provides two options you can use to find your patient.
The first option is the easiest, using the MRN or HCN and associated ID type-as follows:
June 3 issues/tips
- still intermittent-however, I’m told it is a lot more reliable if you concentrate on scanning the QR code
rather than the bar code on the bracelet as this is what the system is looking for.
-in the timeline-fix is coming. It is being displayed on the summary sheet. Certain ventilator data also not coming across. This has occurred as a result of another EPIC team not communicating with the Anesthesia team when they made changes to the system. The analysts are spending a lot of time trying to return the system to its original release state (with all it’s deficiencies
-we thought the fix was in but it is apparently still not working. If “RBC” is required, go to the blood icon and try to assign your units to the RBC option by scanning. If this doesn’t work, then try the “unmatched PRBC”. If this still doesn’t work, you will need to create a note documenting the units and volumes administered. At present, you will have to do this for FFP, Platelets and Cryo. In a massive transfusion protocol, you must hit the “unmatched PRBC” because this what you are receiving.
-the ability to create your own anesthesia “type” macros has now been resolved and you can customize the ones that are currently in your system. I would suggest you limit yourself to the medications that you would like to see on your grid and to leave the reminders and events alone. These help to guide you through completing a proper anesthetic.
-This will be a learning curve. If you know you are going to put the patient on the APS, then try and communicate with the surgeon/surgical resident about this. In this situation, they do not have to worry about any postop analgesia as we are responsible for both the APS phase of care as well as the transition to the “on unit” phase of care-translated, this means that we don’t have to suggest meds for pain control when taking patients off the APS as we are assuming responsibility for this. Therefore, the service only needs to order non-APS meds. If this discussion does not take place or they inform you that it is already done, then you need to access the active orders of the patient and discontinue any medication that you plan on using for the APS phase of care. Otherwise, you will be blocked from ordering these meds.
-you cannot put your staff starting time before the Anesthesia Start time. The system is very fussy with this stuff.
-people noticing that the custom Px macros they worked on in personalization have disappeared. This stems from the fact that the macro was created in the incorrect Px. Refer to the Personalization cheat sheet on the WIKI which specifically itemizes the exact name of the Px you need to personalize.
At present, many of you have noticed that in certain circumstances, your PACU orders are blocked. The fix is imminent but for now, try to do things in the timeline that the orders will be enacted; i.e. do your PACU orders first followed by the APS orders. You will not be blocked if you do it in this order.
Stop Data Collection
Make sure you “Stop Data Collection” in the OR. This dissociates the capsule device on the back of your machine from the patient’s record. YOU CANNOT go to PACU, navigate to Intraprocedure and “Stop Data collection”. The computer you are working on in the PACU is NOT connected to the Capsule Device.
Should be appearing now. Have a look. They will save you the step of searching for a particular drug.
If a patient is taking a non-formulary drug and you want to continue in the postop period, then look for “unknown” in the orders. You will find a generic drug for which you will have to complete many details in order to release. If the patient is being admitted to the APS, then when you sign off on the drug, you will be prompted for a phase of care-make sure you chose the “APS”.
-still not finding their way to the Anesthesia Consult list. This doesn’t mean that a consult doesn’t exist. You can navigate to a patient’s orders and look under active orders to see if the consult truly does exist. Right now, the workaround is to carry a list of outstanding consults and scratch them off your list once complete. Everything else remains the same.
Labels were missing OHIP numbers this morning, probably the result of a glitch with the admitting process. The OHIP number started to appear in the afternoon. I have noticed that the billing labels do not contain OHIP version codes. This is a problem. Will request inclusion. In the meantime, here is one way you can access the OHIP number and version code:
Select the Admission
Pre June 3
-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.
-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 “
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.
You have 0.040 u/ml running at 75 ml/hr = 3 u/hr
3 u/hr = 3000 mu/hr = 50 mu/min (if I’ve done my math correctly)
If you don’t want to do this, then write a memo stating your mix and your infusion rate.
-problem on the weekend with consults not showing up in the Anesthesia Consult folder. This has been resolved.
-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