This document will take the user through:
Adding a patient to the APS service
Rounding on the APS
Modifying an Order
Transitioning patient off the APS+/- Follow Up list
Completing an Inpatient APS consult
Following an APS patient discharged from hospital (telephone assessment)
When a decision is made to place a patient having surgery on the APS, it is
that the surgical service NOT place any orders in the following classes:
Any surgical orders written before the APS orders will TRUMP the APS orders. In this scenario, the anesthesiologist should receive notification that drugs contained in the above classes have already been ordered. In this case, the anesthesiologist will have to DISCONTINUE these drugs so that the APS drug orders are in force during the APS phase of care (you will see how to discontinue orders in this document).
At Go Live, there will likely be confusion in that the surgical service may not choose to order any pre-admission patient meds, leaving everything to you. This is NOT the case. APS policy states that a patient may continue to receive their usual anti-depressants, anti-psychotics, anxiolytics, anti-convulsants and benzodiazepenes unless otherwise ordered by the anesthesiologist. Translated, the surgical service can order these drugs.
Adding a patient to APS
in EPIC will be a two-step process
Completing the Acute Pain Service Orders
Completing the APS consultation
While in the Intraprocedure workspace, click ‘Orders’ in the toolkit.
Use “aps” as a keyword. Once you find the ORDER set, you should favourite it.
The next three screen shots show the extent of the APS order set. All nursing interventions are ticked off by default. As with other order sets, you will learn to customize in Personalization so that you don’t need to fill out your preferred options repeatedly. You will even be able to make multiple variations of a particular order set (including a blank version). If you don’t like the default dosing of a drug, feel free to change.
Notice the default order
“General\Admission\Patient on Acute Pain Service (APS)”.
This selection is responsible for getting the patient onto the
“CIV” or “GEN APS Active Patients”
Once you have completed the orders, hit
at the bottom right. Your patient will be admitted to the APS immediately (you will be able to see patient on the “CIV/GEN APS Active Patients” roster) and your orders will become active once the patient is admitted to the PACU.
Now, you need to document your
note. Hit “
” and select “
This will take you to the APS navigator. This is where you will also access APS rounding notes, a generic anesthesia consult note and progress notes.
The steps below illustrate how to create a speed button to take you to the APS Consult note.
Hit the wrench in the Consult note section and it will open up the speed button workspace.
Hit the magnifying glass and begin typing “ATL AN APS INITIAL” and you will find ONE match. Accept this selection and you will have created a speed button
Notice that the patient has been identified as being on the Acute Pain Service (from the initial order set created in the OR)
Hit the “
speed button or “
Consult Notes\+Create Note in Notewriter
” and you are presented with your consult note.
highlighting. These are “
”. It looks like a bunch of crazy syntax but it is going to allow you to choose from pre-determined text. To complete, place your cursor over the first
shading (in this case, “
” and hit
. You will get a list of options from which to choose. A
drop down-indicates you have one choice. A
drop down-multiple choices.
When obvious, we have put the most common response as the default selection. Hit the “
” key and you will move on to the next smart list.
” or back arrow if you need to go back. If a drop down list consists of wild cards (***), this will allow you to add text NOT available in a particular list. If you select wild cards as your option, you MUST type something in lieu of the ***, otherwise you will not be able to sign the note. You can also free text in your note. Place your cursor outside any blue or yellow highlighting and enter relevant information.
This will take some getting used to. If you really mess things up, just cancel the note and start again. “
” the note when complete
A charge capture window now displays. At the present time, both the Civ and Gen rely on the provider in the OR to bill for the APS Consult. Therefore, click “Cancel Session” to move past this requirement.
You have now satisfied the two prerequisite steps to admit to the APS. Orders have been generated and the patient now resides on the list. Complete all other required intraprocedure documentation.
Rounding on the APS
The Patient List status board allows us see patients currently assigned to the APS. You will favourite this list so that is easily accessible.
the patient (not double clicking) will show relevant information at the bottom of the screen under “
Hit the “
” button to navigate to the APS navigator (should look familiar from when you completed the APS consult).
Now we are back in the APS Rounding Navigator. Unlike ACUPAM, the APS Consultation and daily progress notes will live under separate tabs.
Notice how the APS Consult note completed in the OR lives in the “Consult Note” section.
Now it’s time to round on the patient. There are two ways to open up a new APS note.
Click on “
+Create Note in Notewriter
use the speed button that you have created, “
Create your note using the appropriate sections (APS Rounding, IV PCA Use, Neuraxial block,…..)
PLEASE REMEMBER TO USE THE PULL DOWN TO LABEL THE SERVICE AS “
Acute Pain Service
”. This will allow easy filtering of all notes when doing APS Rounds
Any button you hit forces text to your note. There is also a summary box in every section to allow for free text.
When you have completed your note, click “
”. You will be now be prompted to bill your visit. Document the billing provider and select “
” to bring up the preference list to drop charges.
Select the appropriate charges and click “
You will be prompted for a diagnosis. This must be completed as MOHLTC will not accept these charges without a diagnostic code. Click on the Dx icon (link).
You are presented with a list of problems that are currently on the patient’s problem list. If you don’t like what you see, you can add a diagnosis.
and enter. Select
from the match and click “Accept” (not pictured)
Charge capture block re-appears with the new diagnosis. Click “
” and you’re done with current note.
Notice the list of progress notes in the navigator with all progress notes for this patient and the body of my most recent note visible.
It is very common for an APS nurse to document a note on the patient.
In this case, it is critical that the APS nurse tick, “Cosign required”
(in this example, we are assuming that Sylvain Boet is the RN).
When the note is now opened by another user, the APS progress note by the RN (or anyone else) will appear. Notice “Cosign Needed”
As the supervising physician on the APS, I can now edit, copy, Cosign or Attest the note.
Modifying Orders on the APS
One of the most common things we do on the APS is to make adjustments to the APS regiment. From within the APS navigator, click on “Manage Orders” or click on the “Orders” icon.
Go to the “
”. There would typically many orders in addition to those for the APS. You may want to filter orders by “Phase of Care”. The Acute Pain Service is a virtual phase of care created for TOH by EPIC. Only the current active APS orders will appear.
It is decided that the patient may benefit from Pregabalin and Nabilone. Neither drug was originally ordered and we cannot modify the original order sheet. You have several options but the most reliable one would be to use a Quick list that exists specifically for the APS. Click on “Q
Select “Acute Pain Service” and you will see a wide selection of meds that are specific for the APS Phase of Care.
Depending on the medication order, a Rx box regarding the specifics of the order will appear. In other situations, we have defaulted the specifics and they automatically move to the “
Confirm that you are ordering the correct dose, correct route, correct frequency (if the frequency is incorrect and the appropriate dosing schedule is not presenting as a quick select, use the magnifying glass to find the correct frequency). If you need to specify a time limit, then use the “
” and select either doses, hours, days. Click “
” to move the order to the “
The order went directly to “
”. Sign the orders once you are done making modifications. Notice the specifics. If you are not happy with the default dose, click the link to open and make the required changes.
At this point, your new orders may not be active but moved to “
Signed and Held
”. This allows the RN to peruse any new order on a patient.
The RN will release the orders and they will then be found in the “Active” section.
Modifying an active drug uses the same concept described above. If you decide you want to “
” a drug, then click “
”. It will appear as “
Orders to Discontinue
” in “New Orders”. If you want to modify a pre-existing drug, then click “
Please note that for drugs that follow a weaning process, it is NOT necessary to discontinue. Once the patient has been weaned off, the RN can enter the “Active Orders” and “Discontinue”
(If a patient is seen on a visit and a modality has already been discontinued, it would make sense to discontinue it at this point).
Transitioning-Discontinuing Patient from the APS
/Moving Patient to the Follow Up list
In the vast majority of cases, the APS transitions a patient from IV parenteral to oral meds before discontinuing from the service.
In the EPIC world, Anesthesia has agreed to take responsibility for ensuring an orderly transfer of all transitional meds
(rather than the current traditional “suggestions” requiring a cosign by the attending service).
To do, this make sure that all your transitional meds are active and all IV parenteral meds have been discontinued.
When rounding, navigate to the APS Active Patient list.
Find your patient, highlight and click on the APS icon to get to the navigator.
You are now back into the PAU navigator. Multiple options to manage the orders on this patient.
To keep it simple, you may want to sort by:
Phase of Care, Go to: APS
The first thing we need to do is to “Discontinue” the patient from the APS.
Doing this first will prevent some Advisories from appearing which will stop you in your tracks.
For each drug, click “Modify”. At this point, a medication box may open for you to confirm or modify the order you plan to transition.
Keep going until you have dealt with every medication/other order contained in the APS Phase of Care. This may seem cumbersome, but it does provide an extra level of safety in that you are forced to see what drugs/orders you are transitioning.
DO NOT SIGN
Go to the pulldown “
” (partially hidden below) and select, “
Phase of Care
The current phase of care, “Acute Pain Service” is ticked for all orders.
Change the phase of care to “
” and click “
You are now returned to the Orders. Click “
Notice that the phase of care with all the transitioned orders shows as “
”. This will insure that the RN no longer sees “
Acute Pain Service
” phase of care. That should hopefully dissuade the RN from calling anesthesia for any issues related to these orders.
In certain situations, you may wish to discontinue the patient from the APS but continue to follow.
Navigate to the Quick List section and select “
Acute Pain Service
”, then the “
Follow Up\Acute Pain Service Follow Up
You may also choose to let the attending know that the patient has been discontinued from the APS.
When all this has been done, “
” the orders. Once again, you will be asked questions regarding the phase of care that the order(s) should be applied to.
Make the appropriate changes and “
Navigate to the list, “APS Follow Up” and your patient should now reside on this list.
In patient APS Consultation
You receive a call from the floor to see a patient in consult for consideration. You proceed to the floor. You can find this patient under the “
” list or under the inpatient unit (in this case, A3)
Clicking the “
Inpatient consult to Acute Pain Service
” link opens up the consult note for review.
Highlight the patient and click the “APS” icon (Not the Consult (Pre-Proc) icon)
You are back in the APS Rounding Navigator. This time, you want to work within the “
” section. Either click on 1)“
+Create Note in Notewriter
”, use pulldown list to do the same or 2) click on “
APS Consult Note
” speed button if you have created.
You are now presented with the APS Consult Note. Please remember to put “
Acute Pain Service
” as the type of Consult. This will be helpful for future filtering. If a RN is doing the consult, then “
” must be selected. If a resident is doing the note and wants to review with staff before signing off, “
” is the appropriate step as it will not be officially on the record for others to see until signed.
An explanation regarding quick lists is found on page 12 of this document.
You have now completed step 1 of the process. However, you still need to
ORDER the APS meds
Go to the ORDERS tab. Type in “acute pain service”. Make sure you favourite this order set for the rest of time.
Refer to Page 4 of the document for Order completion instructions.
Return to the patient list, highlight the patient and click the link, “complete”. This will remove the patient from the Consult list. Your orders have placed the patient on the Active roster.
Outpatient Telephone Assessments
In EPIC, outpatients need to be transferred from the APS Active list and placed into a telephone follow up list BEFORE they are discharged/removed from APS Active list.
This workflow describes the steps to place the patient onto the telephone list.
Please follow the steps listed below.
Otherwise, you run the risk of losing your patient and then having + difficulty getting them on to the Telephone list.
Complete your APS orders as per usual
Identify your patient on the respective “CIV/GEN APS Active Patient” list
When discharge is imminent (that would be immediately if catheter is placed in an outpatient setting), MOVE your patient from this list to the “Shared Reminder Lists\CIV/GEN APS Telephone Follow Up” list (drag and drop).
“Discontinue” your patient from the APS.
To do this, find your patient on the “APS Active Patient” list and click on the “APS” icon.
This will take you to the APS navigator.
At the bottom of the navigator, you will see the “
Click this button and your patient will fall off the inpatient list.
You now want to telephone your patient. Open “Patient Lists”, highlight your patient and click on the Shared Reminder List\ “CIV-GEN-RIV APS Telephone Follow Up” tab.
You are now back in the APS navigator.
Click on “
+Create Note in Notewriter
You now see the APS rounding progress note.
Any of the rounding tabs can be used to document your note.
When you no longer want the patient on the telephone list.
Identify patient on the telephone list.
Right click and “remove patient”
When patient is no longer being followed as an outpatient, then go to list, “
APS Telephone Follow Up
”, highlight patient,
click and REMOVE.
Patient no longer on list.