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The first thing to know when logging into EPIC is “where am I ?”.  Epic only remembers where you were last.  This is of particular importance to an AA as they move from Campus to Campus on a regular basis.

 

When you log in to EPIC, pay particular attention to what environment you are logging into.  The three relevant environments for an anesthesiologist include:

 

CIV V ANESTHESIA

GEN V ANESTHESIA

RIV V ANESTHESIA

 

 

If you pick any other environment, you will NOT see what you need to see.

 

 

 

The screenshot below indicates that I am signed into the Riv V Anesthesia environment. 

 

 

If you login to the wrong environment, you can logout and then log back in to the correct one.

 

 

 

 

 

 

Another option is to “Change Context”

 

 

 

 

 

 


Let’s begin the ECC flow. The patient will be selected from the appropriate OR list.  At this point, the patient can be opened by either double clicking (if in the correct phase of care) or selecting “Pre”.  There should never be an issue in EPIC where you need to call the Preop area and ask that a patient be transferred.  EPIC allows you to place a patient in the appropriate phase of care.

 

 

 

You are now in the Pre-Assessment area (left of screen).  Click the arrow to review information on a given topic. (or LEFT to LOOK as you should NOT have to enter any information-only to confirm what you have reviewed).

You will see information entered automatically by the system or by the Preop RN.  This includes,

1. information related to the procedure,


2. previous anesthetics contained in the EPIC database (3 previous years of SIMS anesthesia records will be contained in EPIC).  Anything prior to mid 2016 will be accessible by a special archive viewer.

the most recent vitals,


3. Current Allergies and Medications.  IT IS VERY IMPORTANT TO CLICK THE TWO BOXES titled, Mark as Reviewed ”.  This will time stamp the record and be reflected in the Quick pre-eval note you will generate.

 


NOTE: In the ECC, there is NO pharmacy tech.  Due to the high throughput and the fact that many patients are on multiple medications, there will be no electronic entry of medications on the day of surgery.  We will continue to receive a paper copy of the meds (similar to today).  You can still click the “ mark as reviewed” to indicate you have reviewed the paper copy.


 

4. Anesthesia and Surgical Hx.  In the last year, the nurses are no longer completing Preop assessments as they once did using Preop Manager (and the Nursing 71a form).  As a result, you may not find any information in this area (Anesthesia Hx, Surgical Hx, Fam. Hx anesthesia probs, tobacco, EtOH, substance Hx)

 

 

 

5. Family hx, tobacco,EtOH, substance hx.

If there is information populating this area, click “ Mark as Reviewed ”.  If not, do not click.

 


Now, let’s move over the right side of the screen ( RIGHT to WRITE ).  Click the pulldown, “ create note ” and select the “AN PRE-EVAL-QUICK EVAL”

You will be presented with the following.  This is the anesthesia note.  Hit the “ Evaluation ” button.

Any significant pre-determined and relevant issues from a previous anesthetic history will be automatically imported into the note.  In the example below, there is nothing.  This would be a common occurrence until the patient has several encounters in EPIC, specifically having undergone previous surgical procedures.

 

As per the SIMS rapid assessment, complete the medical Hx.  If you need to elaborate on a field, simply place your cursor over the field and begin typing.  Notice that every descriptor has both a + (have problem) and (don’t have problem) sign.  Each system also has a general “neg” box that can be checked. 

 

You may see the occasional triangle “caution”.  This serves as a reminder to you that at any point in the past, a physician has identified the issue as relevant to the patient.

In the example above, sleep apnea has been identified as an active problem.  This is a reminder to you and you will probably click on the field to bring it into your note.

Don’t forget to note that you discussed the plan with the attending.  Note the anesthesia type, “MAC”, then sign the note.

 

Physical Exam (if relevant-likely not required in the ECC)

 

You will likely hit the “healthy patient” macro for most patients and complete an airway exam.

 

Anesthesia Plan (if relevant-likely not required in the ECC)

Complete the ASA , Anesthesia Technique-“ MAC ”, “ NPO as per CAS guidelines ” and that you discussed plan with the patient, then “ Sign ” the note.


Click “ Anesthesia Start ” or scroll down to view.  Hitting “ Anesthesia Start ” will timestamp current time.  Hitting the green ribbon will allow you to back time your Anesthesia Start.  This should be the time at which you are first in attendance with the patient.  If you want, you can hit the start before you begin chatting with the patient.  Alternatively, the AA in the OR can hit the “ Anesthesia Start ” event and back time.  If the bed bay AA/MD hits anesthesia start in the pre-procedure navigator, it will not show up in the Intraprocedure navigator.

 

Shut down the case


You are now in the OR.  You will see a familiar Status Board

Highlight your patient and select “Intra” or double click if you see a purple box which identifies the patient as being in the Intraprocedure environment (if you double click on a patient with a yellow box , the Preprocedure navigator would appear.  If you end up in the Preprocedure navigator, it is easy to go to the Intraprocedure navigator.

 

This is what you will see.  Click on “Intraprocedure” to take you to the anesthesia record.

Place monitors on the patient and click, “ Start Data Collection ”. If the AA in the bed bay did not click on “ Anesthesia Start ”, you would see this as the first event instead of “ Start Data Collection ” Also note all the reminders that you will need to complete before you leave the OR

 

 

IT IS CRITICAL THAT YOU Click “ Start Data Collection ”, otherwise NO vitals will come across to the anesthesia record.

 


You will be presented with the following screen.  We need to reconcile that we have the correct patient.  There will be a scanner on your anesthesia workstation and you will scan the QR code on the patient’s bracelet.  As of this writing, there are only scanners attached to the rooms where there is an anesthesia machine.  We are requesting additional scanners for the other rooms.  If you do not have a scanner, you will need to enter a reason as to why the scanning did not take place (use magnifying glass) and select “ Scanner not available ”, then click “ Override ” at bottom right.

 


Remember that your primary responsibility is to the patient.  Do what you need to do, administer meds, adjust IV, etc, then return to complete the chart using the Reminders to assist you.

Click on the “ Staff ” reminder.  Click “ Add Me ” to bring up your name in the first box.

 

 

Search and add attending staff. Document your times by clicking in the appropriate box for both yourself and the attending staff.  It is very important for you to enter the attending staff supervising in the ECC, otherwise you will NOT be able to administer medications .

 

Click the “ ASA ” Reminder and document ASA

 

 

Click the reminder “ Checklist ” reminder

 

 

Select “ Eye Check Complete ” macro if you are working in a room without an anesthesia machine.

 

The four things you do routinely will automatically be selected.

 

Click “ Check Complete ” macro if you are in a room with a fully functional anesthesia machine.

Click the “ Anesthesia Type ” reminder and document Anesthesia Type – MAC

 

Click the “ PIV ” reminder and document PIV -hitting the reminder will bring up the procedure note.  You will probably create a macro to auto select what you do every time (typically 22g, laterality-right, location-hand, site prep-alcohol swabs). “ Sign ” the note.

 


What about the common scenario where an AA or an anesthesiologist starts the IV in the holding area?

 

The AA in the OR is still going to pull up and complete the IV procedure note.

 

However, it is very easy to indicate that someone else was responsible for the procedure.

 

To do this, complete the procedure not.  Click on the providers and change the name of the “Performing Provider”. 

 

Sign ” the note and move on to the next reminder.

 

 


Hit the “Meds/Fluids” reminder.  Notice the drugs in the left hand column under “Add New”. These are the drugs that were automatically loaded by the macro and appear on the grid.

 

 

Document Medication Delivery.  Below, I have selected Midazolam.  Click on the time, then on the dose to add.

 

 

If you want to add another drug at the same time, click on the drug. Notice the drug is administered by an AA but is authorized by the supervising Anesthesiologist.  It would not be possible for the AA to administer any drug unless the Supervising Anesthesiologist had been added to the Staff in a previous step.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Click on the “ Block ” reminder.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hitting one of the macros at the top (“ Topical RIGHT ” or “ Topical LEFT ”) will populate a good part of the procedure note.

 

 

 

Sign the note and move on.

Entering your meds populates the timeline as below.  Notice that your lidocaine gel application also appears even though you added the drug in the Procedure note (indicated by grey colour)

 

 

Fluids are considered medications in EPIC.  Select the appropriate fluid, click the time and hit “ New Bag ”.  EPIC is not like SIMS in that it does NOT ask for the bag size.

 

Hitting the “ Close ” will save your work and put the fluid on the timeline.

You may have a patient (eg. diabetic) that arrives to the holding area/OR with an IV hanging. 

It will NOT automatically appear on medication grid.  You need to go to the “ Active ” tab in “ Meds/Fluids

Now enter the admin as either “ml/hr” or “ml”

Enter the time and rate.

Fluid now appears on the timeline.

 

Click on the “ Block Placed ” event.  This will put a flag on the timeline (acts as a reference marker).  In this workflow, we already documented the block so we can file it at that time.

 

There are a few more reminders that will appear during the case. Click reminder-“ Document Oxygen Delivery

 

 

Click reminder-“ Position

 

If fluids have been given during the case, we need to reconcile before leaving the OR. Click reminder- “ Post Fluid Reconciliation ”.  Otherwise, you can ignore or delete it.

 

 

 

You will open the following screen and choose what to do with the current fluid in recovery.  You will likely “ continue ” the fluid and “ Accept ” the order (bottom right but not seen in this screen shot)

 

Click “ Stop Data Collection ” to dissociate the monitor from the patient at the end of the case but do not close your patient. Unlike SIMS, EPIC will not let you forward time an event.

 

Take your patient to PACU and complete your verbal handoff to the RN.

Return to the holding area to begin your next case. 

When you return to the OR (with or without the patient), your computer will still have the previous patient on your screen.  Hit the “ Post Procedure ” tab on the left sidebar.  There are two things you need to do at this point.

1.                  Handoff patient to receiving nurse.  Attention to which button you are pressing.  If you hit the green handoff button, you will document the handoff at current time.  Because we are back in the OR and the handoff probably happened 5-10 min. earlier, we need to back time this event

 

 

Hit the “ Handoff ” button with the little clock icon.  This will allow you to back date the time.  If you hit the “ + Handoff to Receiving Nurse” button, you will enter the handoff at current time and then be forced to have to correct for accuracy.

 

Notice the back timing of the event.  Now hit “Close”

 

 

2.                  Anesthesia Stop

As per above, hit the green “Anesthesia Stop” button so you can back time the event to what you consider to be the end time for the case.

 

 

 

If you have followed all these steps, there should be NO outstanding requirements to successfully close the encounter.

 

You will see the following:

“Sign Visit” and you are done.  Now close the chart.

 

You will be returned to the Status Board.  Select the current patient and carry on.


ATTESTATION

 

The supervising staff in the ECC will need to attest to the Medical Directive allowing the AA to administer drugs. 

 

The attestation is for the following so please be familiar to what it is you are authorizing the AA to do.  If you are uncomfortable with any of the dose ranges, please communicate directly.

 

In order to attest, open the patient’s chart and navigate to the Intraprocedure navigator from any computer.  You can use your own computer if desired.

 

 

 

 

 

 

Select the “ Medical Directive AA-01-Eyes

 


The body of the medical directive is as follows:

 

 

 

 


Hit “ Accept

 

 

 

 

 

 

 

 

 

 

 

 


 

 

Want people to be aware of what they are attesting to.

 

 

 

 

Staff reconcile the attestation.

 

 

 

 

Option 2

 

 

 

 

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