Transcript Update 2013-10-20-RAPID TEMPLATE, Changes, Refresher

SIMS FILE PUSH-OCT 2013
• File push to occur weekend of October 20
– New template to address high volume/rapid
turnover (RAPID TEMPLATE)
– “GA-Anesthesia Standard” template changes
– Refresh my memory
Rapid Template
• Rapid Template designed to accommodate high volume
rooms at the Riverside Campus (cysto, D&C, Litho) ONLY
• Features include:
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No need to complete formal Preop Assessment using Preop Manager
Default template includes most commonly administered drugs
Customized Event Sets
Customized Icons
Using the RAPID Template
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Launch Anesthesia Manager
Select Patient as per usual fashion
• Use pull down menu on
ADT screen to select
the RAPID Template
•
Should you accidentally launch the
incorrect template, simply
TRANSFER your patient back to the
network and start from the
beginning
RAPID Template-HOME Screen
SYSTEM Icons-NO CHANGES*
*addition of anesthesia WIKI to all templates discussed later in ppt
CUSTOM ICONS-Modified
CUSTOM ICON-PIT
This ICON will place an
“O” on the timeline
and add the following
text to the Events:
•“Oxytocin 20u/L added to IV
Fluid (O)”
CUSTOM ICON-END GA
This ICON will place an
“g” on the timeline and
add the following text to
the Events:
•Oropharynx suctioned as
required
•Adequate spontaneous
ventilation resumed
•Opens eyes to verbal
stimulation OR exhibiting
purposeful movement
•Airway device, (ETT/LMA), if
present, *removed, ventilating
well
•End General (g)
Italics denote changes from “Anesthesia Standard”
CUSTOM ICON-ZZZ
This ICON will place an
“g” on the timeline and
add the following text to
the Events:
•Oropharynx suctioned as
required
•Adequate spontaneous
ventilation resumed
•Airway device (ETT/LMA), if
present, *left in situ
Italics denote changes from “Anesthesia Standard”
this icon can be used when taking a patient to the PACU who has not emerged from GA
MEDICATIONS-Default
New Medications:
•Ketamine mg
•Ketorolac mg
•Lidocaine PF (Pain) mg/kg
•Remifentanil mcg
FLUIDS-Default
New infusions:
•Lidocaine 1% PF (PAIN) mg/h
•Remifentanil 0-1 mcg/kg/min
•Ketamine (GA) mg/h
•Propofol mcg/kg/min
EVENT SETS-Modified
•3 new Event Sets added:
•A!01_Rapid Preop Eval
•A!05_Rapid GA
•A!10_Rapid MAC
•Remainder of Event Sets
stripped down
EVENT SET A!01_RAPID
Preoperative Evaluation
• takes the place of Preop Manager
– Review of Systems (Events) relating
to procedures specific to the RAPID
template
– Review of Systems (Events) relating
to CVS and Resp system
EVENT SET A!01_RAPID
Preoperative Evaluation
• takes the place of Preop Manager
– Review of Systems (Events) relating
to GI/End/Haem system
– Physical Exam (Events) related to
the Airway
EVENT SET A!01_RAPID
Preoperative Evaluation
• takes the place of Preop Manager
– Physical Exam (Events) related to
the CVS/Resp systems
– Relevant lab, Meds, Allergies, NPO
status
– Anesthetic Plan
A!05_RAPID GA
• Highlighted events are new
A!05_RAPID GA
• Highlighted events are new
A!10_RAPID MAC
• Highlighted events are new
Anesthesia Standard Template Changes
• The push of the RAPID TEMPLATE has given us the
opportunity to incorporate changes to the “Anesthesia
Standard” template
• I am happy to report that we have recently established a SIMS
Committee. This Committee will:
– meet on a quarterly basis
– Is multidisciplinary in representation (IT/Nursing/Anesthesia)
• Anesthesia Reps: Zunder, Jee, Bryson, Pysyk
– will facilitate improvements and upgrades in a timely fashion
“GA-Anesthesia Standard” Template Changes
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Eliminating subheadings
General fixes to various event sets
Anesthesia WIKI
WRONG PATIENT protocol and documentation
Preop Manager pull down for Meds/Allergies
Preop Manager-addition of “HER” pathway to Alerts
Artifact Rejection
Surgeon NOT requesting antibiotics
Addition of Albumin 5% to database/protocols
Documenting on the INCORRECT patient
Subheadings
Originally programmed as ON by
default, we realize they take up
precious screen real estate
New Default Setting is OFF
All meds and fluids to be listed
alphabetically
General Fixes-Event Sets
A001_Anesthesia Type
• (M)_Monitored Anesthesia Care-Deep
Sedation
– added in at request of Business Groups to
reflect changes to the MOHLTC Schedule of
Benefits
General Fixes-Event Sets
A005_PACU-SDCU-ICU Report
• Reminder by QPS Committee to
submit a PSLS Report should you
answer YES to:
“Periop Adverse Event/Near Miss:
General Fixes-Event Sets
A011_Basic GA
• Steep Trendelenberg (Position
Checks q1h)
– Added at request of QPS Committee
• Trend/Rev Trend Angle
– Added in at request of QPS Committee
• Upper arm Krauss armrest
– Position in Event Set changed
General Fixes-Event Sets
A012_Basic Spinal
• Please REMEMBER to chart
SPINAL Drug Dosage in
Medications
– Added in as a reminder to
document as audit
committees have noted
absence of spinal med doses
General Fixes-Event Sets
A013_Basic MAC
• Same options added to this
event set similar to
– Basic GA
– Basic MAC
General Fixes-Event Sets
A066_Regional Upper Limb
• Local anesthetic thru needle
– Typo corrected (used to say
“catheter”
General Fixes-Event Sets
A150_Thoracic GA-DLETT
• Eschmann Stylet (Bougie)
– Position in Event Set changed
Anesthesia WIKI
Displays all Educational/Update Material Relevant to SIMS
http://wiki.med.uottawa.ca/display/WIKITHESIA/SIMS+Reference
Preop Manager
New Med/Med Allergies “pull down” list
• Will contain ~80 of the most
commonly prescribed
medications.
• The generic name is in brackets
and follows the common trade
name of the drug
• The list is organized alphabetically
by generic name
• Please forward any suggestions
for further additions to the list
A similar “pull down” will be created for the most common Allergies.
Hopefully, this will facilitate creation of a more comprehensive consult rather than having to look
at Med Rec sheets (paper or electronic). We have no control over Nursing who will continue to
use the “Med Rec” solution. However, residents should be encouraged to use the “drop down”
menu for their “in patient” consultations. Staff/Residents/Fellows should be encouraged to use
the “drop down” menu for Preop Assessments completed on the day of surgery.
Preop Manager
New Medication pull down list
Acetaminophen
Tylenol with Codeine (Acetamnophen Combo)
Tylenol #3
Cordarone (Amiodarone)
Amitryptiline (Amitryptiline)
Norvasc (Amlodipine)
Atenolol (Atenolol)
Lipitor (Atorvastatin)
Monocor (Bisoprolol)
Pulmicort Turbohaler (Budesonide)
Atacand (Candesartan)
Captopril (Captopril)
Tegretol (Carbamazepine)
Celebrex (Celecoxib)
Celexa (Citalopram)
Plavix (Clopidogrel)
Pradaxa (Dabigatran Etexilate)
Dexamethasone (Dexamethasone)
Valium (Diazepam)
Diclofenac (Diclofenac)
Digoxin (Digoxin)
Diltiazem (Diltiazem)
Vasotec (Enalapril)
Nexium (Esomeprazole)
Pepsid (Famotidine)
Fentanyl Citrate (Fentanyl)
Proscar (Finasteride)
Symbicort (Formorterol)
Flovent Diskus (Fluticasone)
Monopril (Fosinopril)
Lasix (Furosemide)
Glyburide (Glibenclamide)
Nitro Dur (Glyceryl Trinitrate)
Hydrochlorothiazide (Hydrochlorothiazide)
Hydromorphone IR (Hydromorphone)
Hydromorphone Contin CR CAP (Hydromorphone)
Ibuprofen (Ibuprofen)
Indemathacin (Indamethacin)
Atrovent HFA (Ipatropium Bromide)
Avapro (Irbesartan)
Trandate (Labetalol)
Prevacid (Lansoprazole)
Synthroid (Levothyroxine Sodium)
Prinivil (Lisinopril)
Ativan (Lorazepam)
Mevacor (Lovastatin)
Metformin (Metformin)
Metoprolol (Metoprolol)
Morphine Sulphate (Morphine)
MS Contin (Morphine)
M Eslon (Morphine)
Singulair (Montelukast)
Naproxen (Naproxen)
Trasderm Nitro (Glyceryl Trinitrate)
Nortriptyline (Nortriptyline)
Zyprexa (Olanzapine)
PMS Oxycodone
Oxycontin (Oxycodone)
Dilantin (Phenytoin)
Potassium Chloride
Predisone (Prednisone)
Seroquel (Quetiapine)
Altace (Ramipril)
Zantac (Ranitidine)
Xarelto (Rivaroxaban)
Crestor (Rosuvastatin)
Ventolin (Salbutamol)
Advair (Salmeterol)
Serevent (Salmeterol)
Zoloft (Sertraline)
Zocor (Simvastatin)
Flomax (Tamsulosin)
Bricanyl Turbohaler……(Terbutaline)
Spiriva (Tiotropium Bromide)
Tridural (Tramadol)
Verapamil Hydrochloride (Verapamil)
Coumadin tab (Warfarin)
Preop Manager
Addition of HER Pathway
• Added at request of
PAU to reflect patients
that may be eligible for
“HER”
Artifact Rejection
• In order to prevent spurious
results from being imported into
SIMS, artifact rejection as
described will be incorporated for
– Invasive Blood Pressure
– Heart Rate
– Temperature
Surgeon NOT requesting antibiotics
• The absence of an antibiotic
dose in the SIMS database
may be interpreted as
failure to administer when
in fact, the drug is
specifically NOT requested
by the surgeon during the
Preop pause.
• In order to capture the
request NOT to administer,
please place a 0 for dose
under Cefazolin
5% Albumin
• As a result of concerns
related to HES, a request
has been made to add 5%
albumin to the database
• “*Anes_Fluids In” protocol
has been updated
Documenting on WRONG PATIENT protocol
• In order to prevent confusion, we’ve come up with ONLY two options. The
appropriate choice will be determined by two main factors:
– How long have you been documenting on the INCORRECT patient?
– Is there ample time to document on the CORRECT patient?
• We have created a new event set titled, “A235_Incorrect Patient”. Please
follow the steps and complete the required fields for the option that has
been chosen.
– Please refer to the Anesthesia WIKI for more detailed information
Documenting on WRONG PATIENT protocol
NO MORE PAPER
• No more paper PAU Pre-assessments accompanying
chart
• use hallway PC’s and launch either
– vOACIS
– Preop Manager
Refresher Points
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How can I minimize EKG artifact?
How can I eliminate white space on the monitor
Documentation of Demographics in Satellite areas
Printout Start/Stop times
Remote View
IV tips
OR Corridor computers to access Preop Manager/vOACIS
EKG artifact
• SIMS obtains HR
information from the EKG.
• Interference creates
multiple artifacts that are
recorded
EKG artifact
• To eliminate artifact, change
the HR source from AUTO to
Pleth
EKG artifact
Atrial Fib-HR Source AUTO
PDF in vOACIS
EKG artifact
Atrial Fib-HR Source PLETH
PDF in vOACIS
Eliminating blank spaces
Eliminating blank spaces
Right click anywhere in the “Real
Time Variables”
Eliminating blank spaces
Highlight the variables (Ctrl-Click) that you do not wish to display and hit <<Remove
Eliminating blank spaces
Blanks spaces have now disappeared.
NB. All MEASURED variables are CAPTURED, PRINTED and ARCHIVED.
What you see on the screen is ONLY what you choose to VIEW.
Documenting DEMOGRAPHICS in satellite areas
In Satellite areas, it is OUR responsibility to add in the Medical Team (surgeon is
not populated as in the Main OR) and the Procedure (not populated as in the Main
OR). There should be a cheat sheet in these various areas which lists the most
popular procedures and the keywords used to find them.
Documenting DEMOGRAPHICS in satellite areas
Cheat Sheet-Labor and Delivery
Cheat Sheet-Diagnostic Imaging
Documenting DEMOGRAPHICS in satellite areas
Cheat Sheet-Ultrasound
Cheat Sheet-Endoscopy Suite
Documenting DEMOGRAPHICS in satellite areas
Cheat Sheet-Dental Clinic
Printout Start/Stop times
In the above list of “Events”, notice how the “Anesthesia Case Start (S) is at 07:30
and the next documented anesthesia event-”GE Health Care Aestiva machine #:” is
at 07:39
Printout Start/Stop times
1
1. Start time in print spool changed to 08:00
Printout Start/Stop times
? All descriptors entered before 08:00- preoperative events and
machine check are not printed to the pdf
Printout Start/Stop times
Anesthesia Start Time at 07:30 is time stamped on the record regardless of the start time in the print spool
First event other than anesthesia start is recorded at 07:39
Printout Start/Stop times
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4
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2.
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4.
Hitting the printer icon will bring up the print spool so you can adjust time
Enter in the first anesthesia event
Enter in the last anesthesia event
Upload to vOACIS
Printout Start/Stop times
Notice how 07:30 anesthesia stamp is included even though the print spool was set to 07:39
Notice how the all events relative to the Preoperative Evaluation and Equipment check are now included
Remote View
Check in on ANY patient in the SIMS system
•last patient on your list now in the PACU
•electronic record from a previous surgical procedure(s)
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1. Pull down Census Type to pick “Surgery patients-Today”
2. Find your patient from the OR list or Enter MRN of patient if procedure on different date
3. Hit Remote View
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1. You are now looking at a patient in “Remote View” (notice white banner at top)
2. Timeline shows patient in the GA (PACU) Postop and GA (Surgical Post-op) sessions
Remote View-Nursing assessments
Scan to see how your patient is doing with regard to pain, nausea/vomiting, etc.
IV tips
Multiple IV’s-same fluid
Click on “fluid order”
Notice default is IV
IV tips
Multiple IV’s-same fluid
Use slider to choose IV Site
Roll mouse over orderlocation of IV is now identified
IV tips
Patient arrives with IV (less than full bag)
Patient arrives to Operating room
with an IV running-only 350 ml. left
in bag
Bag is completed and you go to
hang a new bag. The system
assumes the NEW bag is similar in
volume to the previous bag-350 ml.
IV tips
Patient arrives with IV (less than full bag)
You need to change the
volume to reflect what is in the
new bag, typically 1000 ml.
IV tips-”Undoing” an IV Fluid
You recognize that you
intended to start a 1L bag
rather than a 350 ml bag.
You click on the
“350”dialogue box appears
Hit “Undo” and you get the
following message
IV tips-”Undoing” an IV Fluid
Reason for “error” message is
because there has been activity on
the 350 NS (in this case, a bag level)
In order to eliminate the fluid order,
you will need to “Undo” all changes
made to the order from current
time back to start time.
IV tips-”Undoing” an IV Fluid
Notice how the “bag level” is now
gone.
Now, click on the start of the order
and UNDO
IV tips-”Undoing” an IV Fluid
The fluid order has now been deleted