Transcript HED and HEO/WIZ Downtime - Vanderbilt University Medical Center

HED AND HEO/WIZ
DOWNTIME
Be Prepared
HED AND HEO/WIZ DOWNTIME
Saturday May 12, 2012 at 700pm
Till approximately
Sunday May 13, 2012 at 12 Noon
Downtime for:
Order Entr y (HEO/WIZ), Nursing Documentation (HED),
Nursing Med Administration System( Admin_Rx)
Systems not down: StarPanel, Medipac, Accudose, Inpatient and
ED Whiteboard.
WHAT YOU’LL LEARN
 Impact of the extended downtime
 Roles and responsibilities – educator/unit leadership
MR/AA and sss
 Workflow/timelines – getting ready for downtime,
processes during downtime, and recovery from
downtime
 Supplies/ Forms needed for downtime
 Managing Admissions, Discharges and Transfers
IMPACT
 All orders will be written and processed
manually
 Look up orders prior to DT in starpanel
 Use paper Physician Order Sheet (POS)
 Use Transfer Order Sheet for transfers and as
reference for orders prior to DT
 All documentation will be on paper
 Paper MAR
 DT Flowsheets
 OPC manually updated w/ orders
IMPACT
 Admission Hx can be in starpanel but will not
generate any orders ( immunizations,etc)
 Accudose will be in override and only have
order prior to DT
 To recover from downtime any ongoing orders
will need to be entered into HEO/WIZ
 Pharmacy enters medications
 Nurses enter non medications
BOTTOM LINE
THIS IS A REALLY BIG DEAL
Staf f not familiar with manual processes for such an extended
time.
Many have not ever used manual forms and will need training
ROLES & RESPONSIBILITIES
Educator/ Unit
Leadership
• Design & implement
plan to educate/ reeducate nursing staff
• Assure MR scheduled
for entire DT
• Review RN staffing for
DT and recovery and
schedule additional
staff prn
• Touch base with all
staff working during DT
to assure they are
knowledgeable
AA/MR
• Order Supplies ( black
pens, paper, POS,
Home Care Instruction
Sheets, labels)
• Print Forms from Edocs
• Stock DT kits- assure
all unit specific
flowsheets needed for
extended dt are printed
• MR to attend MR
training session
CAPS/
SSS
• Resource to unit
educator/leadership
re: DT Preparation and
DT Processes
• Assist with
educations/ reeducation
• Communicate w/
providers re: DT
processes
• SSS Web site w/
resources needed
• Update Edoc DT forms
GETTN’ READY FOR DOWNTIME SESSIONS
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Computer Talk: Gettn’ Ready for Downtime Sessions
Register in LMS
Attendance is Mandatory for 1 MR and 1 Leadership person
from each Unit
4/27 730-830 VCH B319 & 407 Oxford house
5/3 1930-2030 VCH B319
5/5 1930-2030 in 407 Oxford house
5/1 730-830 VCH B319 & 407 Oxford house
5/8 730-8300 VCH B319 & 407 Oxford house
EDUCATE OTHER STAFF
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MR meetings
Staf f meetings/ unit boards
Small groups
Charge nurse meeting
1 on 1 with those working the weekend
Posters
Share the powerpoint – feel free to use/ modify for your area
TIMELINES
Weeks prior to dt:
educate and get
supplies
Sunday May 13
Noon- Recovery
from Downtimeenter orders/ enter
data in HED/Admin
Rx
Sat May 12 : Place
on charts DT POS,,
print labels, place
DT req @ desk
Sun May 13 0700shift change: print
OPC & update with
orders since DT,
initiate new DT
flowsheets and Fall
risk Flowsheet
Sat May 12 1700:
retrieve Phm
generated MARS,
print TOS place on
chart, Print OPC
Sat May 12 1900HEO/WIZ , HED and
Admin Rx Downuse DT processes.
DOWNTIME KIT
Re p l e ni s h k i t
A l l k i t s s h o u l d c o n t ai n :
 Laminated Downtime Checklist;
 Physician Order Sheet (POS)- E-Procurement ORDER ASAP
 Nursing Downtime Flowsheets- EDOCS (Appropriate to unit - gen care, ICU, ED for VUH and
VCH, NICU, VPH;
 Downtime Falls Flowsheet (revised 2012) EDOCS
 Medication Administration Records (MARs )- EDOCS
 Downtime Requisitions ( revised 2012)- EDOCS
 VCH Patient Discharge Instructions (MC 4085); VUH Patient Discharge Instructions (MC
2418) COPY CENTER: ORDER ASAP
 Braden Skin Risk Assessment Guidelines EDOCS
O t h e r d o c ume n t s t h a t m i g h t b e n e e d e d :
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ICU Blood Gas DT Req ( new) EDOCS
Insulin Drip Downtime Guidelines ( new) EDOCS
Nurse Administered Heparin Drip Protocol ( new) EDOCS
Downtime Restraints Flow sheet EDOCS and policy – policy manual
Complex wound flowsheet
PCA/ Epidural Policies – Policy manual
Assessment Guidelines VUH and VCH EDOCS
PREPARING FOR DOWNTIME
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Order Copier Paper
Order Black Pins
Order Patient Labels
Increase Staf fing
Place Phm Fax
# on Fax
Machine
VUH – 7a-7p 39879
VUH – 7p-7a 31640
VCH – anytime – 66402
VPH – pharmacy rounds during day,
VPH – 7p-7a – 31630
PREPARING FOR DOWNTIME
SAT M AY 1 2 DAY SH I F T
Early Day shift Saturday Morning
For pts. not being discharged by 5p,
Medical receptionist will
 Place Physician Order Sheets (POS) in blue charts TWO per chart,
with patient labels attached on all three pages, DO NOT
ADDRESSOGRAPH
 Print 2 Downtime Flowsheets for each patient place labels, DO NOT
ADDRESSOGRAPH
 Print 2 Fall Risk Assessments for each patient place labels DO NOT
ADDRESSOGRAPH
 Print 30 labels for each patient and place in chart
 Print downtime reqs and place in convenient location at desk
 Place black pens at nurses station
PREPARING FOR DOWNTIME
SAT M AY 1 2 17 0 0
1700 Saturday
 MR Checks printer to assure has paper ( paper MARS will be
generated by pharmacy)
 MR Retrieves MARs from designated printer & distribute. Prints
to as follows: CCT on each unit, VUH on south side, VCH on B
pods, MCN on each unit)
 MR prints Diet List
 MR prints “Overview of Patient Care” (OPC) and Transfer Order
Sheet (TOS) & distributes
 RN addresses outstanding Inpt Whiteboard (Inpt WB) indicators
while information still current( VAP, Falls)
 RN saves monitor/vent data to DAS before start of downtime.
DAS will not receive data from these systems during the
downtime so any values that need to be documented during this
time will need to be manually entered on downtime forms.
 For units that have centralized charts, MR place charts at patient
rooms
PREPARING FOR DOWNTIME
SAT MAY 12 1700
 Charge Nurse identifies all patients with restraints and
contacts provider to renew orders for all pt with restraints
 Charge Nurse identifies all pt with potential transfer or
discharges and contacts provider to enter orders/ generate
discharge letter before dt
 RN documents Planned Priorities and Nursing Summary on all
patients in HED
 Night Shift WILL NOT do Priority Problems or Nursing Summary during downtime
 RN transcribes cumulative Intake and Output for their shift on
the 7p-7a downtime flowsheet
 Ensure OPC and Transfer Order Sheet are printed (MR to Print)
DOWNTIME
SAT M AY 1 2 1 9 0 0 DOW N T I ME BE G I N S
Order s
 Provider/ RN writes order s on paper Physician Order Sheet and give to MR
or RN for processing.
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print & sign name, write pager # on all orders
1 set of orders per page
Use ONLY BLACK INK and press hard ( going thru 2 copies )
Any Verbal/ telephone orders require a read back to the provider and will require co signature by provider
 MR Aler ts RN of any STAT order s
 MR Fax copy of each POS to Pharmacy 
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VUH – 7a-7p 39879
VUH – 7p-7a 31640
VCH – anytime – 66402
VPH – pharmacy rounds during day,
VPH – 7p-7a – 31630
 If Scanning, MR scans POS
 MR transcribes new, modified, & discontinued order s to the paper MAR
 MR completes DT requisitions for labs, ancillar y depts & blood bank (one
requisition per dept) and calls to inform of order or sends order to
ancillar y depar tment. Complete a DT req for future occurrences of ancillar y
order s that are scheduled during the downtime.
DOWNTIME
SAT M AY 1 2 1 9 0 0 DOW N T I ME BE G I N S
Orders ( cont)
 MR updates Diet list with any diet orders
 MR denotes “DT” next to ongoing orders that will need to be
entered once the system comes back up
 MR Pull out desk copy of written physician order sheet and
places at nurses’ station to assist with tracking of orders
during downtime – ie CXR in am, O2 at 2l/m , Albuterol
treatment q6h
 RN checks StarPanel e-MAR for previous med admin times &
verifies schedules are correct on paper MAR
 RN’s verify transcription is correct & signs MAR
 For units with real time scanning: MR scans physician order
sheet, highlights document and places back in the blue chart
and place back at the patient bedside
 RN writes new orders on OPC or for large number of orders
can make copy of DT Physician order sheet
DOWNTIME
SAT M AY 1 2 1 9 0 0 DOW N T I ME BE G I N S
• RN/CP document interventions on manual
flowsheets and Meds on paper MARs. (consider need
for additional flowsheets for restraints, complex wounds
etc and print from Edocs)
• For New Admissions, complete Nursing Admission History
in Starpanel but RN writes a protocol order on the paper
physician order sheet for any protocol generated flu and
CPAP orders. Positive screens for ancillary departments
will be communicated via ancillary dashboards and will
not require an order.
DOWNTIME
NIGHT SHIFT SAT 5/12- SUN 5/13
MR Round at least Q4h during DT
 Checks for any missed orders
 Restocks with DT order sheets as needed
12Midnight –
 MR assures printer is stocked with paper in prep for printing of next
day’s MARS
0100-0200
 MAR’s printed by pharmacy, MR place in Blue Charts, and Notify RN
 RN compares and verified Sunday’s MAR with Sat’s MAR and makes
any corrections. Alert Pharmacy to Downtime Downtime Downtime
any schedule changes
ADMISSION/ DISCHARGES/ TRANSFERS
SPECIAL CONSIDERATIONS
Admission
Discharge
Transfer
•Complete Admission Hx in Starpanel- write protocol order for pnuemovax
of CPAP prn
•Make copy of admission orders since OPC will not have orders
•Discharge Orders are written but prescriptions can be generated via
RxStar in Starpanel
•Use Home Care Instruction sheet if patient letter is not generated or is
incomplete
•Document discharge instruction in narrative portion of DT flow sheet
•Provider uses Transfer Order Sheet ( TOS) to denote transfer orders –
lines thru any orders to discontinue, denotes modifications to orders and
writes new orders on blank lines. Dates/times and signs TOS.
•MR faxes TOS to pharmacy and processes orders per DT procedures.
RECOVERY FROM DOWNTIME
( A P P R O X I M AT E LY N O O N S U N D AY M AY 1 3 )
O r d er s
 R N to e n te r i n H E O / W I Z a ny o n g o i n g n o n p h a r m a c y o r d e r s
 n o n - m e d i ca t i o n P h a r m ac y to e n te r i n H E O / W I Z a ny o n g o i n g p h a r m a c y o r d e r s
 PROVIDERS SHOULD NOT ENTER ANY ORDERS THAT WERE WRITTEN DURING DOWNTIME.
This is to avoid duplication of orders.
 Restraint Orders Renewed
 Orders completed during downtime should not be entered in HEO/WIZ.
 P r o v i d e r s to c o s i gn o n p a p e r a ny v e r b a l , te l e p h o n e o r p r o to c o l o r d e r s w r i t te n o n
p hy s i c ia n o r d e r s h e et s d u r i n g d o w n t i me . O n g o i n g o r d e r s i n i t ia te d d u r i n g d o w n t i m e
w i l l b e e n te r e d i n H E O / W I Z a f te r d o w n t i me a n d c a n b e e l e c t ro n i ca l l y c o - s i g n e d .
D o c um e n t a t io n
 R N to e n te r i n H E D
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Last set of vital signs
Documentation for foleys and IV inserted or discontinued and wounds initiated or ended
Downtime Start and Stop time on Asmnt/Inter ventn Tab
Cumulative Intake and Output for Saturday and Sunday
 Example of Back time for Saturday’s Cumulative from paper flowsheet, (3/12/2012, 0645).
 Will need to subtract what was charted from 7a-7p on 3/12 in HED from 24 hour cumulative from the paper flowsheet.
 Sunday’s cumulative will be the current cumulative from the paper flowsheet
 R N to c o n f i r m m e d s i n C a r e O r g a n i z e r u s i n g p a p e r M A R - c a r e f ul ly c h e c k i n g
s c h e d ule s a n d i n f o r m in g P h a r m ac y o f s c h e d ul e c h a n g e s v i a c a r e o r g a n i z e r
 I n A d m i n R x , R N n o te s o v e r d ue s a n d d o c ume n t a s “ a l r e a d y g i v e n - s e e M A R ” i f
a d m i n i s te r e d & c h a r te d d u r i n g DT
WHAT TO DO
AFTER DOWNTIME
( A P P R O X I M AT E LY N O O N S U N D AY M AY 1 3 )
 RN’s Continued
 HED
 Admin Rx, medications with outstanding schedule need to be addressed
 Asmnt/Interventn Tab, document start of downtime and end of downtime.
 RN Enters Cumulative Intake and Output for Saturday and Sunday
 Example of Back time for Saturday’s Cumulative from paper flowsheet, (3/12/2012, 0645).
 Will need to subtract what was charted from 7a-7p on 5/12 in HED from 24 hour cumulative
from the paper flowsheet.
 Sunday’s cumulative will be the current cumulative from the paper flowsheet.
 Restraint Orders renewed
 Priority Problems with goals back time to morning shift. Complete at end
of shift Planned Priorities and Nursing Summary.
RECOVERY FROM DOWNTIME
S U N D AY M AY 1 3 17 0 0
Approximately 1700 Sunday, MR’s will after HEO/HED have been
up and stable for several hours.
 Remove and Discard all unused downtime documents with patient
labeled attached; place any unlabeled dt documents in DT kit.
 Remove Transfer Order Sheets
 For units with real time scanning, MR will scan documents in to EMR
 Downtime flowsheets
 Downtime POS (physician order sheets) that were missed
 TOS (transfer order sheets) that were missed - may discard if no orders
denoted on TOS
 Re-locate charts per unit protocol back to location for scanning
 to shredder and discard to shredder
SUPPORT DURING DOWNTIME
SSS will have staff on site making rounds prior to downtime Sat 5/12,
during downtime and during recovery from downtime.
Watch your fax machine for updates re: status of the downtime and for
detailed instructions.
Update will also be sent out via charge nurse pager and via the starpanel
banner.
Contact the Help Desk 343-4357 if help is needed.