EP17-2 Evidence Based Practice Oversight Committee

Minutes

Location:Service Center, Board Room

Date:April 04, 2012(in-person preferred when possible, info below)

Time:4:00 – 5:30

Invitees: Heade, Kimberly; Benz, Julie; Chambers, Jodi;Fisher, Donna; Fulton, Jane; Garko, Candace; Mydler, Todd;

Schottstaedt, Louise; Trainor, Jodee; Walsh, Peter; Ward, Rhonda; Watson, David L.; Charnsangavej, Chutaporn;

Camplese, Lisa; Trujillo, Tana; Thomas, Mack; Reed, Sean; Feaster, Amy; Oster, Cynthia; Sime, Natalie; Long, Rhonda;

Coniglio, Ray; Ferris, Linda; Woods, Jeffrey; Dookeeram, Dave; Sandoval, John; Dickinson, Matthew;

Kimminau, Krystina; Bernard, Noreen; Kirby, Sharon B; Ceci, Carol; Andrews, Bonnie; Sirridge, Sharon

Guests: Ann Peterson, Kim Hegemann,

Time / Content / Presenters / Discussion / Follow-up / Completion Date / Responsible
4:00-4:10 / Reflection
Attendance Log
Approval of Minutes / Noreen Bernard
Kim Heade / Reflection on relationships
Minutes Approved
4:10-4:25 / Prep Upcoming Events
  1. VAP
-Team Dates
(April 17, 20 and 27)
-Data Review
-Bundle Discussion
-Charter Review
-Pilot Takeaways
  1. DVT/PE
-Team Dates
(May 3, 24 and 31)
-Team Leaders
  1. FY 13 Planning Event
-Accepting suggestions for review / Kim Hegemann
Matt Dickinson
Mack Thomas
Jodi Chambers
Mack Thomas
Kim Heade /
  1. Planning meeting – Literature search on S drive, Putting together survey monkey for RT, ICP, and facility champions on current state
Data presented by Mack comparing DRG coding of VAPs to ICP NHSM VAP rate show a discrepancy. Of N=30, 20 had VAP DRG. Look at further drill down. (Ask ICP to review?)
  1. Mack showed Indigo data of post op rates for DVT/PE. Would want to look at if they were on a prophylaxis – based on medication ordered.
3. Looking to collect suggestions – What fields should we have them answer? Name, Title, Facility, Suggestion, Type of suggestion (based on data, based on current evidence, based on individual practices/observation/research, based on hospital/group practice, meet EBP criteria (that we used last December to rank), contact information. Send out through MVW and Centura Connections? / Send out surveys
Continue further drill down of data. SAH to review as well.
Further drill down / 4/6/12
4/13/12
4/26/12 / Kim
Mack
Jodi/Dawn
Mack
4:25-4:40 / Review Current Teams
  1. HF Discharge Instructions
  1. Outpatient Falls
  1. Counts/Surgery Checklist
  1. Specimen Management
  1. Maximizing the Gift
  1. Contrast Induced Nephrophathy
  1. Obstructive Sleep Apnea
  1. HACA
/ Ann Peterson
Kim Heade
Jodi Chambers
Kim Heade
Jodi Chambers
Pete Walsh
Kim Heade /
  1. In progress. Day 2 meeting on March 16th – clarified purpose to improve metric for core measures, looked at previous solns and prioritized, visiting nsg unit, cardiac rehab, and hospitalists. Tasks – checklist at Avista on core measure review, look at abstraction element disagreements, customize Micromedex patient education, possible IT solns for med rec accuracy, better way to ID patient using hospitalist list, simply nsg documentation on HF teaching, core measure teaching for staff. Next meeting in 10 days.
Get with the guidelines –1) medication optimization 2) early follow up and care coordination/TOC/ 7 day follow up 3) enhanced patient education with HF expert, disease management program, etc. (make sure we are not building closed systems)
  1. Ready. OP Falls ready to roll out. Policy in S drives. Learn module was created – do we want to use it or have it be optional? Facilities need to put in their initial order for OP falls brochures so we can pay for the cost of the design and then put it out on workflow one. Should we also look at possible option to add to Micromedex even if outpatient?
Micomedex will be integrated into patient portal and meditech along with their record.
  1. Ready? Counts policy revised- to limit duplication of content and put references in back (from 17 to 5) but content the same. Recommended to have roll out through OR directors and educators vs. normal EIT route.
New software does allow live dual links to AORN website. May just need to help evolve based on new process
  1. Almost ready- Meeting with Barb Arbuthnot regarding specimen tracking and occurrence reporting. Toolkit is ready and Learn module was going to approval March 5.
  1. Not ready – Still need to update order sets. Policy and toolkit are being finalized.
  1. Close. Collecting lessons learned from Penrose and considering it for EBP Project resuscitation in FY13.
Renee looking at recommendations from staff. Part local culture and waiting for cardiology form input.
  1. Not ready - Policy has been complete since December but making changes to the OSA intervention screens (still looking at best way to initiate nursing care instructions)
  1. Follow up with Olinda Spitzer – in Meditech forms for SMC but not in CPOE?
/ Discussion with Steve, Sharon, and Jeff on what is being done and how to coordinate efforts
Could leave outpatient falls as optional. Look at Mosby and Micromedex.
Ask system policy group for decision making and then send to OR director/educators.
Check with Olinda on order set progress / 4/13/12 / Jodi
Noreen
Cheryl
4:55-5:15 / Discuss Post Implementation
  1. CAUTI
  1. Diabetes Management
/ Cindy Oster
Louise Schottstaedt
Jeff Sippel /
  1. Meditech screens went on 3/13 however complex GU assessment is not linked to algorithm for removal. Cindy emailed Sharon Kirby about that today. Learn module went through task force Monday with minor revisions. Suggest add link on MVW to CAUTI toolkit so it is accessible to staff on workstations. Lots of questions/calls on whether they can edit, do they have to do this, and some facility disagreement (opt out) on insertion for male catheter due to inconvenience
Should we incorporate proper insertion in with the sterilization education? Not reflected in current knowledge components. Cindi believes Mosby will be including anatomical component
  1. Met today to make changes to order sets and MAR. Meeting next week to get into CPOE build and plans to work on physician CME. Issues still to be resolved with Pharmacy regarding eMAR, reflexing, and regular insulin on floors
/ Permissions for MVW for toolkit.
Not sure which facility is not-may be in minutes. Give to Jodi
Discuss at medical council / Kim
Cindi
Jodi
Noreen
Jodi
Todd
5:15-5:25 / Requested Discussion
  1. Hierarchy of Evidence for leveling
2. Clinical informaticists communication – ask / Cindy Oster
Sharon Kirby /
  1. Look at forming subgroup for this
Cindi, Noreen, Julie,
Recommend: Joe Heit, / Ask for crit care rep, - need physician representation, pharmacist
5:25-5:30 / Next Steps
Adjourn / Kim Heade
Lisa Camplese
Jodi Chambers /
  1. Heparin protocol – new CPOE order set differs between ACC dosing (Pharmacy group looking at it)

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09/17/2018