Name of Group/Meeting: Nursing Informatics Advisory Committee (formerly HED Advisory Committee)

Date / Time / Location: October 18, 2012, 2-3pm, 5053/5-54, MCE, North Tower / Next Meeting: November 1, 2012, 2-3pm, 5053/5-54, MCE, North Tower
Chair: Sara Turcotte and Nancy Rudge for Karen Hughart & Vickie Thompson /
Recorder: Elma Bunch
Attending: Arlene Boudreaux, Elma Bunch, Heather Campbell, Paula Case, Jennifer Erickson, Sheree Foster, Heather Freeman, Anisha Fuller, Jill Gaddes, Aaron Hirsch, Gwen Holder, Manda Mitchell, Michael Norris, Shelly Padgett, Bill Raines, Nancy Rudge, Sara Turcotte, Cheri Wood
Meeting Objectives:
1.  Information sharing on new features & training and implementation plans if applicable
2.  Decision making on new enhancements
3.  Begin to identify significant enhancements needed (for future prioritization).

AGENDA

/ MINUTES
Who/Time / Topic / Summary / Decision / Next Steps
Sheree Foster
15 minutes / Discussion and feedback needed for new accudose override reasons. Please see attached document / Accepted by the committee.
Changes to occur approximately December 1, 2012 / Announcement of the coming changes will be posted on the accudose machines and newsletters. The changes will also be sent out to the Managers and Educators.
R0018695
Special Neuro Nancy Rudge
5 minutes / Special Neuro changes initiated by Arlene Boudreaux / Accepted by the committee. It was recommended that there be a space for noting pupil changes / Arlene will look into making the recommended changes
R0023786
Sarah Shoop 6A myelo suppression
5 minutes / There is nowhere to enter the flu vaccine expiration date into HED. The lot number is there to enter and gets transferred into star browser but per CDC and drug company guidelines the expiration date must also be recorded. There shold be a slot to enter that info so it gets transferred to the patients record in starbrowser.
CLINICAL POLICY MANUAL VACCINATIONS
V. Documentation:
A. Document vaccination history in StarPanel.
1. Appropriate location is either in StarPanel Immunization Form tab, which can be accessed in the Nursing Admission History.
2. To document the history of vaccine received outside of Vanderbilt, choose the ‘non-certificated’ box in the StarPanel Immunization Form.
B. Record vaccine administration in StarPanel or AdminRx.
1. AdminRx Documentation – Document vaccine administration via the bar-coded medication administration system, entering the required information for each vaccine as prompted by AdminRx.
2. AdminRx data is electronically transferred to StarPanel Immunization Form.
3. For areas that do not use AdminRx, document on StarPanel Immunization Form.
4. Elements to be included are:
a. Name of vaccine;
b. Delivery of VIS, including edition date of VIS;
c. Date, site and route of administration;
d. Manufacturer of vaccine;
e. Lot number of vaccine;
f. Name of individual administering vaccine;
g. If vaccine not given, document reason. / Discussion needed regarding VUMC policy and compliance
No changes required. The pharmacy logs the lot number and the expiration date. If there is ever a question about the expiration date the required information can be obtained through the pharmacy. / NA
Sara
Safety documentation
10 minutes / Safety documentation began Tuesday October 16 for several adult units. There has been lots of good feedback from users and with resulting modifications planned. Tuesday October 23 the majority of the remaining adult units will go live with this documentation. / Request discussion and feedback.
Feedback –
·  looks confusing at first glance, but not so bad once you use it a couple times
·  restraints are not convenient where they are – possible to have their own tab or be put in Quick Access
·  Concern that if it is left where it is they will be non-compliant due to it being under the assessment tab.
·  Please turn the indicator light back on – it is very helpful / Nancy will look into the recommendations and get back with the committee
Sara
Documentation indicators
5 minutes / Interested in feedback regarding the use of indicators and how they would ideally integrate or enhance nursing workflow. Plans for future use should reflect the needs of the users. What is helpful, what works for you, what does not? (Colors, triggers, time frames, references etc) / Request discussion and feedback
Feedback –
·  Dashboard indicators guides the nurses’ work and is very helpful but it does not help with patient care.
·  Standardize colors – green on the PEWS is confusing – green usually means everything is good to go – the questions mark needs to stand out more. We nurses are in a hurry they do not notice the question mark.
·  PEWS indicators are muddled.
·  Indicators are different with each unit.
·  The priority problems – the red indicator light comes on at 3:00 PM telling nurses to write their summaries, but it is too early in the shift
·  Adult admission indicator is always red, but it gets locked down and the nurses cannot go in to complete the information – please unlock so it can be completed and/or updated without calling the help desk. / Nancy will look into this issue.
This has been addressed and is being worked on.
Sara
Pain reassessment ideas
10 minutes / The adult units are in the midst of a corrective action for pain reassessment documentation based on a Joint Commission requirement. It has been implemented, but is not showing the expected results using the methods we have available. What thoughts can you share about things available to us that would help improve the pain reassessment results? Currently available technologies for leadership and staff are 1) fix it now reports for monitoring documentation 2) pain indicator on dashboard 3) adding pain assessment to medication administration in Admin-Rx
See attachment for the Pain Reassessment Rounding to meet JCAHO requirements. / Request discussion and Feedback –
·  This is still in Education mode
·  Many have still not completed the LMS training.
·  Unclear about the fields and what drives the fields
·  Could there be an indicator in Admin RX to alert nurses to reassess pain?
·  Nurses would like a prompt to remind them to chart the pain scores. Many are reassessing but not remembering to chart the score. / Nancy indicated that they are working on prompts for a subset of meds. They do not want a prompt to show up for every med given to patients.
They are continuing to reassess this process.
All / Updates and announcements / NA

AcuDose Override Reasons SBAR

Situation:

There are currently 24 pre-formatted override reasons available for selection in AcuDose along with a free form option. A review of documented override reasons in AcuDose shows both inappropriate selection of pre-formatted reasons and lack of clarity when using the free text option.

Background:

TJC Standard MM.05.01.01, EP1 requires pharmacist review of medication orders prior to removal from floor stock or automated storage unless:

1.  The provider is present to control the ordering, preparation, and administration of the medication, or

2.  When a delay would harm the patient in an urgent situation.

Assessment:

AcuDose overrides were reviewed for Mar – May 2012 to assess utilization of currently identified pre-formatted reasons. These reasons were selected in only 39% of the reviewed transactions (11,641/30,142).

Current Options / Utilization / Percent of Total
Level 1 Medical Patient / 3005 / 10%
Level 1 Trauma Patient / 1575 / 5%
Emergency Bedside Procedure / 1561 / 5%
Physician Orders – Respiratory / 1503 / 5%
Keys/Misc Narc/Pt Specific Access / 1345 / 4%
Delivery Medications for Mother and/or Newborn / 937 / 3%
Cardiac Post Op Room Setup / 377 / 1%
Post Partum Hemorrhage / 282 / 1%
Cardiovascular / Cardiopulmonary Emergency / 222 / 1%
Anesthesia Procedure / Epidural Placement / 208 / 1%
Acute Pain / 170 / 1%
Agitation / 139 / 0%
Contractions / 44 / 0%
Priming of Lines / 40 / 0%
Bronch Lab Patient with MD Present / 37 / 0%
Acute GI Distress / 33 / 0%
Hyper/Hypoglycemia / 31 / 0%
Psychiatric Emergency – Code Green / 31 / 0%
Acute Neurological Event / 29 / 0%
Dialysis – Epogen Use / 28 / 0%
Outpatient Procedure with MD Present / 15 / 0%
Sepsis / 13 / 0%
Anaphylactic Reaction / 8 / 0%
Dehydration / 8 / 0%
Total of Pre-Formatted Selections / 11,641 / 39%
Free Text Option / 18,501 / 61%
Total / 30,142 / 100

AcuDose overrides were reviewed for the same time frame (Mar – May 2012) to assess the applicability of the identified reasons to a simplified list of appropriate reasons. Only 42% (12,719/30,142 = 42%) of the documented reasons provided sufficient information for categorization.

Recommended Reason / Applicable Transactions / Percent of Total (30,142)
Urgently needed such that delay might cause patient harm / 7,139 / 24%
Prescriber is physically present and can oversee administration / 3,732 / 12%
Keys / Misc Narc / Pt Specific Access / 1,345 / 4%
Line flush / medication dilution / priming of line* / 320 / 1%
Downtime / 183 / 1%
Subtotal / 12,719 / 42%

*Note that large volume fluids, sodium chloride 0.9%, and misc non-drug items were excluded from the review data.

For the remaining documented reasons (17,423/30,142 = 58%) the following were generalized categories:

“Other” Category of Reason Entries / Applicable Transactions / Percent of Total (30, 142)
Ordered medication (e.g. MD order, physician order, verbal order) / 12,350 / 41%
Respiratory orders / 1,505 / 5%
Nonsense (e.g. letter, numbers, symbols, blank) / 1,031 / 3%
Non-specific message (e.g. Needed, Meds, PRN) / 731 / 2%
New patient / Post Op / New order / 521 / 2%
ED / 484 / 2%
Room set up / 386 / 1%
Travel / Transport / 222 / 1%
Non Emergent (e.g. dialysis, comfort, HA, itching, wound care, insulin, return, restock, education ) / 193 / 1%
Subtotal / 17,423 / 58%

Recommendation:

Change the pre-formatted AcuDose override reasons to the following to match TJC Standard MM.05.01.01, EP1 and delete the free text option.

1.  Urgently needed such that delay might cause patient harm

2.  Prescriber is physically present and can oversee administration

3.  Keys / Misc Narc / Pt Specific Access

4.  Line flush / medication dilution / priming of line

5.  Downtime

Special Neuro request

Neuro Deficits category listed above facial drooping, to appear:

Neuro Deficits
Facial Drooping / Right or left
Communication Deficit / Dysarthria, aphasia, expressive, receptive
Extra Ocular Movements / Impaired, nystagmus, right, left, upward, downward
Memory / Short term, long term, impaired
Gaze / Deviated, right, left, disconjugate
Attention / impaired, right, left, neglect
Pronator Drift / Right, left
Motor Deficits / Ataxia, fine impaired, gross impaired, right, left
Neuro pt indic should go here instead of below HEADACHE / Agnosia, apraxia

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