Common Work Flow Instructions - FEB 5 2020 EDITION

HOW TO GUIDE TO COMMON WORKFLOWS (click the links below)

NOTE WRITING TIPS ORDERS - Can't Find a Medication in System ORDERS - Blood - Massive Hemorrhage Protocol ORDERS - Blood - Emergent Blood Administration ORDERS - Blood - Standard Blood Administration ORDERS - Goals of Care Designation (GCD) ORDERS - Re-Ordering Home Medications ORDERS - Outpatient IV clinic - Therapy Plan ORDERS - Outpatient Regular Blood Transfusion - Therapy Plan ORDERS - Drug Infusion - Common Doses DISPO - Bridging Medications (Meds to Go) DISPO - Next Day Diagnostic Imaging DISPO - Outpatient Labs and Diagnostic Imaging DISPO - Common Referral Pathways DISPO - Interfacility Transport (Not Complete) DOCUMENTATION - Consent DOCUMENTATION - Results and Phone Conversations/Consults DOCUMENTATION - Expect/Document on a patient (Non-RAAPID) DOCUMENTATION - Expect/Document on a Patient (RAAPID) DOCUMENTATION - Letter Writing to Physicians (Communications) HANDOVER GENERATING DAILY SHIFT REPORTS (FFS Billing)

Note Writing Tips •

TRUE BLANK NOTE a. Click the drop down menu from “My Note” b. Click Blank Note (NOT ED BLANK NOTE TEMPLATE) i. This will stop you from having to use the Smartblocks (HPI, ROS, PHYSEXAM) that make editing a note highly unintuitive

•

Personalized standard outline/template for your Primary Note a. Create a smartphrase (see your workbook for instructions) with the headers that you want (eg. History, Physical Exam, Impression and Plan) b. Click the wrench within the Note Tab i. Maximize your window and exit a side by side view to see the wrench

c. Enter your smartphrase name and click Add

d. When you write your note, click the speed button to pull up your smartphrase/template (see KHL template in the 1st image)

YOU CAN’T FIND A MEDICATION IN THE ORDERS 1. Be less specific in searching (and more sensitive) a. don’t type out full word Example: Search Beri, instead of Berinert 2. Check the Facility List

3. If you really can’t find a medication, use the NON FORMULARY MEDICATION order

ORDERING BLOOD - Massive Hemorrhage Protocol • • •

Call the blood bank to activate the MHP All blood administration paper work is done on paper!!!

Order the “Massive Hemorrhage Protocol” Order Set o Search terms include MHP, Massive, Hemorrhage o This is primarily Q30 min lab work and TXA administration o Once the patient is stabilized and the MHP is over, DISCONTINUE the Q30 min MHP bloodwork in the “Active Orders” tab within Orders.

ORDERING BLOOD - Emergent Blood Administration • For patient’s requiring blood IMMEDIATELY o Call the blood bank and ask for X number of units. They will send the blood per current state processes. o Go to orders and use “Transfusion Medicine” Order Set o Use the Transfusion Orders Emergent

ORDERING BLOOD - Standard Blood Administration • • •

For patients who have time to have a Type and Screen drawn (not necessarily complete).

This allows the blood bank to system match the patient to the unit of bloods sent to the ER (Uncrossed or Cross Matched blood) Open the Transfusion Medicine Order Set Go to Transfusion Orders and choose the blood product you require

•

Determine how many units you want to prepare

• Determine how many units you want to transfuse (which can be LESS than the amount prepared) and how fast to transfuse

ORDERING GOALS OF CARE DESIGNATION (GCD) 1. To view GCD, look to the storyboard. To update their GCD, go to the orders section and search “GCD” or “Goals of Care”

2. Type in any further clarifying details

3. To Print - hover over GCD on the storyboard and click the report to print

4. Or Go into the GCD screen and click the Order ID to view and print

REORDERING HOME MEDS •

Go to the Orders Tab

•

Click Order Home Meds (1)

•

Click Reorder Home Meds (2)

ORDERING GOALS OF CARE DESIGNATION (GCD) 5. To view GCD, look to the storyboard. To update their GCD, go to the orders section and search “GCD” or “Goals of Care”

6. Type in any further clarifying details

7. To Print - hover over GCD on the storyboard and click the report to print

8. Or Go into the GCD screen and click the Order ID to view and print

ORDERING HOME MEDS • Go to the Orders Tab • Click Order Home Meds (1) • Click Reorder Home Meds (2) o The meds listed are documented from either previous admissions to hospital or the bedside nurse performing a medication reconciliation

OUTPATIENT IV CLINIC 1. Go to ORDERS 2. Select “Therapy Plan”

3. Search for “Antimicrobial” and select either the Adult or Peds option. a. Favorite this so it doesn’t need to be searched for next time

4. Fill out the Therapy Plan Properties a. add a “Problem”

5. Order the appropriate medications and sign the therapy plan.

6. Follow your local workflows to book the appointment time for the patient (typically asking your unit clerk to book an appointment for the patient).

7. If you need to edit/discontinue a therapy plan a. Go to Order -à Therapy Plan and either Edit Plan and click Actions

OUTPATIENT ROUTINE BLOOD TRANSFUSIONS

For patient who require frequent routine blood transfusions 1. Go to ORDERS 2. Select “Therapy Plan”

3. Search for “Blood Transfusion” and select either the Adult or Peds option. a. Favorite this so it doesn’t need to be searched for next time

4. Fill out the Therapy Plan Properties a. add a “Problem”

5. Order the appropriate medications and sign the therapy plan.

6. Follow your local workflows to book the appointment time for the patient 7. If you need to edit/discontinue a therapy plan a. Go to Order -à Therapy Plan and either Edit Plan and click Actions

DRUG INFUSIONS (COMMON DOSES) Continuous Infusion Settings Drug name

Dosing units mg/min

Ordering concentration 1.8mg/mL Standard (450mg/250mL) OR (360mg/200mL) 3mg/mL High (750mg/250ml) (Central line)

EPINEPHRINE

Typical 0.1-0.3 mcg/kg/min

16mcg/mL Standard (4,000mcg/250mL) (Peripheral) 60mcg/mL High (15,000mcg/250mL)(Central)

Fentanyl

Typical 1-3 mcg/kg/hr Typical 0.02-0.2 mcg/kg/min

10 mcg / mL 50 mcg / mL (fluid restricted, central, or dose demand) 4mcg/mL Standard (1,000mcg/250mL) (Peripheral) 8mcg/ml High (2,000mcg/250mL) (Central)

Typical 0.5 mg/kg/hr

1mg/mL Standard (100mg/100mL) (Peripheral) 2mg/mL High (200mg/200mL) (Fluid restricted or central)

Typical 0.5-2 mg/min mg/hr

5mg/mL (undiluted drug) Standard (500mg/100mL)

AMIODARONE Concentration of mixed bag: 2mg/ml Dosing unit change

ISOPROTERENOL Dosing unit change

KETAMINE Dosing unit change

LABETALOL

Midazolam

mg/hr

0.5mg/mL (125mg/250mL) 1mg/mL (250mg/250mL) (Fluid restricted or dose demand) 1mg/mL

NITROGLYCERIN

mcg/min

0.2mg/mL (50mg/250mL)

NOREPINEPHRINE

Typical 0.1-0.3 mcg/kg/min

16mcg/mL Standard (4,000mcg/250mL) (Peripheral ONLY) 64mcg/mL High (16,000mcg/250mL) (Central ONLY)

Typical 15-50 mcg/kg/min

10mg/mL (undiluted) (1000mg/100mL)

LORAZEPAM Dosing unit change

Dosing unit change

Dosing unit change

PROPOFOL Dosing unit change

*High Concentration: Central access, consider with fluid volume restricted patients or high dose demand patients (only use high concentration peripherally if the benefit outweighs the risk)

*Standard Concentration: Peripheral access

BRIDGING MEDICATIONS (MEDS TO GO)

1. Go to the disposition navigator 2. In the discharge templates, select “DISCHARGE WITH BRIDGING / CONTINUED THERAPY MEDICATIONS” 3. Edit the bridging medication communication order

4. Select the medication from the list and enter the number of doses or write in the comment box (especially if multiple medications are going to be dispensed). This is COMMUNICATION order for our nurses.

5. If you are sending the patient home with a prescription, order the prescription as you normally would, sign and automatically print.

NEXT DAY ULTRASOUND 1. Go to the Disposition Tab 2. In the discharge templates, select ED US NEXT DAY – AHS LOCATION 3. Select your US type (or add a new order in the suggested orders

4. Complete the US Order - *** Critical Step *** a. Select Edmonton Zone and hospital it will be performed at b. Set the Priority to STAT

5. Follow your local hospital processes to obtain a time for the US. a. Typically, notify the Unit Clerk of the US Order so they can arrange a time for US.

ORDERING OUTPATIENT LABS and DIAGNOSTIC IMAGING 1. Go to the Disposition Navigator 2. Add a new order to the “Prescriptions and Orders” section

3. Type the Lab you want to order a. You will likely need to go to the facility list b. Then look under “After Visit Procedures”

*Use can still use Dynalife lab requisitions and MIC and/or INSIGHT Requsitions for Outpatient XR / US etc.

COMMON REFERRALS IN CONNECT CARE (CC) – ADULT 1.

2.

3.

4.

5.

6.

Go to the Disposition Tab Go to Prescriptions and Orders Section – Add New Order Search “Refer” and “Name of Consultant” (Gen Med, Surgery, Urology, etc) Click on the “Ambulatory Referral to …” order Select Department Fill out other questions and write your referral note in the Comments Section

General Internal Medicine • Order Name – Ambulatory Referral to General Internal Medicine • Department Name – EDM UAH KEC GIM • All referrals go to the above order (Urgent GIM, Urgent HTN) Cardiology • Order Name - Ambulatory Referral to Cardiology • Department Name – EDM UAH MAZ CARDIAC EASE • All referrals go to Cardiac EASE – they can redirect to Afib, CHF, etc.

Gastroenterology • Order Name – Ambulatory Referral to Cardiology • Department Name – EDM UAH ZLC GASTROENTEROLOGY • All referrals accepted here (IBD, Luminal, Cirrhosis) Neurology • Urgent Neurology Clinic o Order Name – Ambulatory Referral to Neurology o Department – EDM UAH KEC URGENT NEUROLOGY • Stroke Prevention Clinic o Order Name – Ambulatory Referral to Neurology § Department Name • EDM UAH WMC STROKE PREVENTION • EDM GNH STROKE OP • EDM RAH CSC STROKE PRVN Urology • Order Name – Ambulatory Referral to Urology • Department Name – EDM UAH KEC UROLOGY CLINIC • Reason – UROLOGY – then choose your indication (Kidney Stone (Acute/ureteric)) Early Pregnancy Loss Clinic • Order Name – Ambulatory Referral to Obstetrics / Gynecology • Department Name – EDM RAH LH EARLY PREG LOSS (not active currently)

•

Department Name – EDM GNH EARLY PREG LOSS (ACTIVE)

Home Care Referral • Order Name - Ambulatory Referral to Continuing Care Access • Department Name – EDM P124 CCA OTHER COMMON REFERRAL PATHWAYS THAT REQUIRE PAPER/FAX • Order Name – Ambulatory Referral to Other External Program/Service o *** This enables the unit clerk to attach the referral form/letter to an electronic referral so: § it is filed in CC correctly (the referrals section) § the referral be tracked by our unit clerks (referral received, appointment times etc.) so if patients call the ED, the unit clerks can provide patients information about the referral. o We are working on getting Unit Clerks access to ORDERS so they can place these orders for us.

• Common Clinics Not on CC o Plastic Surgery Hand Clinic o Orthopedic Consult LineGeneral Surgery FAST Clinic

INTERFACILITY TRANSPORT WORKFLOW

DOCUMENTING CONSENT • Enter the Patient’s Chart and look to the Storyboard for the Consent Navigator

• Find the Correct Consent Form o The 2 most commonly used forms will be § Treatment Plan – Procedure § Emergency Healthcare Exception (AKA 2 Physician Consent) § Click the Add button to see all the consent forms in system currently (and let me know if any forms are missing)

• Fill out the Consent Information on the LEFT • Sign with the E-Signature pad or computer mouse on the RIGHT

DOCUMENTING ON RESULTS, PHONES CALLS TO PATIENTS AND PHYSICIANS (TELEPHONE CONSULTS) Option 1 – “TELEPHONE ENCOUNTER” 1. Click RED EPIC à Patient Care à Telephone Call (Tip – Favorite the button) 2. Find Patient and Document the Call

3. This telephone call will now show up in chart review, under encounters and notes ***Benefit – you can print out a telephone encounter report for billing purposes ***Con – it isn’t immediately clear if you performed an action on the result (eg. positive microbiology).

Option 2 – IN BASKET RESULT NOTE 1. If the result is in your in-basket, click Result Note

2. Click the result you want to write a note on 3. Deselect “Route Note To” 4. Write a note and click “File to Chart” which will create a progress note in Chart Review

HOW TO EXPECT AND DOCUMENT ON A PATIENT (NON-RAAPID)

***DON’T EXPECT A PATIENT – USE TELEPHONE ENCOUNTER*** Previously in EDIS, we could expect patients and write a short clinical note.

Unfortunately with CC, if you expect a patient for example at the UAH, but the patient shows up at Leduc, the chart will be “Locked.” The clinical team in Leduc will have limited access to the chart (can’t fully register the patient, process orders, etc.) until the patient is discharged from the UAH expected list.

If you want to document a clinical note, USE TELEPHONE ENCOUNTER.

“TELEPHONE ENCOUNTER” 1. Click RED EPIC à Patient Care à Telephone Call (Tip – Favorite the button) 2. Find Patient and Document the Call

3. This telephone call will now show up in chart review, under encounters and notes

HOW TO EXPECT AND DOCUMENT ON A PATIENT (RAAPID) 1. RAAPID will create an expected patient in the ED once the patient has been accepted to the receiving hospital. This will likely be at the end of the RAAPID phone call (this may take a few minutes) 2. On your ED track board, click the “Pending Arrivals” tab

3. Double click the patient and add a note.

LETTER WRITING - COMMUNICATIONS 1. Go to the Drop Down Menu and Click COMMUNICATIONS 2. ***Personalize this (click the wrench) as not personalizing makes letter writing highly unintuitive.

•

• •

In the Default letter template field o choose AHS ED GENERIC LETTER and name it § This letter templates automatically pulls in your department information and patient information Additional letter templates (optional) o AHS AMB GEN BLANK TEMPLATE for a completely blank letter Click Accept

3. When you want to write a letter, click new communication which will automatically load your letter template (AHS ED GENERIC LETTER).

•

If you choose a contact who is using CC, this symbol will appear o when you send the letter, it will route to the recipients in-basket in CC.

•

If you choose a contact who is not in CC but using fax, this symbol will appear o when you send the letter, it will electronically fax the letter. o If you want your unit clerk to fax the letter, you can click “Print for Patient” and manually fax the letter.

HANDOVER 1. Go to your My Pts. List (side by side view) Select a patient and “Write Handoff”

2. OR from within a chart, go to the drop-down menu and click write handoff (Tip: Favorite or Personalize this)

3. Write Your Note

4. During handover, go to “My Pts” (side by side view) Click Reports à Click Handover to view the reports When handover is complete – sign out to reassign your patients

GENERATING DAILY SHIFT REPORTS •

Daily Shift Reports

o Click on My Reports à Click on Library à search “Manual” § The report “AHS ED Daily Shift Report Last 18 Hours for Manual Billing” should appear § Click the STAR to favorite this report – this will now appear on your “My Reports” § Run the Report to get a list of your patients you saw on shift

•

For a report of telephone encounters o Click on Library, search “Telephone” and the report “AHS ED Telephone Encounters Last 24 Hours” should appear § Click the STAR to favorite this report – this will now appear on your “My Reports” § Run the Report to get a list of your patients you made telephone encounters for over the past 24 hours.