Admission History Data Base Changes VUH 10/13, 17, 20/2011

1. Admission History Data Base Changes VUH 10/13, 17, 20/2011

2. Change in Philosphy

3. Admission History Data Base Changes VUH • Identify concerns • Philosophy Change • Commit to need for change • Describe changes to admission history • Begin a unit-specific plans • Resources and tools to assist • GO LIVE 11/15/11. Why What How

4. Roles and Responsibilities & Materials Unit Implementation plan template Copies of the policies Training Aides Video clip Practice scenario Training patients name and MRN LMS module FAQ on SSS web site Debriefings- flyer • SSS • Provide education for unit leadership • Resource for unit • Provider training resources for units • Round during implementation • Unit Leadership • Assess current workflow and impact of changes • Conduct unit education and assure staff complete • Support during implementation • Leadership to round during implementation to elicit feedback and monitor progress.

5. If it ain’t broke…..

6. If it ain’t broke….. 97% of admission hx started- only 10 % completed TOO LONG! Nurses “live” in HED – can’t we put this in HED??? No reminders if not finished 8 hours is not long enough time to get it done. Must leave Admit History form and go to HEO to enter orders It doesn’t track who entered each piece of data so I start a new one even if there is a draft When I am worried about keeping patient alive upon admission, I shouldn’t have to document discharge plans Redundant information collection- Patient complained they have already answered these No one looks at it! This is just a waste of time

7. VUH and VCH Reps • VCH Acute Care (& 3A) – Christy Weems, Educator, VCH Float Pool • PCCU, VCH – Lydia Colley, Educator, PCCU • Peds ED & Obs. – Missy Sweeney, Assist. Mgr., Peds ED • VUH Critical Care – Crystal Creath, 10N • VUH Acute Care – Sabrina (“Sam”) Henley, 8s • VUH Procedural Areas – Tiffany Richmond, Assist Mgr., Cath Lab • VUH OB – Rosha Spencer & Blair Anderson • VUH Op. Svcs. – Cathy A. Lee, RN, PACU; Diane Johnson, Dir., Op. Svcs.; Laura Hollis, Op. Svcs. • Vicki Thompson, VCH Admin. • Deborah Ariosto, Dir., Patient Care Informatics • Karen Hughart, Dir., Systems Support Services • Nancy Rudge & Bill Raines, HED Builder Team • Cheryl Dozier, Accreditation and Standards • Ex Officio for specific questions: Mary Reeves, Sandy Bledsoe, Julia Morris, Julie Morath, Page Conatser, Jenny Slayton, Stephanie Randa, (Exec. Sponsor) Work began May 2011

8. Vision and Goals • Collect data once and pass to all systems and users who need to view • Collect data by time it will be needed • Minimize data collection during critical stabilization period (1st 1-2 hrs.) Meet minimum regulatory requirements Optimum workflow process associated with admission phase of care (up to 24 hrs. max.) HITECH

9. TRIED TO FORMAT IN HED DATA Amount of scrolling up and down and back and forth to see data and what was incomplete was impossible Future: Admit History data imported into HED

10. 5 Admission History

11. If short stay converts to regular status, additional data elements must be captured. ED will complete StarPanel Triage Form If patient is admitted will initiate Admission History

12. Content Net Change = 0

13. Decreased Need to Toggle to HEO/WIZ Auto generated orders and alerts eliminate need for nurse to enter some orders in HEO/WIZ

14. Not a form to complete but data to collect Positive Social Work screen generates Social Work notification Data displayed on OPC, Team Summary, Ancillary Dashboards Immunization screen generates order for vaccine and scheduled for 10am next morning Religion, tobacco status, and other information, stored and retrieved on subsequent admissions

15. Electronic Signature Tied to Data Click to display ID of person collecting data

16. MANY EYES WILL SEE THE DATA

17. Data Shared OPC, Charge Nurse Worksheet Link to view Team Summary, Resident Handover Readmission Risk Scale (in development) Eventually imported into HED

18. Reminders Adm Tx Dischg Hover over indicator to see what Admission requirement is not yet completed (ie section 1,2,3) = done within correct time frame = time frame to complete nearly over = time frame to complete has expired (BUT action still needed!)

19. 3 Sections

20. I Critical for Safe Care

21. I Critical for Safe Care New visitor policy: patient is allowed to have support person stay with them 24/7 Data will be shown on OPC initially and then other electronic documents later

22. I Critical for Safe Care Legal Documents All permanent chart documents now scanned at discharge

23. I Critical for Safe Care New Present On Admission Screening Awareness is Key to Improved Communication Among Team Members

24. Positives will trigger various decision support responses: • Pacemaker/ICD triggers HEO decision support w/ MRI orders • Dialysis prohibits some renal dose adjustment warnings in HEO • CPAP home use will trigger protocol order for Respiratory Care evaluation • Medication Pump usage will be shared as appropriate with other disciplines • Patient Pregnant, Patient Lactating sent to Pharmacy for decision support on medications .

25. CPAP Summary –What You Need to Know • Patients that use CPAP at home need to use CPAP in the Hospital • RT will evaluate machine - will probably use VUMC equipment to assure proper functioning • In addition: • Increased vigilance when general anesthesia, sedation, or intravenous (IV) analgesia/opioids are required. • Elevate head of bed 30-40 degrees if not contraindicated • Communicate that the patient has obstructive sleep apnea during handover to other care providers as well as in transfer to ancillary departments A Protocol order will be generated from the Nursing Admission History when the nurse documents a positive response from the patient . “Home CPAP Evaluation and Initiation” order will generate to the Respiratory Therapy Department and the respiratory therapist (RT) will evaluate and initiate therapy at the patients bedtime.

26. Leaving a question blank or selecting “Unable to complete” triggers indicators on the inpatient whiteboard.

28. II - Plan of Care

29. II Plan of Care Past Medical & Surgical History Physician responsibility to enter and link displays in Admission History

30. II Plan of Care If select “yes” smokes must select response regarding frequency

31. Global Immunization It our responsibility to screen patients for appropriate vaccines and offervaccines to patients that meet positive screening criteria. Patients always have the right to decline.

32. Influenza • 5% - 20% of population in US gets the flu • 200,000 people are hospitalized from seasonal flu-related complications • between 1976 -2006, flu-associated deaths range from a low of about 3,000 to a high of about 49,000 people. The 2011-2012 flu vaccine will protect against the three influenza viruses that research indicates will be most common during the season. This includes an influenza A (H1N1) virus, an influenza A (H3N2) virus, and an influenza B virus. Flu season October till March 1 and everyone six months and older should get vaccinated.

33. Pneumonia • In 2007 • 1.2 million hospitalized • 52,000 people died from the disease Death from pneumonia is one of the most common causes of death in America from a vaccine-preventable disease. Globally, pneumonia causes more deaths than any other infectious disease. VUMC 2010 Admitted with diagnosis of Pneumonia (community or hospital acquired) Of those, 750 patients were readmitted within 30 days with a pneumonia related condition. Wikimedia Commons.

34. II Plan of Care

35. II Plan of Care

37. Pneumococcal Vaccine Indications See why decision support is needed within the Admission History? Indications for pneumococcal vaccination are as follows: • Age 65 years or older with no or unknown history of prior receipt of pneumococcal polysaccharide vaccine (PPV) • Age 6-64 with no or unknown history of prior receipt of PPV and any of the following conditions: • Cigarette smoker • Chronic cardiovascular disease (e.g. congestive heart failure, cardiomyopathies) • Chronic pulmonary disease (e.g. asthma, chronic obstructive pulmonary disease, emphysema,) • Diabetes mellitus • Alcoholism or chronic liver disease (cirrhosis) • Functional or anatomic asplenia (e.g. sickle cell disease, splenectomy) • Immunocompromising condition (e.g., HIV infection, congenital immunodeficiency, hematologic and solid tumors) • Immunosuppressive therapy (e.g., alkylating agents, antimetabolites, long-term systemic corticosteroids, radiation therapy) • Organ or bone marrow transplantation • Chronic renal failure or nephrotic syndrome

38. If selected that pt has had an immunization, it will update the immunization record as a historical vaccine.

39. Document administration of the vaccine, including reason not given in cases where the patient declines or has a identified contraindication identified at time of administration

40. Screenings II Plan of Care

41. II Plan of Care Nutrition Dashboard Positive screen trigger notification to nutrition services via the dashboard

42. Learning Readiness II Plan of Care Information will display on OPC and eventually feed Readmission screen and Patient Education and Engagement Record (PEER)

43. II Plan of Care OB has Lactation Screenings

44. III- Discharge and Functional Screen Section

45. III Discharge/Functional Screens Physician will be notified of positive Functional screens as only providers may order Rehab evaluations in Tennessee

46. Can I do all sections at once? YES The admit history may be completed at one time if that is practical. Important thing is to get the data collected. Previously all data had to be collected within 8 hours. Now have up to 24hrs to collect.

47. Admission History Indicator Not in nurses current workflow to verify Admission History is completed. Indicator on whiteboard should help

48. Even if past 24 hours, collect the data The data is important.

49. Future Changes Notification Bar at top of CWS to display dashboard of patient assignment while in HED or HEO/WIZ or any application. This will make it easier to see indicators and to navigate – coming in 2012 Braden Tool in HED instead of HEO/WIZ is projected to be available soon

50. Obstacles and Actions