Nursing Overview of 2019 Alignment/Upgrade

1. Nursing Overview of 2019 Alignment/Upgrade Nursing Education Adoption Team 2/7/2019

2. Disclaimer: Please note that based on feedback from Validation and User Acceptance testing changes to the build were possible after the development of this presentation.Therefore screen shots available in the presentation may not represent the final build delivered.

3. Top IP Nursing topics to be aware of • Resources • The Brain • Risk for Violence • Hyperspace Secure Chat • Code Status • Glycemic Management • Multi-lingual AVS • SOGI • Wound & Avatar • Procedure Pass • Care Planning

4. Regional Informatics Readiness Leads for Alignment/Upgrade

5. Epic Learning Resources Website Available March 18th • Learning material categories • Epic Updates • User Guides • New Learners • Materials for all Disciplines • Website Link • https://epiclearning.providence.org/Content/Home.htm?tocpath=Home|_____0

6. Available March 18th Epic Learning Home Dashboard • Learning materials available inside of Epic on the Learning Home Dashboards for various users including Nursing

7. Epic Beta Testing Environment • Available • Providence Feb13 • Swedish May16 • Kadlec July • Available for informatics and end users to test new features before their released to live environment • Access Instructions https://community.providence.org/sites/LearnLib/LLNurSupMstr/BETA_How_to_Access.pdf

8. The Brain

9. The Brain: A Central Nursing Activity for Better Shift Planning & Documentation • The Brain presents a timeline view of the orders, events, and requirements for each patient the nurse is assigned to • Nurses can document flowsheet values to satisfy documentation requirements, add patient-specific reminders, and scan patient and medication barcodes to administer medications, all without leaving the Brain • Keypoints: • The patient card – shows key information • Required documentation visibility • Visual Worklist for documentation • Medication administration • To Dos / Tasks

10. The Brain

11. Risk for Violence

12. Patient at Risk For Violence Flag • New FYI Flag ALERT titled Risk for Violence • Will trigger- • Separate alert in Headers • Banners on Landing Pages • PAF columns with Icons Note- Use will be defined by the individual ministry and governed by local policy • Documenting the flag generates an alert to caregivers that a patient has a risk for violence • Patient Header • Patient List • Patient Schedule • Overview Report • OP Snapshot Report • ED Trackboard • Other Reports

13. Who can activate the Risk for Violence FYI Alert? • Access to place the FYI risk for violence alert: • Nurse Managers (should include House Supervisors) • Nurse Executives • Clinic Managers • Security • Social Services • Case Managers

14. Risk for Violence: Operational Considerations • While operational practice around the use of this tool is out of the scope of this project, here are a few identified considerations. • This is adjunctive to local policy and procedure. • Local policy should consider: • Define who meets criteria for this Alert • Define who will place the alert on patient charts • Define criteria for removal of alert

15. Code Status

16. Code Status Updates Full Code – To Be Determined • Removal of partial code as a status • Implementing new report Desired Level of Medical Care Report that’s displayslimits to interventions PrePost Code. These limits are documented by provider when addressing code status with patient/family.

17. Desired Level of Medical Care • New SmartForm for Provider documentation • “Not Addressed” will Default • Text Generation for Goals of Care Note

18. Future State – ACP Summary Banner ACP Summary Report Professional Exchange Report

19. Glycemic Management

20. Insulin (eating or NPO) Order Set • The Providence "Insulin (eating or NPO)" OS was revised to include more robust and concise decision support tools. • Providers will also be able to easily order a reduction in dose of long-acting insulin for patients that are made NPO, with a default of reducing the dose by 20%, enhancing patient safety.

21. Hypoglycemia Management Protocol • The protocol for assessing and treating low blood sugars has been revised, combining improved workflows utilized at Swedish and Kadlec within the existing PSJH protocol. • Many PSJH ministries contributed to make it more uniform and concise. • Workflows for both frequency of monitoring and treatment pathways have been changed.

22. Hypoglycemia Management Protocol, cont. IN ALL CASES Check blood glucose every 15-30 minutes until greater than 100 mg/dl, then recheck in one hour or sooner as clinically indicated. If patient has persistent or recurrent hypoglycemia, treat as above and notify provider. If unable to maintain blood glucose greater than 70 mg/dL after two rounds of treatment, start dextrose infusion (D10W) at 50ml/hr. Recheck blood glucose 30 min after starting D10W then at least hourly and PRN until it is discontinued. Call provider to discuss parameters for D10W discontinuation. When patient is no longer hypoglycemic Resume ROUTINE blood glucose monitoring once blood glucose levels are greater than 100 mg/dl on 2 or more consecutive checks. If patient tolerating PO, give a carbohydrate and protein meal or snack. *History of Bariatric Surgery, give: Post Op day of surgery: Protein Packet (6 g) mixed in 4 oz. clear liquids or milk, to drink as tolerated over a few hours. Day after surgery and up to 2 weeks postop: Protein Packet (6 g) mixed in in 4 oz. clear liquid, milk/ full liquids to drink as tolerated over a few hours. Greater than 2 weeks postop, carbohydrate/protein meal or snack as you would to other patients. Hypoglycemia is defined as: - a blood glucose value less than 70 mg/dL in adults - or blood glucose value less than 60 mg/dL in pregnant patients. Acute effects of hypoglycemia range from asymptomatic to severe. Signs and symptoms include but are not limited to: clammy skin, hunger, restless sleep, fatigue, headache, confusion, visual changes, dizziness, fast heart rate, and irritability. If patient hypoglycemic or displays signs or symptoms of this condition, initiate treatment as follows and notify provider: IF ABLE TO TAKE PO Give 15 g glucose gel, 4 oz. juice, 4 oz. non-diet soda, or 8 oz. milk (per local protocol). *History of Bariatric surgery: Give 15 g glucose gel. If not available, treat with D50W IV as per 2.b. below. Do not delay treatment if gel is not available. IF UNABLE TO TAKE PO IV access: Blood glucose 50-69 mg/dl, administer 12.5 g (25ml) D50W (dextrose 50%) IV over 2 minutes. Blood glucose less than 50 mg/dl, administer 25 g (50mL) D50W (dextrose 50%) IV over 2 minutes. No IV access: Administer Glucagon 1 mg IM (place order if not available on MAR).

23. Multilingual AVS

24. Multilingual AVS: for IP & ED • Multilingual AVS provides the ability to print a patient discharge or instructions in languages others than English. • Includes rule based verbiage for: immunizations, sleep apnea, smoking cessation, Warfarin, Aprepitant, Sugammadex, methotrexate, designated care providers, antibiotics and call 911 verbiage • Epic cannot translate certain pieces of information: procedure names, medications, free text notes BENEFITS • Improved patient experience • Standardization of care and documentation • Continuity of Care • Provide better support and information to our patients whose primary language  is not English.

25. Multilingual AVS: for IP & ED, cont. • Translating finalized and approved into: • Russian • Vietnamese • Simplified Chinese • Spanish • Arabic

26. Sexuality Gender Identity and Preferred Names

27. Sexuality Gender Identity and Preferred Names SOGI Phase 3 focuses on improving the patient experience and on better supporting patient-centered care. Today in Epic you can already capture nuances in patients' sex and gender identity, that goes beyond their legal sex. This upgrade brings additional features throughout the system to use and show patient’s gender identity or sex assigned at birth instead of legal sex when appropriate. The updates make it easier to capture this information upon admission.There are also updates throughout the system that make it easier for users to see a patient's preferred name. This is especially important for transgender or nonbinary patients, but also helps improve the patient experience for any patient with a preferred name that differs from their legal name. Patients can now view and edit this personal information in MyChart.

28. Patient Preferred Name • Its now easier to see patients preferred name • Patient header • Patient list • OP schedule • Labels • Reports • Baby names

29. Legal Sex, Gender Identify and Sex Assigned at Birth • Patient header highlights when there is incongruence between sex and gender identity and sex assigned at birth • Now able to collect sex history in Demographics • Its now easier to see sex/gender identity (labels, lists header, reports, etc.) • MyChart allows patients to update personal sex information

30. Wound & LDA Avatar

31. Major enhancements: Wound Dashboard Avatar Associate Images

32. The Avatar • Users can now review, assess, add, and remove LDAs from an Avatar • The visual representation of the body helps clinicians quickly see where a patient's LDAs are located • Clicking the View back icon rotates Avatar

33. Procedure Pass

34. Procedure Pass Integration Design • Impact to inpatient nursing: the Pre-op/Pre-Procedure checklist is moving out of flowsheets to the Pre-Procedure Navigator • How to find it: • IP Nursing > More Activities > Pre-Procedure Navigator • Consider using the Star on this activity if your area frequently completes the pre-op checklist

35. Care Planning

36. New Plan of Care Generic Template Key Points: • The New Inpatient Plan of Care includes universal goals for every patient • Replaces “Patient Care Overview”

37. Apply Care Plan Guide Template(s) Key Points: Multiple problem options support individualization. Add active problems and goals

38. Future State will be to individualize at this point Current Providence workflow is to ‘select all’

39. CPG’s …Clinical Practice Guidelines now called Care Plan Guides • Still Evidence Based Practice (EBP) • New look and feel • One consistent format • New way to access • 100% Inpatient reviewed & revised • New topics! Key Point: Guides care vs. Prescribes care

40. The NEWComorbidity Template provides further opportunities to individualize Key Points: • The plan can be supplemented without adding the full CPG for the comorbid diagnoses • Co-morbid conditions affecting patient outcomes during the acute care hospitalization should be individualized, managed, re-evaluated daily and documented within the plan of care.

41. Definitions • Co-morbidity: The presence of a health condition that may distinctly impact health outcomes for the patient’s admission based on: • The nature of the health condition (controlled versus uncontrolled) • The relative importance of the co-occurring conditions (acute on chronic conditions, e.g., hip fracture with diabetes) • The chronology of the conditions (recent diabetic versus childhood disease) • Patient perception of the condition

42. Definitions (cont.) • Active management of co-morbid conditions in the care plan: Patients with existing health conditions (acute or chronic) requiring treatment, therapy, or other interventions and/or has a direct impact on the outcome of care • General Guidance: Providing education that supports guidelines for co-morbid functionality within the care plan and principles of individualizing care based on co-morbid conditions.

43. Definitions (Cont) • General direction: Providing education that supports guidelines for co-morbid functionality within the care plan and principles of individualizing care based on co-morbid conditions. • A patient with a history of a disease/condition should be assessed to determine if the condition is pertinent to the patient’s outcome • Surgical admissions with a history of Diabetes controlled by diet should add “Diabetes” as a co-morbid condition secondary to the risk of Surgical Site Infection (SSI) secondary to postoperative hyperglycemia • Surgical admissions with a history of depression and being treated with medication exhibiting no signs or symptoms of depression does not need an additional co-morbid condition of depression

44. Beginning and During Shift: Key Points: • NEWOverview Report • Review the care plan • Review patient education • Update patient goals

45. End of Shift Key Point: Document the evaluation of each goal through the new document button

46. Outcome Definitions Example goal: Stable heart rate and rhythm • Met: Goal has been achieved • Example: No arrhythmias for 24 hours, taken off telemetry • Ongoing, progressing: The patient is improving toward the goal • Example: Patient occasionally having a fib, moving toward baseline heart rate and rhythm • Ongoing, not progressing: The patient has shown little or no progress and care plan will continue to reflect that. Note that this includes no progress. • Example: Little change in admitting rhythm, still providing medical management and assessments • Unable to meet, plan of care revised: Goals have been changed because patient is not anticipated to meet them as currently identified. • Example: Since admission it has been determined the patient’s unstable heart rhythm is their “normal abnormal” • Not met, adequate for care transition: Although this goal still applies to this patient their next level of care is appropriate to continue to address it. • Example: Being discharged to SNF where medication management will be used to continue to manage unstable heart rhythm.

47. Create a plan of care note Key Point: Summarize the overall assessment of patient’s progress toward all goals.