Admission History Data Base Changes VUH

10/13, 17, 20/2011

Change in Philosphy

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.

What

Why

How

Roles and Responsibilities & Materials

Unit Implementation plan template

Copies of the policiesTraining AidesVideo clipPractice scenarioTraining patients name and MRNLMS moduleFAQ on SSS web siteDebriefings- 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.

If it ain’t broke…..

If it ain’t broke…..97% of admission hx started- only 10 % completed

No reminders if not finished

TOO LONG!

Redundant information collection- Patient complained they have already answered these

No one looks at it! This is just a waste of time

Nurses “live” in HED – can’t we put this in HED???

Must leave Admit History form and go to HEO to enter orders

When I am worried about keeping patient alive upon admission, I shouldn’t have to document discharge plans

8 hours is not long enough time to get it done.

It doesn’t track who entered each piece of data so I start a new one even if there is a draft

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

Collect data by time it will be needed Minimize data collection during critical stabilization period (1st 1-2 hrs.)

Meet minimum regulatory requirements

Collect data once and pass to all systems and users who need to view

Optimum workflow process associated with admission phase of care (up to 24 hrs. max.)

Vision and Goals

HITECH

TRIED TO FORMAT IN HED

Amount of scrolling up and down and back and forth to see data and what was incomplete was

impossible

DATA

Future: Admit History data imported into HED

5 Admission HistoryAdult Admission History

• patients <18 in VCH or VUH

Pediatric Admission History

• Pulls data forward if prenatal care @ VUMC

OB

• Will add Immunization screen but date TBD

VPH Admission History

Short Stay Patients

Less time to complete since short

LOS(Cath Lab, Same Day

Surgery)

Less data needed for safe, high quality

care

Complete by mid point of anticipated

LOS

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

Net Change = 0

Some Items

Removed

Some Items Added

Immunizations

CPAP and medication

pumps

Changes to Tobacco Screen

Past medical surgical history

Shortened Screenings

Religion

Content

Decreased Need to Toggle to HEO/WIZ

Auto generated orders and alerts eliminate need for nurse to enter some orders in HEO/WIZ

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

Electronic Signature Tied to Data

Click to display ID of person collecting data

MANY EYES WILL SEE THE DATA

Data Shared

Link to view

Eventually imported into HED

Team Summary, Resident Handover

OPC, Charge Nurse Worksheet

Readmission Risk Scale (in development)

RemindersAdm 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!)

3 Sections

I• Critical for

Safe Care• 1-2 hours

II• Plan of Care• 6-8 hours

III• Discharge

Plan and Functional Screen

• 20-24 hours

I Critical for Safe Care

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

I Critical for Safe Care

Legal Documents

All permanent chart documents now scanned at

discharge

I Critical for Safe Care

New Present On Admission Screening Awareness is Key to Improved Communication Among Team Members

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 .

CPAP Summary –What You Need to KnowPatients 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.

Save As DraftSaves in StarPanel, generates

HEO/WIZ orders prn and updates electronic documents and

dashboard

Other Nurses can document additional information

Triggers indicators

Will display alert if all questions are not completed

Leaving a question blank or selecting “Unable to

complete” triggers indicators on the inpatient whiteboard.

Save As FinalSaves in StarPanel,

generates HEO/WIZ orders prn and updates electronic

documents

Do ONLY after all 3 sections completed

Additional edit must be done in an amendment

Triggers indicators

II - Plan of Care

Past Medical & Surgical History

Physician responsibility to enter and link displays in

Admission History

II Plan of Care

II Plan of Care

If select “yes” smokes must select response regarding frequency

It our responsibility to screen patients for appropriate vaccines and offer vaccines to patients that meet positive screening criteria.

Patients always have the right to decline.

Global Immunization

32

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.

Influenza

Flu season October till March 1 and everyone six months and older should get vaccinated.

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.

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Pneumonia

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.

Wikimedia Commons.

In 2007 1.2 million hospitalized 52,000 people died from the disease

VUMC 20103000Admitted with diagnosis of Pneumonia

(community or hospital acquired)

Of those, 750 patients were readmitted within 30 days with a pneumonia related condition.

II Plan of Care

II Plan of Care

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Pneumococcal Vaccine IndicationsIndications 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

See why decision support is needed

within the Admission History?

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

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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

II Plan of Care Screenings

Nutrition Dashboard

Positive screen trigger notification to nutrition services via the dashboard

II Plan of Care

Information will display on OPC and eventually feed Readmission screen and Patient Education and Engagement Record (PEER)

Learning ReadinessII Plan of Care

II Plan of Care

OB has Lactation Screenings

III- Discharge and Functional Screen Section

III Discharge/Functional Screens

Physician will be notified of positive Functional screens as only providers may order Rehab evaluations in Tennessee

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.

Section 3

Section 2

Section 1

Admission History Indicator

Not in nurses current workflow to verify Admission History is completed.

Indicator on whiteboard should help

Even if past 24 hours,

collect the data

The data is important.

Future ChangesNotification 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

Obstacles and Actions

“Nothing motivates more than success. We need to define and engineer visible performance improvement. “

Next Steps• Discuss with leadership team and finalize training plan.• Insert your unit’s training patients in the practice scenario• Review “all docs” in StarPanel for each training patient to evaluate which staff have practiced

Optional Resources Web Based ResourcesSSS Web Site->Education for Staff->General Tutorialshttp://www.mc.vanderbilt.edu/root/vumc.php?site=sss2 LMS Module (ready by 10/31) Title “Admission History Changes 2011” http://vanderbilt.mzinga.com/app/servlet/navigation

Important Dates/TimesMore Sessions like this one 10/17 Mon 1-3pm 407 Oxford House- makeup 10/20 thur 1130-130 407 Oxford House-

makeup

Implementation 11/15 Tue SSS will make rounds Call Help desk (3-3457) if need assistance

Debriefing Sessions Nov 16 730-8am CVICU conference room Nov 17  730-8am 11 North conference room Nov 18 12noon -1230 11 North conf room