Exemplary Professional Practice INTERPROFESSIONAL CARE · EP12 Advocate BroMenn Medical Center 3...

EP12 Advocate BroMenn Medical Center 1

Exemplary Professional Practice INTERPROFESSIONAL CARE

EP12 - Nurses assume leadership roles in collaborative interprofessional activities to improve the quality of care.

Provide one example, with supporting evidence, of a nurse-led (or nurse co-led) collaborative interprofessional quality improvement activity.

Quality Improvement Opportunity Identified

In March of 2014, physicians began computer order entry into Advocate BroMenn Medical Center’s (ABMC) electronic medical record (EMR) system, Meditech. Computer order entry resulted in unintended duplication, omissions and inappropriate timing of serial troponin orders. Troponin, a protein released into the bloodstream after heart muscle is damaged, is a specific indicator of a recent myocardial infarction (heart attack). Troponin is detectable in the bloodstream within three to six hours of heart muscle damage, and peaks at 12 to 24 hours, remaining elevated for up to 14 days. Ideally, serial troponin levels should be obtained at the onset of chest pain, and re- evaluated three and six hours following chest pain onset to determine if levels are increasing, which would help differentiate if myocardial damage had occurred. Prior to March of 2014, the physician would write an order for the troponin series and the unit secretary would then enter the orders in the EMR. Patients with the correct number of serial troponins entered at the correct time were noted to be 84% with the written order process. In March 2014, when the physicians began entering orders using Computerized Provider Order Entry (CPOE), the laboratory noted a decline to 60% of the patients receiving the correct order series during the first month. Laboratory associates also noted 29% of troponins were cancelled, reordered, or retimed due to improper sequencing or duplicate order entry. As a consequence of mistimed orders, patients were having multiple unnecessary phlebotomy sticks, or more alarming, troponin test results were not available to the provider in a timely manner to efficiently manage the patient’s care. During a discussion at the May 6, 2014, Chest Pain/Cardiac Collaborative meeting, James McCriskin, DO, Cardiologist and Chest Pain Center Medical Director requested Michael Mueller, MBA, BSN, RN, CCRN, Cardiovascular Service Line Director, schedule a meeting with Information Systems (IS) associates to identify potential options to correct the issues (Exhibit EP12.1 Chest Pain/Cardiac Collaborative Committee Minutes May 2014).

Nurse Leadership

Michael appointed Beverly Glendon, BSN, RN, Cardiac/Pulmonary Data Quality Specialist and Chest Pain Center Coordinator, to lead an interprofessional subcommittee with the objective to review issues with the troponin order entry process, and to develop and implement a solution. The Chest Pain/ Cardiac Collaborative Troponin Subcommittee was formed and held their first meeting on June 24, 2014


(Exhibit EP12.2 Chest Pain/Cardiac Collaborative Troponin Subcommittee Minutes June & July 2014).

Interprofessional Team Members

To ensure comprehensive quality improvement success, nurses from Cardiovascular Services, the Emergency Department (ED), and IS, as well as laboratory and physician partners, were asked to participate on the subcommittee. The subcommittee participants included (Exhibit EP12.2 Chest Pain/Cardiac Collaborative Troponin Subcommittee Minutes June & July 2014):

Beverly Glendon, BSN, RN, Cardiac/Pulmonary Data Quality Specialist and Chest Pain Coordinator

Dana Altenburger, MD, Pathologist and Laboratory Medical Director

Janelle Durdle, MT(ASCP), Laboratory Director

Nancy Hand, MT(ASCP)SC, Laboratory Chemistry Section Head

Larae Jackson, MSN, RN, Hospitalist Clinical Coordinator

Michael Mandrell, BS, BSN, RN, CCRN, CEN, CPEN, CPN, Emergency Department Nurse Educator

Marie Ngom, MD, Internist and Hospitalist Medical Director

Lori Ritter, RN, CEN, Emergency Department Trauma/Quality Coordinator

Laura Severs, MHA, MLS(ASCP), Laboratory Medical Technologist

Sandy Young, RN, Clinical Informaticist Collaboration and Quality Improvement

The Troponin Subcommittee participants brainstormed possible options for improving the computerized ordering process. Originally, participants believed ED orders became inactive when a patient transitioned to an inpatient nursing unit bed. Beverly contacted a Chest Pain Center Coordinator from another medical center using Meditech, the same EMR, and noted the facility’s practice in the ED demonstrated serial troponin orders transferred to the inpatient nursing units. Through collaboration with James Nevin, MD, ABMC’s Vice President of Medical Management, and review of medical staff bylaws, it was learned that ED orders could remain active after a patient transfers to an inpatient nursing unit, creating opportunity to reduce unnecessary and incorrectly timed troponins through process change.

The subcommittee proposed building an order set in Meditech for serial troponins to be initiated upon ED arrival, and including troponin redraw at three and six hours thereby eliminating multiple orders and timing errors. The medical center’s inpatient nursing units and ED EMRs were built on two separate Meditech platforms which created a number of challenges for the subcommittee. After several trials of Meditech redesign, the team was able to have troponin order sets initiated in the ED successfully transition to the inpatient nursing units upon transfer/admission of the patient.

Once the order set was built, Sandy Young, RN, Clinical Informaticist; Michael Mandrell,

BS, BSN, RN, CCRN, CEN, CPEN, CPN, Emergency Department Nurse Educator and


Nancy Hand, MT(ASCP)SC, Laboratory Chemistry Section Head. conducted rigorous

testing among the different service areas to ensure the order set would work correctly.

Testing was completed on July 16, 2014. Facilitated by Beverly, the team reconvened

on July 23, 2014 with goals to view a demonstration of the computerized ordering of

serial troponins, to set an implementation date, and to plan education for the healthcare

providers. Throughout the project, Beverly provided updates to Dr. McCriskin and

Michael.

Education for the revised serial troponin ordering process consisted of a process flowchart (Exhibit EP12.3 Troponin Ordering Flowchart) and troponin ordering instructions (Exhibit EP12.4 Troponin Order Instructions), including Meditech screen shots. The educational tools were emailed to physicians, lab associates, nurses, nursing technicians and secretarial associates. The handouts were also posted in the ED and on the nursing units. On September 2, 2014, the new ordering process was implemented. Beverly rounded on the nursing units to answer questions during the week of implementation. Through concurrent review, laboratory associates were able to identify physicians requiring additional education and training, which was provided.

Success of the project was measured by monitoring the troponin series ordering after the quality improvement activity was completed. After implementation of the practice changes for ordering serial troponins, patients receiving the correctly timed troponin order series increased to 87% the month of December 2014, from 60% in March 2014.

8.4.16 jlm

Chest Pain/Cardiac Collaborative Meeting

DATE: 5/6/2014 START TIME: 7:00 END TIME: 0830 LOCATION: Heart Center

Present: Bev Glendon RN, BSN, Cardiac Data/Quality Specialist & Chest Pain Center Coordinator; Dr. James McCriskin, AMG-IHL, Chest Pain Center Medical Director; Michael Mueller, RN, MBA, CVSL Administrator; Dr. Braastad, Interventionalist AMG-IHL; Donna Schweitzer APN, Critical Care; Jenny Messier RN, Manager Case Management; Eileen Owen RRT, MBA, Manager Invasive Cardiology, Cardiac Rehab, Non-invasive Cardiology; Laura Severs, Med Tech, Laboratory Dept.; Ron Bartlett, RN, MSN, ED Manager at Advocate Eureka Hospital; Andy Button PA-C, AMG-IHL; Dept.; Jeff Smith RN, BSN, Case Manager CVCU; Peggy Watkins ED Triage/Clinical Coordinator; Lori Ritter RN, ED Trauma/Quality Coordinator; Michael Mandrell RN, BSN, ED Educator; Sandra Gifford, Dietition; Teresa Bailey RN, BSN, MOSU Manager; Gay Shoot RN, BSN, Palliataive Care Coordinator; Sally Gambacorta, Manager of Wellness; Christie Rocke RN, BSN, Wellness; Beka Lavicka RN, BSN, HF Nurse; Shelly Jimenez RN, BSN, CVCU/ICU Manager; Jeff Smith RN, BSN, CVCU Case Manager; Dr. Ngom, Hospitalist Director

Excused Absence: Greg Scott RN, MS, EMT-P, EMS Coordinator; Nancy Hand, Chemistry Facilitator

TOPIC DISCUSSION ACTION / RESPONSIBLE PERSON / DATE

Wins Normal & Bloomington Fire Departments have been awarded AHA EMS Recognition for STEMI Care. This is a new award from AHA.

Chest Pain Dashboard

AEH commended for D2D2B of 74 minutes.

Review with Gibson City transfer-in in March. Discussed opportunity to consider calling ambulance first then Priority Line. D2D2B 106 min.

Code STEMI updates

Express STEMI Process Review: Recent case with delays in STEMI Referral Center trying to give report. Review of process discovered Cath Lab not always contacting STEMI Referral Center for report. Revisions to flowchart:

1. Cath Lab staff to obtain faxed ECG/other documents from Patient Placement’s office.

2. Cath Lab to call STEMI Referral Center for report (phone #s of outlying hospital posted in the cath lab.

New ED physician orientation going well: Now includes review of processes for Code STEMI, Code Gray, and Sepsis Alert

Code STEMI orders reviewed. Changes: 1. Due to 3 choices of P2Y12 inhibitors, the drug choice is to be directed by the interventionalist. 2. (After meeting) Interventionalist requested to have IV of Normal Saline infusing at

.

B. Glendon will facilitate changes in CPOE.

Exhibit EP12.1

Date Page


200 ml/h. to help prevent Acute Renal Injury.

Serial Troponins CPOE has not been able to accommodate serial troponins well. In March 29% of troponins cancelled/reordered/re-timed. This is mainly due to serial orders not being able to continue from the ED due to Meditech capabilities. Task group with Lab, IS, ED, and myself set up.

After review of Medical By-Laws, VP of Medical Management indicated that ED orders can extend into inpatient/observation side for 12h in the non-ICU areas. With this in mind, proposal presented to start the troponin series in the ED.

After review of proposal there was agreement to decrease the serial troponins from q 4h through 16h from hospital arrival to 12h. There has been no method found to allow Meditech to automate serial troponins based on initial draw time from ED to obs/inpt status. However, physicians requesting more attempts are made.

Dr. McCriskin requested Mike Mueller set up a meeting with IS to look at additional options.

ACC-NCDR Conference Update

B. Glendon reported:

1. Consideration for Public Reporting including PCI Discharge Meds, Risk-adjustedMortality, and Risk-adjusted bleeding.

2. Risk-Adjusted Kidney Injury—continued emphasis.3. ACTION: Focus on non-STEMI care, including use of ADP Inhibitors (i..e.,

Clopidorgrel) on medically treated patients.

Blood Cholesterol Guidelines & Hypertension Guidelines—Effects of Patient Education

Patient education materials r/t to the 2013 Blood Cholesterol Guidelines and the 2014 AMA Hypertension Guidelines.

Dr. McCriskin recommends no changes be made to patient ed materials, except change goal of LDL on electronic discharge instructions to “as set by physician.”

B. Glendon will send request for Information Systems to change. (Has not yet been completed as of 8/21).

Post Acute Care Network

Jenny Messier indicated progress being made to try to initiate PAN sometime in August. Nursing home selections, APNs, and physicians to see patients in the NH are yet to be finalized.

Palliative Care Update

Gay Shoot explained her role. Palliative care screening done to assist with referrals. Goal is to have an OP f/u program in the future.

2

Chest Pain/Cardiac Collaborative: Troponin Subcommittee Meeting

DATE: 6/24/14 START TIME: 14:00 END TIME: 15:00 LOCATION: IS Planning Room

Present: Bev Glendon RN, BSN, Cardiovascular-Pulmonary Data/Quality Specialist & Chest Pain Center Coordinator; Nancy Hand, Chemistry Facilitator, Laboratory Dept.; Lori Ritter RN, Trauma Quality Coordinator, Michael Mandrell RN, BSN, ED Nurse Educator; Janelle Durdle, Laboratory Manager; Sandy Young RN, Information Systems


Purpose of Meeting

Since initiation of CPOE, it has been identified that there are opportunities to improve ordering troponins. Problems noted:

• Excessive troponins ordered: ED orders troponins while patient is in their dept; newseries starting when patient arrives to the floor. (Previously secretaries placed orders and timed off of troponins ordered in ED).

• Meditech does not recognize time of first troponin to automate timing ofsubsequent troponins when crossing departments due to current capabilities in Meditech.

• Following q 4h troponin schedule has reduced from above 80% to 60% with CPOE.• In March when CPOE started, 29% of troponins cancelled/reordered/re-timed.• St. John’s in Springfield shared that serial troponins start in the ED and continue to

nursing floor• Dr. Nevin states the medical by-laws supports carrying over orders through 12h

from ED for non-ICU; 6h for ICU. He supports a process to carry over serial troponinsfrom the ED.

• Dr. Nilles will support a process to have troponins cross over from the ED(documented in their Dept of Emergency Medicine minutes).

B. Glendon has been asked by CV Service Line Director to implement best possible solution to above problem. Thus this task group is re-convening.

Note: The troponin series will be reduced to maximum of 12h as “ok’d” at the Cardiac Collaborative/Chest Pain meeting in the Spring.

Troponin in Test

As previously proposed, continue work on serial troponin starting from the ED. TROP4 lab order will be eliminated to make this process work.

Previous test involving troponin must be re-worked on since new version of Meditech.

Michael Mandrell and Nancy Hand will work on adapting troponin ordering to the new Meditech version. (Test completed 7/16)

Exhibit EP12.2

Date Page


Must not only look at Meditech but also interface with MobiLab. Will wait on making order changes and education plan until confirmation that test with new version complete.

Review of troponin ordering process (pending success of “test”).

ED Presentation: 1. When troponin ordered in ED, it will automatically order the troponin series

(0-4-8-12h) 2. When transferred from ED, the admitting physician should continue the order

using the transfer link (process of reviewing orders when patient is transferred from department to department). If the admitting physician does not click on transfer, the troponin orders will continue but under the ED physician’s name.

3. ED physician has the option to discontinue troponins. (Dr. Nilles will encourage EDproviders to NOT cancel the reflexed series when placing an order for troponins). Admitting physician has the option of not reordering troponins.

Direct Admit or Troponin Series Needed during Hospital Stay after Admission: Order Sets with routine serial troponins, such as ACS/MI orders)

1. Order troponin series by clicking on “suggested set” for serial troponins under themain set of orders

Orders w/o routine troponin series: 1. Initiate troponin series from “single” orders by searching for troponin

Discharged from ED to Home: 1. As current practice, troponin orders timed after discharge will automatically be

cancelled.

A single troponin test can always be ordered. Physicians still have the option to edit the time intervals but will be encouraged to utilize the q4h scheduled set as BroMenn’s schedule.

B. Glendon commented we still have physicians struggling with “transfer” orders. Success of this process will be contingent on educating physicians on the ordering process.

After successful completion of “test,” this task group will reconvene to develop educational material for physicians and staff. (Meeting scheduled for 7/23).

2

Date Page


CareMaps/ Order Sets Affected

The following orders reference serial troponins:: 1. Atrial Fibrillation Admission Orders2. ED Code STEMI orders3. ED Trauma Orders4. ED Chest Pain Orders5. Chest Pain R/O MI orders6. ACS/MI Orders7. CHF Orders8. Emergent (ED) Stroke/TIA orders9. Ischemic CVA orders

Once the “test” is completed, Bev Glendon will have the cardiac orders adjusted and signed by Dr. Braastad; Lori Ritter will f/u on the ED orders; Bev Glendon will f/u with Kristin Peterson and Tori Steinkoenig for the neuro orders (made aware 7/17 but have not received a response).

Sandy Young agreed to expedite changes in CPOE.

Implementation tentative goal is August

3

Date Page



Present: Bev Glendon RN, BSN, Cardiovascular-Pulmonary Data/Quality Specialist & Chest Pain Center Coordinator; Nancy Hand MT, (ASCP), SC, Chemistry Facilitator, Laboratory Dept.; Lori Ritter RN, Trauma Quality Coordinator, Michael Mandrell RN, BSN, ED Nurse Educator; Janelle Durdle MT (ASCP), Laboratory Director; Sandy Young RN, Information Systems, Dana Altenburger, M.D., Medical Director Pathology; Larae Jackson RN, MSN, Hospitalist Office Manager; Marie Ngom, M.D.


Demo of Revised Troponin Ordering

Michael Mandrell and Sandy Young demonstrated revised serial troponin ordering. It was demonstrated that the serial troponin orders will cross over from ED to the inpatient side.

No problems with interfacing with MobiLab.

The ED physician orders an initial troponin. There is a prompt in the ED order sets for the 3h and 6h troponins. ED physicians need to manually select the 3h & 6h troponins. They will then transfer to inpatient side if not drawn in ED. Dr. Nilles, Chair of Department of Emergency Medicine has already stated he will instruct the ED physicians to select the 3h and 6h troponin when the automatic initial troponin is ordered.

Serial troponins will be pulled off the applicable orders sets, i.e., Chest Pain orders. A prechecked “suggested set” will be placed under the main order set (essentially a “subset”).

Bev Glendon will work with Colleen Ewen RN, BSN in Clincal Education on all orders that include serial troponins. After Colleen reviews, Sandy will make the changes in Meditech.

4

Date Page


There is still the capability to order single or serial troponins as separate orders as needed.

Implementation Date

The team selected August 25th as implementation date, pending any problems.

Educational plan

The team decided that a handout explaining the need for change and an outline of the new process could be sent electronically to pertinent healthcare providers. The handout will be posted on the nursing units close to implementation time. ED will provide information in the ED newsletter as well.

Bev Glendon willing to visit nursing units the week of implementation to field questions as needed.

Michael Mandrell and Lori Ritter will assist ED physicians and staff as needed.

Bev Glendon will draft a process flowchart as an educational tool. It will be sent to members of the team for feedback/revisions. Complete within next couple of weeks.

Further meetings

The team agreed that further communication on this project could be done via e-mail.

5



Present: Bev Glendon RN, BSN, Cardiovascular-Pulmonary Data/Quality Specialist & Chest Pain Center Coordinator; Nancy Hand, Chemistry Facilitator, Laboratory Dept.; Lori Ritter RN, Trauma Quality Coordinator, Michael Mandrell RN, BSN, ED Nurse Educator; Janelle Durdle, Laboratory Manager; Sandy Young RN, Information Systems


Purpose of Meeting

Since initiation of CPOE, it has been identified that there are opportunities to improve ordering troponins. Problems noted:

• Excessive troponins ordered: ED orders troponins while patient is in their dept; newseries starting when patient arrives to the floor. (Previously secretaries placed orders and timed off of troponins ordered in ED).

• Meditech does not recognize time of first troponin to automate timing ofsubsequent troponins when crossing departments due to current capabilities in Meditech.

• Following q 4h troponin schedule has reduced from above 80% to 60% with CPOE.• In March when CPOE started, 29% of troponins cancelled/reordered/re-timed.• St. John’s in Springfield shared that serial troponins start in the ED and continue to

nursing floor• Dr. Nevin states the medical by-laws supports carrying over orders through 12h

from ED for non-ICU; 6h for ICU. He supports a process to carry over serial troponinsfrom the ED.

• Dr. Nilles will support a process to have troponins cross over from the ED(documented in their Dept of Emergency Medicine minutes).

B. Glendon has been asked by CV Service Line Director to implement best possible solution to above problem. Thus this task group is re-convening.

Note: The troponin series will be reduced to maximum of 12h as “ok’d” at the Cardiac Collaborative/Chest Pain meeting in the Spring.

Troponin in Test

As previously proposed, continue work on serial troponin starting from the ED. TROP4 lab order will be eliminated to make this process work.

Previous test involving troponin must be re-worked on since new version of Meditech.

Michael Mandrell and Nancy Hand will work on adapting troponin ordering to the new Meditech version. (Test completed 7/16)

Exhibit EP12.2

Date Page


Must not only look at Meditech but also interface with MobiLab. Will wait on making order changes and education plan until confirmation that test with new version complete.

Review of troponin ordering process (pending success of “test”).

ED Presentation: 1. When troponin ordered in ED, it will automatically order the troponin series

(0-4-8-12h) 2. When transferred from ED, the admitting physician should continue the order

using the transfer link (process of reviewing orders when patient is transferred from department to department). If the admitting physician does not click on transfer, the troponin orders will continue but under the ED physician’s name.

3. ED physician has the option to discontinue troponins. (Dr. Nilles will encourage ED providers to NOT cancel the reflexed series when placing an order for troponins). Admitting physician has the option of not reordering troponins.

Direct Admit or Troponin Series Needed during Hospital Stay after Admission: Order Sets with routine serial troponins, such as ACS/MI orders)

1. Order troponin series by clicking on “suggested set” for serial troponins under the main set of orders

Orders w/o routine troponin series:

1. Initiate troponin series from “single” orders by searching for troponin Discharged from ED to Home:

1. As current practice, troponin orders timed after discharge will automatically be cancelled.

A single troponin test can always be ordered. Physicians still have the option to edit the time intervals but will be encouraged to utilize the q4h scheduled set as BroMenn’s schedule. B. Glendon commented we still have physicians struggling with “transfer” orders. Success of this process will be contingent on educating physicians on the ordering process.

After successful completion of “test,” this task group will reconvene to develop educational material for physicians and staff. (Meeting scheduled for 7/23).

2

Date Page


CareMaps/ Order Sets Affected

The following orders reference serial troponins:: 1. Atrial Fibrillation Admission Orders 2. ED Code STEMI orders 3. ED Trauma Orders 4. ED Chest Pain Orders 5. Chest Pain R/O MI orders 6. ACS/MI Orders 7. CHF Orders 8. Emergent (ED) Stroke/TIA orders 9. Ischemic CVA orders

Once the “test” is completed, Bev Glendon will have the cardiac orders adjusted and signed by Dr. Braastad; Lori Ritter will f/u on the ED orders; Bev Glendon will f/u with Kristin Peterson and Tori Steinkoenig for the neuro orders (made aware 7/17 but have not received a response). Sandy Young agreed to expedite changes in CPOE. Implementation tentative goal is August

3

Date Page


DATE: 7/23/2014 START TIME: 14:30 END TIME: 15:30 LOCATION: IS Planning Room Present: Bev Glendon RN, BSN, Cardiovascular-Pulmonary Data/Quality Specialist & Chest Pain Center Coordinator; Nancy Hand MT, (ASCP), SC, Chemistry Facilitator, Laboratory Dept.; Lori Ritter RN, Trauma Quality Coordinator, Michael Mandrell RN, BSN, ED Nurse Educator; Janelle Durdle MT (ASCP), Laboratory Director; Sandy Young RN, Information Systems, Dana Altenburger, M.D., Medical Director Pathology; Larae Jackson RN, MSN, Hospitalist Office Manager; Marie Ngom, M.D.


Demo of Revised Troponin Ordering

Michael Mandrell and Sandy Young demonstrated revised serial troponin ordering. It was demonstrated that the serial troponin orders will cross over from ED to the inpatient side. No problems with interfacing with MobiLab. The ED physician orders an initial troponin. There is a prompt in the ED order sets for the 3h and 6h troponins. ED physicians need to manually select the 3h & 6h troponins. They will then transfer to inpatient side if not drawn in ED. Dr. Nilles, Chair of Department of Emergency Medicine has already stated he will instruct the ED physicians to select the 3h and 6h troponin when the automatic initial troponin is ordered. Serial troponins will be pulled off the applicable orders sets, i.e., Chest Pain orders. A prechecked “suggested set” will be placed under the main order set (essentially a “subset”).

Bev Glendon will work with Colleen Ewen RN, BSN in Clincal Education on all orders that include serial troponins. After Colleen reviews, Sandy will make the changes in Meditech.

4

Date Page


There is still the capability to order single or serial troponins as separate orders as needed.

Implementation Date

The team selected August 25th as implementation date, pending any problems.

Educational plan

The team decided that a handout explaining the need for change and an outline of the new process could be sent electronically to pertinent healthcare providers. The handout will be posted on the nursing units close to implementation time. ED will provide information in the ED newsletter as well.

Bev Glendon willing to visit nursing units the week of implementation to field questions as needed.

Michael Mandrell and Lori Ritter will assist ED physicians and staff as needed.

Bev Glendon will draft a process flowchart as an educational tool. It will be sent to members of the team for feedback/revisions. Complete within next couple of weeks.

Further meetings

The team agreed that further communication on this project could be done via e-mail.

5

Revised Troponin & Echocardiogram Orders: Effects on ED & Admission Orders

Containing Troponin

8/27/14

Driving Need to Change Troponin Ordering:

Excessive troponin ordering due to Meditech CPOE functionalities and use of CPOE

In March when CPOE started, 29% of troponins cancelled/reordered/retimed. Process change needed.

Process for Serial Troponin Ordering

ED Presentation Direct Admit

ED Bypassed

Serial Troponins Needed

During the Patient Stay

Troponins automatically

ordered as 0-4-8-12h draws

ED

Discharge?

Yes

Troponins

scheduled after

discharge

automatically

cancelled

No

During transfer order

review process, the

admitting physician

reviews orders from

ED & continues or

discontinues the

troponins.

If transfer order

review process not

done, the troponin

orders automatically

will transfer to the

observation/inpatient

location.

Serial troponins

addressed in desired

CareMap/Order

Set?

No Search for “troponin” under

“Sets.” Select “SERIAL

TROPONINS Q 4H.”

Yes

Serial troponin orders will be

removed from the” main” set

of orders in CPOE. Under

the title of the “main” orders,

serial troponins will be listed

as a “suggested set.” Check

on the troponin suggested set

to order serial troponins.

Search for “troponin” under

“Sets.” Select “SERIAL

TROPONINS Q 4H.”

Example of Serial Troponin

“Suggested Set.” Check if order

needed.

Troponin

change in

CPOE

planned for

9/2/14

Exhibit EP12.3 Advocate BroMenn Medical Center

8/27/14 - On September 2, 2014 troponin ordering is changing. Troponin Ordering has been an issue since going live with in-house CPOE. Many times patients end up with anywhere from 4-12 troponins ordered, and many instances they are not timed correctly. A workgroup has been working since March on how to address the issues with troponin ordering.

All inpatient order sets that contain troponins will have the troponins removed from that order set and attached as a suggested set. So, for example, the Chest Pain R/O MI CM Order set will no longer contain a Troponin. Instead, when you select the order set, there will be a suggested “troponin” order set underneath. This “Troponin” order set should be utilized if we have not drawn a troponin set in the ED. If we already ordered a troponin in the ED (which would reflex the 4-hour, 8-hour, and 12-hour troponins) then this “suggested” Troponin order set should not be selected as the patient would then end up with 8 troponins ordered. (see below)

Ordering of a single troponin is also still available. If you have any questions concerning Meditech please call the CPOE hotline (49-2763). Dr. Dana Altenburger is also available by email [email protected] or phone (49-5129).

Removing the Troponin from the Inpatient Order Sets will also remove it from your “Favorite” Order Sets. The suggested set cannot

be added to your favorites that already exist.

If you need to order this “SERIES TROPONIN Q 4H” Order Set when it is not appearing as a “Suggested” Order Set, search Troponin in

the Order Sets

Exhibit EP12.4 Advocate BroMenn Medical Center

mailto:[email protected]

Exemplary Professional Practice INTERPROFESSIONAL CARE · EP12 Advocate BroMenn Medical Center 3...

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