Joshua Medow MD, MS Christopher Nickele MD, Using the electronic medical record to maximize practice efficiency in Organ Donation Joshua Medow MD, MS Christopher Nickele MD, Christy Hunter,RN,CCRN, Patricia Chesmore,RN,CCRN, Tammy Kundinger,RT, William Tanke,PharmD, Gabriel Norgaard,BS, Tony Frey,BS Doug Miller Symposium April 25, 2013

Disclosure The authors of this presentation have no financial or ethical conflicts to disclose

Outline Efficiency The use of protocols Abilities of the EMR Order sets to increase efficiency Other avenues to increase efficiency

Demands on Time OR ER Outpatient Calls ICU General Care Documentation Pulling you in different directions Documentation

Protocols Nursing care Physician input up front Triggers for call to physician Requires nursing to implement Computerized protocols versus paper1 1. J Burn Care Res. 2011 ; 32(2): 246–255. doi:10.1097/BCR.0b013e31820aaebf

The Team Neurocritical Care Physician Nursing Respiratory Care Pharmacy Hospital IT

Brain dead donor (BDD) Optimizing care Critical care team efficiency Managing parameters / metric driven

Donation After Cardiac death (DCD) donor Donor comfort Optimizing care Critical care team efficiency Managing parameters/metric driven

Protocols – BDD Lung Protective

Protocols – DCD Lung Protective

Protocols – Vasoactive Algorithm

Protocols – Vascular Volume Maintenance Obtain weight in kg If weight is > 20 kg skip to step 5 If weight is > 10 kg skip to step 7 Multiply weight by 4 and skip to step 10 Subtract 20 from weight Add 60 to result and skip to step 10 Subtract 10 from weight Multiply result by 2 Add 40 This is the rate to maintenance (.9ns+20k.) IVF at

Protocols – Vascular Volume management Obtain CVP every 2 hours If CVP > 6 go to step 8 Multiply (7 – CVP) by 5 Multiply the value in step three by the weight in Kg Round up to nearest 10 ml. Do not exceed 2000 mL Give .9 NS at 1000 mL/hr until calculated volume is reached Go to step 1 If CVP is < 13 go to 1 Give lasix 40 mg every 6 hours prn for CVP > 12

Protocols – Free Water Deficit Correction Obtain serum sodium. If serum sodium < 151 skip to step #9. Divide patient admit weight by 2. (VL = patient weight / 2). Number of L of D5W to replace: LD5 = VL – ((150 * VL)/serum sodium). Number of mL of D5W to replace: MLD5 = LD5 * 1000. Round MLD5 to nearest 10 mL. Administer MLD5 at a rate of 500 mL / hour until infusion completed. Wait 2 hours and return to step #1. Obtain serum sodium every 6 hours. If serum sodium > 150 and U.O. > 250 mL/hr give ddAVP 1 mcg every 3 hours and return to step #3.

Protocols – Hematocrit Correction Obtain hematocrit If hematocrit is > 23 no need to transfuse, go to step 1 Subtract hematocrit from 24 Divide resultant by 3 Divide weight by 70 Multiply steps 4 and 5 Round up to nearest integer If value in step 7 is < 7 transfuse number of units in step 7 and go to step 1 Call MD for transfusion concerns

Protocols – Pain and agitation management

Protocol – Pain / Agitation Scores for Dosing Validated Sedation / Agitation Score Table Used for Midazolam Dosing Validated Nonverbal Pain Score Table Used for Morphine Dosing

Capabilities Can follow new labs/vitals instantly Notify nurses instantly Can generate pages to physician automatically When protocol fails When issue needs special attention Meds, transfusions, etc. Orders are through conditional orders, or the order set can actually trigger new orders

Purpose Optimize patient care (organs per donor) Efficiency (collected data) Hours billed Pages generated Physician and nurse satisfaction with process

Methods Tracked critical care hours billed Tracked pages generated Tracked organs procured per donor Developed order sets Brain Dead Donation Donation after Cardiac Death EpicCare (Epic Systems Corporation, Verona, WI)

Organs Procured Per Donor

Critical Care Charges First Hour Milwaukee/Chicago 80th percentile 2010 $961 Madison 80th percentile 2010 $747 Subsequent Half Hour Milwaukee/Chicago $471 Madison $373 CMS is billed through OPO for brain dead patients, therefore, reducing the number of charges for these patients saves society money.

Order set #1 5.9 to 2.3 and 12 to 10. This orderset was for brain dead organ donors.

Learning Curve

Order Set #2 10 to 4.25 and 21 to 9. This orderset was for donation after cardiac death.

Project scope Single example in the neuro ICU Not designed to show patient outcomes Donation success rate Anecdotally patients donated more successfully with less crash donations.

Conclusions EMR can change your practice Use order sets to their full potential Applications to sepsis, ARDS, etc. Algorithms must be carefully vetted Time and money. EMR doesn’t sleep, doesn’t need time off.

Thank you