McKesson Upgrade - ER 11/12 What is ER 11/12? October, 2013 ER is “Enterprise Release” and 11/12 is the software version. This release will upgrade many parts of the McKesson software used in iCare EMR documentation. A few of these changes will impact the user while others will not be seen. Many of the changes in this upgrade support our efforts to meet the “meaningful use” guidelines. Remember meaningful use goals include using data in meaningful ways to promote overall patient safety and quality across the continuum of care.

eMAR, IV ADMINISTRATION, and IV INTAKE DOCUMENTATION Education related to the ER 11/12 upgrade has been broken into modules. You may be assigned more than one of these modules in HealthStream. This module is related to changes in eMAR, IV ADMINISTRATION, and IV INTAKE DOCUMENTATION

This section is related to changes in eMAR

Electronic MAR (eMAR) The Electronic MAR (eMAR) is a “read only” view that can be accessed through “Clinical Apps” The eMAR gives the ability to view: Medications (unchanged), IV fluids and medicated IV Drips (upgraded). Administered, Not Administered, Due, Overdue and Due in the Future medications. Medication details by hovering over the medication. Clicking on administrations will take you directly to HED and the Vitals/Meds/IO tab to administer medications. The eMAR can be utilized during hand off communication/report and is a quick and easily readable view of the patient’s Medication Administration Record. Go to Clinical Apps Electronic MAR

Electronic MAR (eMAR) REMEMBER: this is the new “read only” view of medications, IV fluids and medicated IV drips Continue on for a closer look

Click on the Legend tab for an explanation of symbols Electronic MAR (eMAR) Click on the Legend tab for an explanation of symbols

Electronic MAR (eMAR) Quick View: # of Active, Confirmed / Not Confirmed, Overdue and Due Medications Defaults to a 12 hr. view but can be modified Previous Overdue Due Due in the Future Not Given Blue line represents the current time Last Dose

Medication order information Electronic MAR (eMAR) This medication has one dose that still needs to be confirmed, one overdue dose, one dose due Current Time Medication order information

Electronic MAR (eMAR) Medication location can be viewed in the order information Hovering over any blue button (administration time) will give you more detail Clicking on the blue button will take you to the Vitals/Meds/IO tab in HED Click these buttons to scroll forward and backward through the eMAR

Electronic MAR (eMAR) Administration bubble (enlarged view): shows date and time of administration Clicking on the bubble will take you to HED  Vitals/Meds/IO tab.

Hovering over the administration bubble opens up a detail box Electronic MAR (eMAR) Hovering over the administration bubble opens up a detail box

Electronic MAR (eMAR) Dotted line = IV fluid/medication is assumed to be running based on last charting * This dotted line should not be visible! It indicates that the IV fluid/medication has not been addressed * To review IV fluids, scroll down. This will be your view. Rate at which IV medication is running IV Stopped Solid line = IV fluid/medication is running IV Started

This section is related to changes in IV Administration

IV Administration The most noticeable change: “IV Admin” will no longer be used for IV Documentation IV Administration will now be done through HED  Vitals/Meds/IO tab  IV fluids The next few slides will show basic IV fluid administration. The patient has IV fluid ordered: Normal Saline at 40 ml/hr. Obtain the Normal Saline bag and tubing and enter the patient’s room. Let’s hang the primary IV fluid. 

STEPS FOR BASIC IV ADMINISTRATION Scan the patient’s wristband to ensure that documentation of the IV administration is completed on the correct patient. Click on “Chart”, “Launch HED” and the “Vitals/Meds/IO” tab. Scan the IV fluid barcode. Launch HED and the Vitals/Meds/IO tab IV fluids are now administered here. Review the rate and select a site

Review the Physician order in HEO and program the IV Pump. If everything is correct, scan the patient and then scan yourself. Enter patient identifier per hospital policy. Be sure to program the IV bag as a primary infusion in the Alaris pump. This is very important for accurate I&O which will be discussed later in this module.

0 = Volume infused S= Started The IV administration is recorded in HED  Vitals/Meds/IO tab  IV fluids 0 = Volume infused S= Started

Administering a Medicated Drip Medicated drips are now documented in HED  Vitals/Meds/IO tab  IV Med Drips STEPS FOR ADMINISTERING A MEDICATED DRIP The patient has an order for a Dopamine drip. Scan the patient’s wristband to ensure that documentation of the IV administration is completed on the correct patient. Click on “Chart”, “Launch HED” and the “Vitals/Meds/IO” tab. Scan the medicated IV fluid barcode.

Steps to finish the administration documentation Medicated drips are now administered here Review/enter the rate or dose and select a site When administering weight based medications, if the patient’s documented weight changes, the system will automatically recalculate the rate accordingly Launch HED and the Vitals/Meds/IO tab 12.75 Steps to finish the administration documentation Review the administration detail. If everything is correct, scan your patient and then scan yourself.

Record Med Drips When infusing a Medicated Drip, there is now a “Record Med Drips” button. This feature will assist you with documenting the current Medicated Drip rate. Under IV Fluids, click “Admin”. Review the rate and if correct click “Record Med Drips” button. The IV rate will be documented. Goes automatically to the Review Screen. Scan yourself. You can record/document the rate at which your drip is running by using the “Record Med Drips” button Record Med Drips

The rate is then charted under IV Med Drips for that time.

Proper documentation of IV solutions allows ProMedica to receive higher levels of reimbursement for provision of care. The Upgrade makes it much easier to document completely on all IV infusions: Begin time will continue to be automatically entered when solution is scanned. Documentation must now show the “end time” for the IV and IVPB infusions. Whenever a new bag is hung, always be sure that all previous bags have been “ended” in the documentation. By not “ending” a solution, the documentation looks as if the administration of that fluid has never ended. IV solutions will now show up on the Care Organizer with the Medications so it will be much easier to recognize a bag that needs to be ended.

IV INTAKE DOCUMENTATION This section is related to changes in IV INTAKE DOCUMENTATION

Think about IV Intake in TWO DIFFERENT ways Secondary solutions Primary solutions Intermittent solutions (IVPB) will not be documented from pump volumes. There are TWO ways to document secondary solutions INTAKE. Premixed solutions from Pharmacy have a patient specific label that includes information on rate and volume. These will SCAN into the system and will “AUTO-POPULATE” the intake documentation. Intake from ADD-Vantage and Mini-Bag Plus solutions must be manually entered into the Intake documentation fields. Plain and Medicated Solutions infused as Primary solutions on the Alaris Pumps will continue to be documented by the nurse as a manual entry. It will be VERY important to CLEAR the pump each time a volume reading is recorded.

Administering a Pre-Mixed IVPB When administering any IVPB’s a START and STOP time MUST be charted.    STEPS FOR PRE-MIXED IVPB ADMINISTRATION: An order has been entered for Cefazolin 2gm IVPB every 8 hours. Scan the patient’s wristband to ensure that documentation of the IV administration is completed on the correct patient. Click on “Chart”  Launch HED  “Vitals/Meds/IO” tab. Scan the med. (This process is continued on the next few slides.)

REMEMBER: Program the IVPB medication as a secondary infusion in the Alaris pump Infusing an IVPB as a secondary solution will keep the IVPB volume out of the total volume for the primary solution. IF infusing an IVPB as a primary solution, this volume MUST be subtracted from the total primary infusion volume when I&O’s are completed.

A volume and projected end time will auto populate The Projected End Time and Volume only auto populates for premixed IVPB’s and IVPB’s prepared by Pharmacy A volume and projected end time will auto populate STEPS TO FINISH THE ADMINISTRATION PROCESS: Scan your patient again. Review the administration. If correct, scan yourself.

The IVPB administration is recorded in HED  Vitals/Meds/IO tab  All Meds The slide below depicts the IVPB Medication administration status as “In Progress”. Administration status is “In Progress” when in review mode under “All Meds”

It is REQUIRED for reimbursement to “end” the antibiotic administration in the “All Meds” Section when the IVPB solution has infused. Scan the patient to verify charting is on the correct patient. Choose HED  Vitals/Meds/IO tab  All Meds  Admin. Select the “In Progress” IVPB that needs “ended”. Click end Verify the correct fluid volume The projected end time will populate, not the charting time Review for accuracy before saving Click end and edit the date and time as needed. Scan yourself to save the ended IVPB administration.

The volume for IVPB’s that are diluted by pharmacy or premixed will automatically be recorded in the I & O section After IVPB is “ended”: The IVPB’s status is no longer “In Progress” and The fluid volume has been recorded under intake

When administering any IVPB’s Administering an IVPB reconstituted by the Nurse: ADD-Vantage and Mini Bag Plus When administering any IVPB’s a START and STOP time MUST be charted.    STEPS FOR ADD-VANTAGE AND MINI BAG PLUS IVPB ADMINISTRATION: An order has been entered for Piperacillin 2.25gm IVPB over 4 hours. Scan the patient’s wristband to ensure that documentation of the IV administration is completed on the correct patient. Click on “Chart”  Launch HED  “Vitals/Meds/IO” tab. Scan the med. (This process is continued on the next few slides.)

REMEMBER: Program the IVPB medication as a secondary infusion in the Alaris pump Infusing an IVPB as a secondary solution will keep the IVPB volume out of the total volume for the primary solution. IF infusing an IVPB as a primary solution, this volume MUST be subtracted from the total primary infusion volume when I&O’s are completed.

***IMPORTANT*** The Volume does not auto-populate for ADD-Vantage and Mini Bag Plus. Projected End Time may auto-populate. ***IMPORTANT*** IVPB medications that are reconstituted by the nurse (i.e. ADD-Vantage vials, Mini Bag Plus) will NOT auto populate volumes (and in some cases projected end times) **Important** AGAIN: No Volume will be present here and a projected end time may also not be present Add volume here at the time of administration

Failure to enter the volume infused will trigger an override prompt: If no volume is entered an override reason is required

Ending an ADD-Vantage or Mini Bag Plus DO NOT alter this field!! Doing so will change your medication dose!!! Click End Edit the date and time as needed Scan yourself to save the end time

Interrupted IVPB Administrations The patient’s IV becomes infiltrated during IVPB administration. It takes 1 hour to get a new IV started, making the administration end time 1 hour later than projected. Charting must reflect the accurate infusion end time, but must also reflect the delay of one hour. Mark as significant so that reviewers are alerted to delay infusion. Verify the end time is correct Enter a sticky note explaining the delay when ending the infusion

Zero Order IVPB’s Administering medications before they are profiled by pharmacy is highly discouraged, but necessary in emergency situations or in certain units or facilities. These medications may not include volumes and will never include a projected end time. Zero orders will not have projected end times and may or may not include volumes

Primary IV solution intake is now entered in HED  Vitals/Meds/IO tab  IV Fluids  Admin

Intake Documentation of an Infusing Solution Check the IV pump for primary volume. Press Volume infused. Press PRI/SEC Volume button. 300 300 Make sure to clear the pump EVERY TIME you enter I&Os.

Enter the primary volume from your pump. Click Save. Do Not Use “Calc” button! This is an anticipated volume and is not accurate Use ONLY the pump volume Enter the primary volume from your pump. Click Save. If everything is correct, scan yourself. Enter the amount of primary fluid from the pump Once entered the remaining volume will calculate automatically

There is an order to end the Normal Saline IV Open IV Fluids Administration by going to HED  Vitals/Meds/IO IV fluids Admin. Enter Volume infused from the pump. Don’t forget to clear the pump EVERY TIME IV intake is entered.

Ending a Primary solution  Intake Documentation Change Hanging to Ended. Click Save and then scan yourself if everything is correct. The bag will be charted as Ended and the entered “volume infused” will automatically be recorded into Intake. Don’t double enter. 300 = Volume E = Ended

To Summarize: Proper documentation of IV and IVPB qualifies for higher reimbursement rates. Do not forget: The eMAR is a read-only view that provides important information during hand-off communication. IV Admin will no longer be used for IV Documentation. Premixed and pharmacy IVPB will auto populate with projected end time and volume infused amount, whereas Add-Vantage and Mini Bag Plus will not. IF infusing an IVPB as a primary solution, this volume MUST be subtracted from the total primary infusion volume when I&O’s are completed. When ending an IV infusion, click on the “end” box prior to hanging a new IV. Clearing the IV pump helps ensure complete and accurate I & O.

Thank you for the great care you provide our patients every day! Please direct questions regarding the McKesson Enterprise Release 11/12 Upgrade to your facility’s Hospital IT Support. This education was created in collaboration with Clinical IT, Nursing Leadership, and the ProMedica Center of Nursing Excellence in support of the ProMedica System-Wide Standardization Initiative.