Be Prepared HED AND HEO/WIZ DOWNTIME

Saturday May 12, 2012 at 700pm Till approximately Sunday May 13, 2012 at 12 Noon Downtime for: Order Entry (HEO/WIZ), Nursing Documentation (HED), Nursing Med Administration System(Admin_Rx) Systems not down: StarPanel, Medipac, Accudose, Inpatient and ED Whiteboard. HED AND HEO/WIZ DOWNTIME

 Impact of the extended downtime  Roles and responsibilities – educator/unit leadership MR/AA and sss  Workflow/timelines – getting ready for downtime, processes during downtime, and recovery from downtime  Supplies/ Forms needed for downtime  Managing Admissions, Discharges and Transfers WHAT YOU’LL LEARN

 All orders will be written and processed manually  Look up orders prior to DT in starpanel  Use paper Physician Order Sheet (POS)  Use Transfer Order Sheet for transfers and as reference for orders prior to DT  All documentation will be on paper  Paper MAR  DT Flowsheets  OPC manually updated w/ orders IMPACT

 Admission Hx can be in starpanel but will not generate any orders ( immunizations,etc)  Accudose will be in override and only have order prior to DT  To recover from downtime any ongoing orders will need to be entered into HEO/WIZ  Pharmacy enters medications  Nurses enter non medications IMPACT

THIS IS A REALLY BIG DEAL Staff not familiar with manual processes for such an extended time. Many have not ever used manual forms and will need training BOTTOM LINE

Educator/ Unit Leadership Design & implement plan to educate/ re- educate nursing staff Assure MR scheduled for entire DT Review RN staffing for DT and recovery and schedule additional staff prn Touch base with all staff working during DT to assure they are knowledgeable AA/MR Order Supplies ( black pens, paper, POS, Home Care Instruction Sheets, labels) Print Forms from Edocs Stock DT kits- assure all unit specific flowsheets needed for extended dt are printed MR to attend MR training session CAPS/ SSS Resource to unit educator/leadership re: DT Preparation and DT Processes Assist with educations/ re- education Communicate w/ providers re: DT processes SSS Web site w/ resources needed Update Edoc DT forms ROLES & RESPONSIBILITIES

Computer Talk: Gettn’ Ready for Downtime Sessions Register in LMS Attendance is Mandatory for 1 MR and 1 Leadership person from each Unit  4/ VCH B319 & 407 Oxford house  5/ VCH B319  5/ in 407 Oxford house  5/ VCH B319 & 407 Oxford house  5/ VCH B319 & 407 Oxford house GETTN’ READY FOR DOWNTIME SESSIONS

 MR meetings  Staff meetings/ unit boards  Small groups  Charge nurse meeting  1 on 1 with those working the weekend  Posters  Share the powerpoint – feel free to use/ modify for your area EDUCATE OTHER STAFF

Weeks prior to dt: educate and get supplies Sat May 12 : Place on charts DT POS,, print labels, place DT desk Sat May : retrieve Phm generated MARS, print TOS place on chart, Print OPC Sat May HEO/WIZ, HED and Admin Rx Down- use DT processes. Sun May shift change: print OPC & update with orders since DT, initiate new DT flowsheets and Fall risk Flowsheet Sunday May 13 Noon- Recovery from Downtime- enter orders/ enter data in HED/Admin Rx TIMELINES

Replenish kit All kits should contain:  Laminated Downtime Checklist;  Physician Order Sheet (POS)- E-Procurement ORDER ASAP  Nursing Downtime Flowsheets- EDOCS (Appropriate to unit- gen care, ICU, ED for VUH and VCH, NICU, VPH;  Downtime Falls Flowsheet (revised 2012) EDOCS  Medication Administration Records (MARs)- EDOCS  Downtime Requisitions ( revised 2012)- EDOCS  VCH Patient Discharge Instructions (MC 4085); VUH Patient Discharge Instructions (MC 2418) COPY CENTER: ORDER ASAP  Braden Skin Risk Assessment Guidelines EDOCS Other documents that might be needed:  ICU Blood Gas DT Req ( new) EDOCS  Insulin Drip Downtime Guidelines ( new) EDOCS  Nurse Administered Heparin Drip Protocol ( new) EDOCS  Downtime Restraints Flow sheet EDOCS and policy – policy manual  Complex wound flowsheet  PCA/ Epidural Policies – Policy manual  Assessment Guidelines VUH and VCH EDOCS DOWNTIME KIT

 Order Copier Paper  Order Black Pins  Order Patient Labels  Increase Staffing PREPARING FOR DOWNTIME Place Phm Fax # on Fax Machine VUH – 7a-7p VUH – 7p-7a VCH – anytime – VPH – pharmacy rounds during day, VPH – 7p-7a – 31630

Early Day shift Saturday Morning For pts. not being discharged by 5p, Medical receptionist will  Place Physician Order Sheets (POS) in blue charts TWO per chart, with patient labels attached on all three pages, DO NOT ADDRESSOGRAPH  Print 2 Downtime Flowsheets for each patient place labels, DO NOT ADDRESSOGRAPH  Print 2 Fall Risk Assessments for each patient place labels DO NOT ADDRESSOGRAPH  Print 30 labels for each patient and place in chart  Print downtime reqs and place in convenient location at desk  Place black pens at nurses station PREPARING FOR DOWNTIME SAT MAY 12 DAY SHIFT

1700 Saturday  MR Checks printer to assure has paper ( paper MARS will be generated by pharmacy)  MR Retrieves MARs from designated printer & distribute. Prints to as follows: CCT on each unit, VUH on south side, VCH on B pods, MCN on each unit)  MR prints Diet List  MR prints “Overview of Patient Care” (OPC) and Transfer Order Sheet (TOS) & distributes  RN addresses outstanding Inpt Whiteboard (Inpt WB) indicators while information still current( VAP, Falls)  RN saves monitor/vent data to DAS before start of downtime. DAS will not receive data from these systems during the downtime so any values that need to be documented during this time will need to be manually entered on downtime forms.  For units that have centralized charts, MR place charts at patient rooms PREPARING FOR DOWNTIME SAT MAY

 Charge Nurse identifies all patients with restraints and contacts provider to renew orders for all pt with restraints  Charge Nurse identifies all pt with potential transfer or discharges and contacts provider to enter orders/ generate discharge letter before dt  RN documents Planned Priorities and Nursing Summary on all patients in HED  Night Shift WILL NOT do Priority Problems or Nursing Summary during downtime  RN transcribes cumulative Intake and Output for their shift on the 7p-7a downtime flowsheet  Ensure OPC and Transfer Order Sheet are printed (MR to Print) PREPARING FOR DOWNTIME SAT MAY

Orders  Provider/ RN writes orders on paper Physician Order Sheet and give to MR or RN for processing.  print & sign name, write pager # on all orders  1 set of orders per page  Use ONLY BLACK INK and press hard ( going thru 2 copies)  Any Verbal/ telephone orders require a read back to the provider and will require co- signature by provider  MR Alerts RN of any STAT orders  MR Fax copy of each POS to Pharmacy-  VUH – 7a-7p  VUH – 7p-7a  VCH – anytime –  VPH – pharmacy rounds during day,  VPH – 7p-7a –  If Scanning, MR scans POS  MR transcribes new, modified, & discontinued orders to the paper MAR  MR completes DT requisitions for labs, ancillary depts & blood bank (one requisition per dept) and calls to inform of order or sends order to ancillary department. Complete a DT req for future occurrences of ancillary orders that are scheduled during the downtime. DOWNTIME SAT MAY DOWNTIME BEGINS Downtime Orders

Orders ( cont)  MR updates Diet list with any diet orders  MR denotes “DT” next to ongoing orders that will need to be entered once the system comes back up  MR Pull out desk copy of written physician order sheet and places at nurses’ station to assist with tracking of orders during downtime – ie CXR in am, O2 at 2l/m, Albuterol treatment q6h  RN checks StarPanel e-MAR for previous med admin times & verifies schedules are correct on paper MAR  RN’s verify transcription is correct & signs MAR  For units with real time scanning: MR scans physician order sheet, highlights document and places back in the blue chart and place back at the patient bedside  RN writes new orders on OPC or for large number of orders can make copy of DT Physician order sheet DOWNTIME SAT MAY DOWNTIME BEGINS Downtime Orders

DOWNTIME SAT MAY DOWNTIME BEGINS Documentation RN/CP document interventions on manual flowsheets and Meds on paper MARs. (consider need for additional flowsheets for restraints, complex wounds etc and print from Edocs) For New Admissions, complete Nursing Admission History in Starpanel but RN writes a protocol order on the paper physician order sheet for any protocol generated flu and CPAP orders. Positive screens for ancillary departments will be communicated via ancillary dashboards and will not require an order.

MR Round at least Q4h during DT  Checks for any missed orders  Restocks with DT order sheets as needed 12Midnight –  MR assures printer is stocked with paper in prep for printing of next day’s MARS  MAR’s printed by pharmacy, MR place in Blue Charts, and Notify RN  RN compares and verified Sunday’s MAR with Sat’s MAR and makes any corrections. Alert Pharmacy to Downtime Downtime Downtime any schedule changes DOWNTIME NIGHT SHIFT SAT 5/12- SUN 5/13

Complete Admission Hx in Starpanel- write protocol order for pnuemovax of CPAP prn Make copy of admission orders since OPC will not have orders Admission Discharge Orders are written but prescriptions can be generated via RxStar in Starpanel Use Home Care Instruction sheet if patient letter is not generated or is incomplete Document discharge instruction in narrative portion of DT flow sheet Discharge Provider uses Transfer Order Sheet ( TOS) to denote transfer orders – lines thru any orders to discontinue, denotes modifications to orders and writes new orders on blank lines. Dates/times and signs TOS. MR faxes TOS to pharmacy and processes orders per DT procedures. Transfer ADMISSION/ DISCHARGES/ TRANSFERS SPECIAL CONSIDERATIONS

Orders  RN to enter in HEO/WIZ any ongoing non pharmacy orders  non-medication Pharmacy to enter in HEO/WIZ any ongoing pharmacy orders  PROVIDERS SHOULD NOT ENTER ANY ORDERS THAT WERE WRITTEN DURING DOWNTIME. This is to avoid duplication of orders.  Restraint Orders Renewed  Orders completed during downtime should not be entered in HEO/WIZ.  Providers to cosign on paper any verbal, telephone or protocol orders written on physician order sheets during downtime. Ongoing orders initiated during downtime will be entered in HEO/WIZ after downtime and can be electronically co-signed. Documentation  RN to enter in HED  Last set of vital signs  Documentation for foleys and IV inserted or discontinued and wounds initiated or ended  Downtime Start and Stop time on Asmnt/Interventn Tab  Cumulative Intake and Output for Saturday and Sunday  Example of Back time for Saturday’s Cumulative from paper flowsheet, (3/12/2012, 0645).  Will need to subtract what was charted from 7a-7p on 3/12 in HED from 24 hour cumulative from the paper flowsheet.  Sunday’s cumulative will be the current cumulative from the paper flowsheet  RN to confirm meds in Care Organizer using paper MAR- carefully checking schedules and informing Pharmacy of schedule changes via care organizer  In Admin Rx, RN notes overdues and document as “already given-see MAR” if administered & charted during DT RECOVERY FROM DOWNTIME (APPROXIMATELY NOON SUNDAY MAY 13)

 RN’s Continued  HED  Admin Rx, medications with outstanding schedule need to be addressed  Asmnt/Interventn Tab, document start of downtime and end of downtime.  RN Enters Cumulative Intake and Output for Saturday and Sunday  Example of Back time for Saturday’s Cumulative from paper flowsheet, (3/12/2012, 0645).  Will need to subtract what was charted from 7a-7p on 5/12 in HED from 24 hour cumulative from the paper flowsheet.  Sunday’s cumulative will be the current cumulative from the paper flowsheet.  Restraint Orders renewed  Priority Problems with goals back time to morning shift. Complete at end of shift Planned Priorities and Nursing Summary. WHAT TO DO AFTER DOWNTIME (APPROXIMATELY NOON SUNDAY MAY 13)

Approximately 1700 Sunday, MR’s will after HEO/HED have been up and stable for several hours.  Remove and Discard all unused downtime documents with patient labeled attached; place any unlabeled dt documents in DT kit.  Remove Transfer Order Sheets  For units with real time scanning, MR will scan documents in to EMR  Downtime flowsheets  Downtime POS (physician order sheets) that were missed  TOS (transfer order sheets) that were missed- may discard if no orders denoted on TOS  Re-locate charts per unit protocol back to location for scanning  to shredder and discard to shredder RECOVERY FROM DOWNTIME SUNDAY MAY

SSS will have staff on site making rounds prior to downtime Sat 5/12, during downtime and during recovery from downtime. Watch your fax machine for updates re: status of the downtime and for detailed instructions. Update will also be sent out via charge nurse pager and via the starpanel banner. Contact the Help Desk if help is needed. SUPPORT DURING DOWNTIME