Admission History Data Base Changes VUH 10/13, 17, 20/2011

 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

Unit Implementation plan template Copies of the policies Training Aides Video clip Practice scenario Training patients name and MRN LMS module FAQ on SSS web site Debriefings- 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.

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

 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. L ee, 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 (1 st 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.) HITECH

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

Adult Admission History patients <18 in VCH or VUH Pediatric Admission History Pulls data forward if prenatal 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

Some Items Removed Some Items Added Immunizations CPAP and medication pumps Changes to Tobacco Screen Past medical surgical history Shortened Screenings Religion

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

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

Click to display ID of person collecting data

MANY EYES WILL SEE THE DATA

Link to view Eventually imported into HED Team Summary, Resident Handover OPC, Charge Nurse Worksheet Readmission Risk Scale (in development)

AdmTx 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!)

I Critical for Safe Care 1-2 hours II Plan of Care 6-8 hours III Discharge Plan and Functional Screen hours

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

Legal Documents All permanent chart documents now scanned at discharge

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 Know Patients 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 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 Draft Saves 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 Final Saves 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

Past Medical & Surgical History Physician responsibility to enter and link displays in Admission History

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

The 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. 32  5% - 20% of population in US gets the flu  200,000 people are hospitalized from seasonal flu-related complications  between , flu-associated deaths range from a low of about 3,000 to a high of about 49,000 people.

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. 33 In 2007  1.2 million hospitalized  52,000 people died from the disease VUMC Admitted with diagnosis of Pneumonia (community or hospital acquired) Of those, 750 patients were readmitted within 30 days with a pneumonia related condition.

Indications 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 37 See why decision support is needed within the Admission History?

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

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 39

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) II Plan of Care

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

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

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.

Notification 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. “

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

Web Based Resources SSS Web Site->Education for Staff->General Tutorials LMS Module (ready by 10/31) Title “Admission History Changes 2011”

More Sessions like this one  10/17 Mon 1-3pm 407 Oxford House- makeup  10/20 thur Oxford House- makeup Implementation 11/15 Tue  SSS will make rounds  Call Help desk (3-3457) if need assistance Debriefing Sessions  Nov am CVICU conference room  Nov am 11 North conference room  Nov 18 12noon North conf room