Ian Zunder & Bob Elliott Sept – Oct Update on SIMS

Talk Objectives 2 Highlight changes Pointers Identify common errors Review key concepts

What’s new myTOH has Preop Manager 3 Ward / ICU Consults

What’s new Cubicle Computer with “LIVE” SIMS Apps 4

What’s coming iPad – myTOH / vOacis 5

What’s coming? 6 ICU autologin machines vOACIS – new Census “Surgery patients for tomorrow” Will be able to review your cases in one spot rather than cutting MRN numbers from the OR schedule Lab Interface

Printout Changes 7

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9 Drug routes clearly identified Prefix (Reg) used for Regional drugs Combined Meds & Infusions denoted by “>>” Drug infusions in this section use RATE Drug infusions in this section use MASS per Time Column At this time, PICIS is not able to program the PrintOut so that Combined Infusions appear in the Infusion section with a RATE

10 Printout Changes The problem of Drug Infusion RATES green Until PICIS can fix the problem of Combo Infusions not showing up in the Printout as a RATE, we are going to use a PARTIAL work-around. Single Drug Infusions will revert to the original PICIS style as a FLUID (will appear OnScreen in green) Single Drug Infusion as COMBO Single Drug Infusion as FLUID

11 Printout Changes The problem of Drug Infusion RATES Single Drug Infusions: green will appear OnScreen in green as a FLUID can be selected in Protocols as before will appear in the PrintOut in the INFUSION section will appear as a RATE both OnScreen and in Print Combo Drug Infusions (2 or more drugs): will appear OnScreen in the MEDICATIONS section will appear OnScreen as a RATE will appear in the PrintOut in MEDICATIONS will appear in Print as MASS per Time Column (usually 5 min)

Printout Changes 12 Invasive pressures (in red) trended with non invasive pressures (same graph) Y-axis with BP incremental values of 20 rather than 40 (with grid on graph) SpO 2 values documented as number in addition to histogram scale

Printout Changes 13 Gravity fed fluid infusions documented as a fixed starting volume (not absolute fluid/time) Absolute fluid volumes displayed Better overall Fluid Summary

Printout Changes 14 FFP has had bag levelled to zero RBC paused – and levelled to zero To get the proper display in the Printout – use Pause when bag finished

Data Archiving Will be every minute by default Data is (currently): captured – q30secs displayed – currently q5min (NIBP is exception) archived (stored on server) – q5min Data will be: captured – q30secs displayed – q5min in table / q1min in graph archived – q1min Rationale: In a Critical Event, will you remember to use Emergency Data to insert q1min data into record for archiving? Probably not... 15

Data Archiving Will be every minute by default Will you see anything different on-screen? 16 Art Line shown with RT Interval 5 min Art Line shown with RT Interval 1 min RT Interval can be set by clicking this box

Tricks/Pointers Artifacts Artifacts are a common problem with Anesthesia Information Systems Whatever is on the monitor at the precise moment when the AIMS is checking, gets recorded You must be vigilant! Is an artifact in the graphical trend captured in the “ real time variables ” ? If “ YES ”, this will appear on the printed record If “ NO ”, this will NOT appear on the printed record 17

Artifacts How do you fix artifacts? Correct the variable Memo the artifact 18

Artifacts Correct the Variable Click on variable to be corrected 3. Use the Comment field to document “Artifact” 2. Input corrected value 4. Hit Enter button

Artifacts - Finding the Variable to Correct 20 At usual 5 min res, the artifact is seen on Graph but not in Table Switching to 1 min res, the artifact is now seen on both Graph & Table

Artifacts Memo the Artifact 21 If you encounter more than the odd artifact, (e.g. repeated electro- cautery interference) you will probably want to enter a formal Memo

Tricks/Pointers Labeling IV Lines Two IV lines running the same solution How do you keep track??? Label the line!! 22 Click on First IV Bag for this IV line Select alternate IV site from Drop-down Hover Pointer over IV Fluid to see IV Site

Tricks/Pointers Changing the Rate for a Combo Infusion 23 Change Pump Rate using the rate from your pump Switch from “Infusing” to “New Bag” Now you can edit Dose

Tricks/Pointers Eliminating White Space 24

Tricks/Pointers Eliminating White Space 25 1.Right Click over any point of the Variables Or on heading “Real-Time Variables” 2. Select the variables you want to remove 3. Hit Remove 4. Hit “ OK ”

Tricks/Pointers Eliminating White Space 26

Tricks/Pointers Finishing a Case before hitting the PACU Normal Procedure Transfer the patient off the local workstation in the OR In PACU, login to dedicated SIMS computer and locate the patient in Remote View Complete PACU handover Report Finish the Case and Print record Logout

Tricks/Pointers Finishing a Case before hitting the PACU Modified Procedure Initially skip the Transfer In the OR, document PACU handover Report and forward time the event In the OR, document a Finish time and forward time the event When the Print dialogue box appears, make sure that you forward time the “ End Time ” to capture the handover and the finish activity Transfer the patient Printout should be waiting for you on your arrival Can save time in high volume list

Anesthesia Manager Launching the Application 29 Wait until you see the eyes of the patient outside the OR A patient can only be active on 1 workstation at any given time If you “ start session ” on a patient NOT present outside the OR, this patient is not available to the nurses in the Preoperative area.

Anesthesia Manager Selecting a Patient – Starting a SESSION “ Start Session ” not available Patient can only be “ active ” on one machine Assume patient is active in Preop area until proven otherwise-how can you tell? 30

Anesthesia Manager Selecting a Patient – Starting a SESSION 31 “ Remote View ” - Investigate Look for GA (Transfer) Look for Event To OR in the log If patient is NOT in the Transfer zone, then contact Preop area If patient IS in the Transfer zone, technical problem, contact HELP Desk-SIMS technical pager

Anesthesia Manager Selecting a Patient - MOR Default List & Emergency Patients Patients on the Emergency List are initially NOT found on the Main Census List They are maintained on a “Waiting List” which we don’t have access to Ward Clerk (or Nurse) moves patient onto the Main Census List when called for the OR If you do NOT see your patient on the Main Census List, please ask whether the transfer from the Waiting List has occurred. 32

Anesthesia Manager Selecting a Patient - MOR Default List  Occasionally, patient is on the Census list but not under the expected OR CIVEM01, CIVEMO2, CIVEMO3  Scan the list – right to the bottom! 33 …OR - Sort the list by last name A Jon/Jane Doe will show up in a room as above using an alphanumeric name

Anesthesia Manager Selecting a Patient - Satellite Default Lists All workstations outside the Main OR (Civic or General Campus) have a generic pull down list (Lithotripsy at the Riv has a dedicated census) CIV Dental - Admitted Today CIV Endoscopy - Admitted Today CIV Labour and Delivery - Active Patients CIV Medical Imaging - Admitted Today CIVMOR Surgery patients – Today (This is the DEFAULT) CIVMOR Surgery patients - Tomorrow CIVMOR Transfer patients ZZZ SIMS Version A 34

Anesthesia Manager Finding a Patient - Using MRN # 35 Avoid unless absolutely necessary Use the patient encounter # to help select the correct SIMS session -Encounter number is 12 digits Look for a Surgery Date and/or Booking ID

Anesthesia Manager Launching the Application-Using MRN #  Encounter ID consists of a 12 digit number and One alphanumeric value 36

Anesthesia Manager Launching the Application-Using MRN # What happens if I pick the wrong SMS admission Anesthesia Manager won’t talk to OR Manager and the case will show up on a System Admin census as not being complete. What about Remote areas (Diagnostic Imaging/Endoscopy/Brachytherapy) These cases do NOT have a Booking ID Pick the most appropriate encounter/SMS admission This is usually the encounter at the top of the screen search Date you choose should match the day of the procedure 37

Anesthesia Manager Demographics-System Bug  Demographic Screen does not match the active patient Known bug All information entered into the system will be archived and printed CORRECTLY Exiting and re-starting Anesthesia Manager will resolve the problem. 38

Anesthesia Manager Demographics-System Bug It is OK to quit application/power down-unplug computer when a patient is ACTIVE on a local workstation All data is uploaded and archived on the server (cloud) in 5 minute increments (soon to be 1 min) Rebooting the computer/Re-launching Anesthesia Manager should bring up a text box identifying the patient active on the local machine and providing you with options 39

Anesthesia Manager Demographics-Remote Areas Demographics subsections are BLANK and need to be populated Labor and Delivery Dental Clinic Diagnostic Imaging Endoscopy Lithotripsy 40

Anesthesia Manager Demographics-Remote Area Procedure We are responsible for entering the procedure 41

Anesthesia Manager Demographics-Remote Area Procedure 42 All remote areas have cheat sheets Handful of keywords in any remote area will bring up the list of procedures “ Remote ” – important! “ Cysto ” “ Cesarean ” (not “Caesarean”)

Anesthesia Manager Demographics-Remote Area Procedure Hit “ Add ” 2. Enter keyword 3. Find Now 5. Hit “ Add ” 4. Select Procedure

Anesthesia Manager Demographics-Remote Area Medical Team  We are responsible for entering the medical team NO medical personnel (Anesthesia/Surgery) will be listed in Remote areas 44

Anesthesia Manager Demographics-Remote Area Medical Team All physicians practicing in remote areas will be listed in the pull down list Please inform a SIMS super user if a physician does NOT appear in the list 45

Macros Inserted into the program because of the lack of visual prompts typical of a paper record If followed, ensures (as best as possible) that important components of the record are NOT forgotten 46

Macros Very important to use the “ Start ” icon Places the important Start-Time stamp (event) on the anesthesia record (Can be done manually through Add Event – but why bother?) System Admin checking to make sure that certain prerequisite information is on the record 47

Macros You will be notified if “ Anesthesia Start Time ” is NOT documented IMPORTANT OHIP NOTE: Make sure you enter a Anesthesia Start Time that is the same as the Start Time you submit to OHIP 48

Macros Only use the Start Icon ONCE! Above example – 1 st click => incorrect Start Time of 21:20 entered 2 nd click => tried to correct Start Time to 21:15 End result => SIMS will use the chronologically LAST Start Time listed! Proper way to correct => EDIT the time by double-clicking or Use the Edit Button 49 Incorrect Start Time entered 1st Correct Start Time entered 2nd

Macros The events in this Event Set (A010) are to be used to provide proof that the physician has reviewed a formal Preoperative Assessment/Consult Previously done in Preoperative Manager-viewed in vOACIS) It does NOT replace a formal Preoperative Assessment 50

Macros Simply choosing events may not provide ample proof to having reviewed a Preoperative Assessment done by a colleague “ bullet points ” in the Comments section suggest that you have reviewed the Preoperative Assessment or had a discussion with the patient 51

Macros These macros put markers on the timeline (R, G, M) and indicate a “ Start-Flag ” in the log General Start Regional Start MAC Start Provide a reference point for future entry of comments/drugs They do NOT represent Anesthesia “ Start Time ” They do NOT enter a specific “ Anesthesia Type ” for you Reminder – Anesthesia Types start with: (G)_ or (R)_ or (C)_ or (M)_ 52

Macros You will be notified if “ Anesthesia Type ” is NOT documented. You should pick ONE-and-only-ONE Anesthesia Type! Admin reports will document if more that one type of “ Anesthesia Type ” (including duplicates) have been entered 53

Macros Don ’ t add events to the log using Macros if you have not performed the event Eg. “ End GA ” macro when a spinal anesthetic has been performed Eg. “ End GA ” macro when a patient is left intubated 54

Event Log Imperative that you check your event log at some point during every case Insure timeline makes sense Delete inaccurate entries 55

Protocols-Combined Medications 56 Extensive library of protocols, many of which contain combined medications and organized by: Major categories most commonly used Regional anesthesia drugs Alphabetical by “ Class ” For system purposes, a combination can contain 1-4 different drugs. Building in this fashion allows the drug to show up in both the “ medication ” and “ fluids ” part of the electronic record Combinations are primarily generic Bolus doses kept at 0 units Infusion doses kept at 0 units/hr Exceptions are the most commonly used combinations (eg. Fentanyl 250 ug/Lidocaine 200 mg) Exceptions are the most commonly used epidural/spinal concentrations (eg. Bupiviaine 0.25% + Morphine/Fentanyl)

Protocols-Combined Medications 57 Don’t even Double-Click

Protocols-Combined Medications 58 If this Box appears when choosing a Protocol, You are Editing the Protocol – CANCEL!

Protocols-Combined Medications 59 Do NOT enter ANYTHING!

SIMS Help 60 FUNCTIONAL ISSUES-Super Users (working hours only) Civic Campus Zunder Bryson Charapov General Campus Elliott Gagne Szeto TECHNICAL ISSUE-HelpDesk (14136) Password resets Network connectivity Printing problems Computer related issues