1. 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

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

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

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

5. 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 ; 32(2): 246–255. doi: /BCR.0b013e31820aaebf

6. The Team Neurocritical Care Physician Nursing Respiratory Care
Pharmacy
Hospital IT

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

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

9. Protocols – BDD Lung Protective

10. Protocols – DCD Lung Protective

11. Protocols – Vasoactive Algorithm

12. 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

13. 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

14. 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.

15. 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

16. Protocols – Pain and agitation management

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

18. 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

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

20. 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)

21. Organs Procured Per Donor

22. 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.

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

24. Learning Curve

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

26. 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.

27. 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.

28. Thank you