1. Admission History Data Base Changes VCH 11/2 1p-3p Place B319 11/8 Tue 3p-5p B319 makeup 11/15 730-930 am B319 makeup

3.  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 11/29/11. What Why How

4. 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.

6. 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

7.  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

8. 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

9. 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

10. Adult Admission History patients <18 in VCH or VUH Pediatric Admission History Pulls data forward if prenatal care @ VUMC OB Will add Immunization screen but date TBD VPH Admission History

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

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

13. 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

14. Click to display ID of person collecting data

15. MANY EYES WILL SEE THE DATA

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

17. 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!)

18. I Critical for Safe Care 1-2 hours II Plan of Care 6-8 hours III Discharge Plan and Functional Screen 20-24 hours

20. 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

21. Legal Documents All permanent chart documents now scanned at discharge

22. New Present On Admission Screening Awareness is Key to Improved Communication Among Team Members

23. 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 Pressure Ulcers on admission will display on the PUPS dashboard but an orders will need to be entered in HEO/WIZ if WOC specialists needs to see the patient. 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.

24. 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 30-40 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.

25. 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.

26. Complete 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 The option to complete is only in section III.

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

29. If select “yes” smokes must select response regarding frequency

30. 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

31. The 2011-2012 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. 31  5% - 20% of population in US gets the flu  200,000 people are hospitalized from seasonal flu-related complications  between 1976 -2006, flu-associated deaths range from a low of about 3,000 to a high of about 49,000 people.

34. FUTURE: If selected that pt has had an immunization, it will automatically update the immunization record as a historical vaccine. Positive screens will result in an order for the flu vaccine being automatically generated in HEO/WIZ when the admission history is saved. The vaccine will be scheduled in Admin Rx with frequency of 1XBYRX and Pharmacist will administer. PCCU, heme/onc, ID, rheumatology and cardiology patients who qualify for the flu shot will have alert sent to a StarPanel worklist and be evaluated by the physician staff/clinical pharmacy. Had flu shot elsewhere= automatic update to immunization record + screen = automatic order in heo/wiz

35. In VCH, the Pharmacist will administer the vaccines and document administration in Admin Rx. 35 Care Organizer and Admin Rx will list the frequency for the vaccine as “ 1X by RX ” to indicate that the Pharmacist will administer. The pharmacist will bring medication instead of it being delivered. MAJOR CHANGE

37. Positive screen trigger notification to nutrition services via the dashboard II Plan of Care

38. Information will display on OPC and eventually feed Readmission screen and Patient Education and Engagement Record (PEER)

41. Physician will be notified of positive Functional screens as only providers may order Rehab evaluations in Tennessee Use the Complete button ONLY WHEN ALL THE DATA HAS BEEN COLLECTED.

42. 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

43. Not in nurses current workflow to verify Admission History is completed. Indicator on whiteboard should help

44. Even if past 24 hours, collect the data The data is important.

45. 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

46. Obstacles and Actions

47. “Nothing motivates more than success. We need to define and engineer visible performance improvement. “

48. 1. Discuss with leadership team and finalize training / support plans. 2.Conduct Training 3. Print and distribute practice scenario 4.Monitor practice by staff 5.Round during implementation 6.Post Debriefing flyer and encourage attendance

49. Web Based Resources SSS Web Site->Documentation updates->Admission History Data Base Changes http://www.mc.vanderbilt.edu/root/vumc.php?site=sss2&doc=33860 LMS Module- Title “Admission History Changes 2011” http://vanderbilt.mzinga.com/app/servlet/navigation

50. More Sessions like this one 11/8 Tue 3p-5p B319 makeup 11/15 730-930 am B319 makeup Implementation 11/29 Tue  SSS will make rounds  Call Help desk (3-3457) if need assistance Debriefing Sessions  Nov 29 th Tue 4-430pm – 5009 VCH  Nov 30 th Wed 2-230 pm – 5009 VCH  Dec 1 Thur 730-8am – 7011 VCH