Download Nursing Documentation Framework

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.
Why
What
How
SSS
• Provide education for unit
leadership
• Resource for unit
• Provider training
resources for units
• Round during
implementation
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
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
TOO LONG!
Nurses “live” in
HED – can’t we
put this in
HED???
No reminders
if not finished
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
Redundant information
collection- Patient
complained they have
already answered these
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
No one looks at it! This is just a
waste of time







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





Work began May 2011
Spencer & Blair
Anderson
VUH Op. Svcs. –
Cathy A. Lee, 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)
Collect data once and pass to
all systems and users who
need to view
Collect data by time it will
be needed
Minimize data collection
during critical stabilization
period (1st 1-2 hrs.)
Meet minimum
regulatory
requirements
HITECH
Optimum workflow
process associated
with admission
phase of care (up to
24 hrs. max.)
DATA
Amount of scrolling up and down and back and forth to
see data and what was incomplete was impossible
Future: Admit History data imported into HED
Adult Admission History
Pediatric Admission History
• patients <18 in VCH or VUH
OB
• Pulls data forward if prenatal care @ VUMC
VPH Admission History
• Will add Immunization screen but date TBD
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
Religion
Changes to
Tobacco Screen
Shortened
Screenings
CPAP and
medication pumps
Past medical
surgical history
Immunizations
Auto generated orders and
alerts eliminate need for
nurse to enter some
orders in HEO/WIZ
Data displayed on
OPC, Team
Summary, Ancillary
Dashboards
Religion, tobacco status,
and other information,
stored and retrieved on
subsequent admissions
Positive Social
Work screen
generates Social
Work notification
Immunization screen
generates order for
vaccine and scheduled
for 10am next morning
Click to display ID of person
collecting data
MANY EYES WILL
SEE THE DATA
OPC, Charge Nurse Worksheet
Link to view
Team Summary, Resident Handover
Readmission Risk Scale
(in development)
Eventually imported into HED
Adm
Hover over indicator to see what
Admission requirement is not yet
completed (ie section 1,2,3)
Tx
Dischg
= 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
• 20-24 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
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.
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
Leaving a question blank or
selecting “Unable to complete”
triggers indicators on the inpatient
whiteboard.
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
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
Global Immunization
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.
Influenza
 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.
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.
Flu season October till March 1
and everyone six months and older
should get vaccinated.
32
In 2007
 1.2 million hospitalized
52,000 people died from the disease
VUMC 2010
3000Admitted with diagnosis of Pneumonia (community
or hospital acquired)
Wikimedia Commons.
Of those, 750 patients were readmitted within 30 days
with a pneumonia related condition.
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.
33
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
See why decision
support is needed
within the Admission
History?
37
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
II
Plan of Care
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)
Physician will be
notified of positive
Functional screens as
only providers may
order Rehab
evaluations in
Tennessee
Section
2
Section
1
Section
3
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.
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
http://www.mc.vanderbilt.edu/root/vumc.php?site=sss2
LMS Module (ready by 10/31) Title “Admission History Changes 2011”
http://vanderbilt.mzinga.com/app/servlet/navigation
More Sessions like this one
 10/17 Mon 1-3pm 407 Oxford Housemakeup
 10/20 thur 1130-130 407 Oxford Housemakeup
Implementation 11/15 Tue
 SSS will make rounds
 Call Help desk (3-3457) if need assistance
Debriefing Sessions
 Nov 16 730-8am CVICU conference room
 Nov 17 730-8am 11 North conference room
 Nov 18 12noon -1230 11 North conf room