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ICD-10 Impact on the ED Process Flow Catholic Health East performed a gap analysis to determine what processes and workflows would be disrupted by the ICD-10 conversion. For instance, the following analysis evaluates risk in the ED process flow. Impact Ranking Level Definitions Minor Impact (Green) Potential for little or no measurable impact to cost and/or schedule of the project Medium Impact (Yellow) Potential for moderate cost and/or schedule increases to the project High Impact (Red) Potential for significant cost and/or schedule increases to the project Risk Ranking Level Definitions Minor Impact (Green) Potential for minimal or routine modifications to the process Medium Impact (Yellow) Potential for moderate modifications to the process High Impact (Red) Potential for significant modifications to the process (work disruption) Cost Ranking Level Definitions Minor Impact (Green) No Costs Medium Impact (Yellow) Cost between $1 and $1,000 High Impact (Red) Cost > $1,000 1 Overall Process Rank for Emergency Department (ED) Patient Flow: High (Red Level) Process Flow Pre-Arrival Patient Patient Arrival Department Function ICD-10 Impact? Impact Risk Cost Medium Medium Minor Yes Medium Medium Medium Yes High Medium High Nursing Receives phone call from sending party— nursing home, other acute facility, EMS Yes Nursing Plans patient location: room set-up No Nursing Patient arrives and is placed in bay -Triage assessment performed, including triage level on triage form. -Med reconciliation initiated – complete home med history form -Notifies physician orally of high-priority patient to be seen ED Registration Receives triage form from nursing, patient registered from triage form data and bedside interview. -Patient signature(s) obtained -Documents scanned into document repository -Labels and armband printed and placed on patient Nursing Initiates order entry - All orders are STAT one time -Protocol orders 2 -Convenience order sets ED Physician Checks board for next patient to be seen based on triage level No ED Physician Reviews home med history form No ED Physician Writes orders on preprinted order set form or blank order form. No -Red sticker on chart to indicate orders to be entered into health information system (HIS) Unit Clerk Enters diagnostic orders into HIS based on physician order sheet Yes High Medium High Medium Medium Medium -Lab, radiology, respiratory, cardiology -Lab labels (yellow) print from laboratory information system when order placed in the HIS -Physician consults: entered in the HIS and phone call to physician for notification of consult -Social services, pastoral care: orders communicated to departments by phone call, not entered in the HIS Nursing Performs labs, EKGs, and respiratory tests as ordered No Nursing Med orders Yes - Medications pulled from the medication management system and ED chart used for 3 charting - Medications not in the medication management system require med order form to be sent to pharmacy via the automated medication management system for pharmacy to dispense Radiology CT scans Yes Medium Low Medium - .Faxes “stat reading” results to ED Ultrasound – Results placed on ED chart ED Physician First reading of X-rays Yes Medium Low Medium ED Physician Evaluates patient, results, and observations Yes High Medium High Determines patient disposition: -Patient to be released from ED -Patient admitted for inpatient care (main hospital or St. James) -Patient admitted to observation -Patient transferred to another facility -Patient transferred to cath lab -Patient transferred to surgery Transfer to Cath Lab Nursing Call “Code 90” upon arrival No -Code 90 alerts cardiology and other team members of patient needing cath lab 4 services. -Code 90 must be completed within 90 minutes. Cardiology Physician Evaluates patient for disposition Yes High Medium High -Move to cath lab -Remain in ED Nursing Notifies admissions to transfer patient to cath lab No Admissions Upgrades ED registration to active inpatient Yes High Medium High High Medium High -Place patient in bed Transfer to Surgery Surgeon Notifies OR of need to schedule patient for surgery Yes Surgery Notifies ED to transfer patient to surgical area No Nursing Notifies admissions to transfer patient to OR No Admissions Upgrades ED registration to active inpatient Yes High Medium High Yes Medium Medium Medium -Place patient in bed Transfer to Observation Service Nursing Notifies admissions to transfer patient to observation service - Fax admit order sheet 5 Admissions Revises ET registration to observation (OBV) hospital service code and patient type = 0 No -Assigns patient to bed: Observation patients can be assigned to unoccupied beds on the nursing floor, express admission unit, or ED overflow bed Unit Clerk Converts patient chart from blue to red/white chart No Nursing Records hourly status updates on observation flowsheet No -If patient reaches 20 hours of observation, nursing contacts physician to determine disposition Physician Determines patient disposition Yes High Medium High Yes High Medium High Yes Medium Medium Medium Yes Medium Low Medium -Release patient -Admit patient as inpatient Admit Patient to Active Inpatient Patient Released from ED Nursing Provides discharge instructions to patient -Instructions for ED patients generated from the ED electronic health record -Instructions for ED/observation patients use hospital manual form ED Physician Completes med reconciliation form and provides to patient 6 -Prescriptions provided to patient (if needed) ED Charge Entry (Billing) Nursing Provides copy of ED forms to ED billing Yes Medium Medium Medium Nursing Updates ED log for patient release No ED Registration Upgrades ED registration Yes High Medium High ED Billing Abstracts chart to identify procedures/supplies for ED services Yes High High High ED Billing Selects procedures from ED screens Yes High High High -Procedures have weighted value -Values calculated to determine final Level of care -Level of care total linked to appropriate charge code (CDM) -Supply charges entered in the HIS ED Diagnosis/Procedure Coding ED Billing Sends copy of ED form to medical records Yes Medium Medium Medium Medical Records Enters diagnosis/procedure codes Yes High High High Source: Catholic Health East. 7