Steph Hoelscher

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Changes To NICU Blood Orders

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The NICU blood orders listed below will no longer have the Lab Alert or Override Reason Form pop-ups when the orders are placed and the patient is in the NICU. The change was requested by the NICU because the Lab Alert and Override Reasons do not apply to the patient population within the NICU. The order has been updated to require a reason for administration of the blood product.

 

Example – No alerts because the patient is in the NICU location.

New required field – Reason for Cryo Order with NICU specific options.

When the orders are placed and the patient is outside the NICU the Lab Alert and Override Reason Form pop-up will continue to open as they do today.

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Additional Significant Events Component Update

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An additional line has been added to the Additional Significant Events component. The component will now notify you if a new admission has been created within 30 days of the previous one.

Current workflow allowed for an alert based only off the EC Readmit Alert/Order. It tracked only potential 30-day readmit Medicare patients.

This new line will appear any time there is a readmit within 30 days regardless of Medicare or the EC Readmit Order.

New Order/Update to Fall Policy

Attention Providers:  New Order/Update to the Fall Policy

The UMC fall policy has been updated to state that “any patient that is a high fall risk and is requesting to leave the unit, must have a provider order on the chart and they must be accompanied by a family member or caregiver”.

Due to this change a new order has been created to be used in this situation and is available now.

The order name is “patient may leave Unit/Floor accompanied by family/caregiver”.

The easiest way to search for this order is by typing in “patient may” in the orders search bar.

Social History Control & PowerNotes - Update

The issues identified earlier this week regarding the new Social History Control data not being able to be pulled into PowerNotes has been updated. The notes and the control were not "broken", but Cerner no longer supports this type of documentation, so there was no existing way to accomplish populating the notes with the nursing documentation.

The clinical PowerChart teams worked to find a better solution this week. As of this morning, there are serveral popular PowerNotes that have had a new template added to the Histories section.

To amend your existing notes to include this (including any precompleted notes), when you are offered the Auto Populate option upon opening a new note, you will have to check the box shown below for each note template you use (one time only):

 

 

 

 

All PowerNotes will have the new template added shortly, but this effort takes time due to the amount of notes that need to be modified. In the mean time, if you have a note that does not yet have the new template, the following is instructions as to how you can manually add the same template wherever you want within your note.

Click a "white" spot in between categories within your note, such as by the Histories section as shown below. Then select the "insert template" icon in the toolbar. If there is Social History nursing documenation already completed, it will now be pulled where your cursor is located. The template you are looking for is called "Social History Control."

 

 

 

Social History Control - Provider Information

This is an update in regards to calls surrounding the new Social History Control that underwent its required installation Monday, July 16th.

Due to Cerner's trajectory towards Dynamic Documentation and no longer truly supporting PowerNotes, this new Social History control has not been integrated into PowerNotes. There is no current existing functionality to pull any Social History nursing documentation data into PowerNotes, and it is not on Cerner’s roadmap to do so.

At this time, PowerChart teams are investigating any other possible options, and we will update clinicians if anything is discovered. Until then, any social history information will be the responsibility of the provider to transcribe or free text that data into their note.

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Radiology: New Central Line Placement Orders

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FYI:

Central line placements performed in Special Procedures will now be more clinically orientated. By searching “SP CVL” in Powerchart, new orders can easily be found. See below:

  • o   SP CVL Non-Tunneled Cath Placement
  • o   SP CVL HD Non-Tunneled Cath Placement
  • o   SP CVL Tunneled Cath Placement
  • o   SP CVL Tunneled HD Cath Placement
  • o   SP CVL Trifusion Cath Placement
  • o   SP CVL Portacatheter Placement
  • o   SP CVL PICC Placement < 5 yo
  • o   SP CVL PICC Placement
  • o   SP CVL Portacth Repair
  • o   SP Central Line Placement
  • o   SP CVL Tunneled Replacement
  • o   SP CVL PICC Replacement
  • o   SP CVL Tunneled Cath Removal
  • o   SP CVL Portacath Removal
  • o   SP CVL Portacath Stripping
  • o   SP CVL Cath Reposition

Medication Modification: Route and Dosage Form Lock

Route and Dosage Form Lock on Modification

Why:

In an effort to decrease potential medication errors and increase scanning compliance rates, Use and Standards approved locking the route and drug form fields when an order is modified.

When: 06-27-2018

After Lock on Modify

Initial order – the route and drug form are able to be changed

 

When ‘Modify’ is selected on a previously entered order the Route and Drug Form are not able to be changed.

Instead of ‘Modify’ right click and select ‘Cancel/Reorder’

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Infectious Disease Documentation and Alert Updates

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TLTR: On July 30th there will be an update to the current infectious disease nursing intake screening. It will include an expansion of the current Ebola and Zika alerts as well as integration of Tuberculosis, Yellow Fever, and Measles as well as the ability to assess outbreaks within the United States.

Infectious Disease Documentation and Alert Updates

After a systematic assessment of workflow and clinical decision support (CDS) related to infectious diseases documentation in PowerChart, it was found that an enhancement was needed. This enhancement includes updating existing nurse intake documentation and development of new alerts for nursing staff and providers. It was developed with several goals in mind:

  • ·         Improving patient AND staff safety
  • ·         Preparation for emerging AND re-emerging infectious diseases (i.e., the recent resurgence   
  •           of Ebola)
  • ·         Preparation for contagious diseases re-emerging within the United States (i.e., Measles and
  •           Mumps due to anti-vaccination movement)
  • ·         Standardize forms between inpatient and outpatient

To prepare, as well as to align ourselves with the national Centers for Disease Control and Prevention (CDC) initiative (CDC, 2018), we had round-table discussions with subject matter experts and selected several disease processes found to be either underdeveloped or non-existent in the system that needed the highest attention:

  • ·         Ebola (exists, undergoing update)
  • ·         Zika (exists, undergoing update)
  • ·         Yellow Fever (new build)
  • ·         Tuberculosis (enhanced build)
  •           MERS (new build)
  • ·         Measles (new build)

The existing PowerForm, Infectious Disease Screen, has been updated to aid in easing the transition for the nursing staff. It is the same form currently used, only with upgrades and modifications.

As of July 30, 2018, if applicable algorithms are met, an alert will be fired for Ebola and Zika (already exists), as well as Yellow Fever, Tuberculosis, and Measles and MERS (new). Other disease processes will be added later as the need arises or by subject matter expert request.

Continue to rely also on your clinical critical thinking skills when working with potentially infectious patients; always follow your institutional protocol. Clinical decision support provides guidance, but your clinical expertise will aid in whether the situation calls for further action or not.

 

 

References

Centers for Disease Control and Prevention. (2018). Adapting clinical guidelines for the digital age. Retrieved from https://www.cdc.gov/ophss/WhatWeDoACG.html

Centers for Disease Control and Prevention. (2018). CDC travelers’ health, 2018. Retrieved from https://www.cdc.gov/ncezid/index.html

Infectious Disease Intake Updates

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Deceased Patient Alert

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Beginning May 8th, when end users attempt to place orders on patients that are marked as ’Deceased’ in the banner Bar, they will receive an alert preventing them from signing the order.

If an end user misses the banner bar message, and place an order a deceased patient, after they click Sign on the order they will receive a prompt stating that the patient has been identified as Deceased and the order will be cancelled.


SmartZone: Alerts for Antimicrobial Stewardship

SmartZone: a decision support tool for clinicians that provides referential information and non-critical notifications in a manner that does not disrupt your workflow, allowing you to view these patient-relevant items and take action on them as needed.

Alerts for Antimicrobial Stewardship Program:

Susceptibility results available (shown above): This alert will populate in SmartZone as an information-only alert when a new susceptibility result is available in the Microbiology Viewer in PowerChart.

Level II Restricted Antibiotic Active for at least 48 hours: This alert will show in SmartZone at 48 hours after the initial administration of a Level II antibiotic if there is no gap in therapy of greater than 28 hours. The alert below will state the name of the antibiotic that meets the criteria instead of just saying “Level II antibiotic.”

 

Level II Restricted Antibiotic Active for 72 hours: This alert will pop up in PowerChart when the provider attempts to close the chart if the patient has had a Level II antibiotic active for 72 hours after the initial administration if there is no gap in therapy of greater than 28 hours. A consult order will fire to pharmacy after the medication administration documentation at 72 hours so that pharmacy can evaluate the antibiotic therapies as well.

If they click the “Document” button, a PowerForm will open with options to document why this antibiotic should be continued.

Are you the primary provider that can assess the need for ___________?

                                No – suppresses the alert for that user for that antibiotic

                                Yes – move to the next question

                Reason to continue abx

                      Results still pending – suppress alert for all users for all antibiotics for 24 hours

                      Results deem therapy necessary – suppress alert for all users for that specific antibiotic

                      Do not wish to narrow therapy at this time – suppress alert for that user for that antibiotic

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Lipid Panel Changes

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Updated Direct LDL Order Education: 7.2.18

As per education provided in June 2018, the UMC lab and financial departments identified that they were receiving no reimbursement for Direct LDLs with Triglycerides less than 400. Based on this, subject matter experts were consulted and a new set of Lipid Panel orders were developed.

You will now find Lipid Panel and Lipid with Cardiac Risk panel for your use.

Contents:

Lipid Panel:

Non-HDL Cholesterol

Triglycerides

VLDL

LDL Calculated

HDL

Cholesterol

 

Lipid with Cardiac Risk:

Non-HDL Cholesterol

Chol/HDL

Triglycerides

VLDL

LDL Calc/HDL

HDL

Cholesterol

 

BOTH panels will have a calculated LDL and reflex Direct LDL when Triglycerides are over 400.

If the triglycerides are over 400, LDL Direct will reflex

If the LDL cannot be calculated you will see this comment.


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Admission PowerPlan: Oncology Patient

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When admitting a patient for Oncology (typically 4E) we must use the ONC General Inpatient Plan. You can find this plan by searching the word General just like you would the General Medicine Plan.

Once in the plan you will notice several differences that is important to oncology patient care. In Patient Care you have the Access Implanted Port, and Perform Neurological Checks.

In the ONC General Inpatient Plan there is also a medication section. This section includes biotene mouthwash, lidocain-prilocains topical (lidocaine-prilocain 25%), and heparin flush.

The final difference in the plan is under Consult MD. You will see in this field a required order, Consult MD. This allows you to choose to choose what service to notify. You can notify either Oncology or Hematology.


Lung Cancer Screening Workflow

Lung Cancer Screening

Based on the results of the 2011 study from the New England Journal of Medicine on low dose CT screenings, UMC now offers lung cancer screening through the Southwest Cancer Center. 

This service is covered by Medicare as health maintenance if the following guidelines are met:

  1. The patient must have a documented shared decision making visit at a Screening Center
  2. The patient must meet the USPSTF requirements for screening
    1. Ages 55 to 80
    2. Smoking history of 30 years or more (an average of one pack a day for 30 years)
    3. Currently smoking or have quit within the last 15 years
    4. No current cancer symptoms requiring a diagnostic workup
    5. Counseling must be provided on the importance of maintaining cigarette smoking abstinence if the patient is a former smoker; or the importance of smoking cessation if the patient is a current smoker and they must be furnished with information about tobacco cessation interventions, if appropriate.
    6. The patient must be entered into the National Lung Cancer Screening Registry through the American College of Radiology

Patients referred to the Lung Cancer Screening program will have a shared decision meeting scheduled with either Dr. Yepes or Dr. Islam.  Our pulmonologists will order the screening CT and provide follow-up on the results of the scan; e.g. regular visits for observation of a nodule, biopsy of a nodule, yearly follow-up for surveillance of a negative CT. 

To order your patient’s lung cancer screening, please select the Consult/Referral SWCC Lung Screening order in PowerChart.  Please educate your patients, they will be receiving a phone call from the SWCC Lung Cancer Screening Program Patient Navigator for scheduling of the initial screening appointment, which will take place at the SWCC, and scheduling of the Low Dose Screening CT of the chest.