New Alert for C. diff by PCR Orders

In the next few weeks, there will be a new alert added that will aid in the prevention of ordering unnecessary C. diff by PCR testing.

As approved by the Use & Standards governance committee, the alert will impact inpatient ordering only.

There will be an alert that will prevent ordering C. diff by PCR if a previous C. diff has been ordered within 7 days.  

According to Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA), it is recommending to not repeat Clostridium difficile testing (within 7 days) during the same episode of diarrhea.  As a result, all Stool C difficile toxin by PCR orders placed within 7 days of the previous order will be rejected.

IDSA Clinical Practice Guidelines

BB Send Blood Product Order Updates

Changes made to the three BB Send Blood Orders and the BB Blood product Cancel order.

Removed the existing order sentences from the 4 orders (BB Send, Pediatric BB Send, NICU BB Send and BB Blood product cancel.) Added a drop down with the needed options.

Current and Future State:

Current:

When you place the above orders you receive this pop up screen with prebuilt order sentences.

Future State:

The 4 orders will now have no prebuilt order sentences but have a drop down with the 5 selections and only allow for 1 selection to be made.

Changes To NICU Blood Orders

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.

Additional Significant Events Component Update

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.

Coming Soon: Smart Ribbon

LINK TO Tutorial Video

Radiology: New Central Line Placement Orders

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

Zero Hour Delay for Portal Labs/Rads/Path

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’

Infectious Disease Documentation and Alert Updates

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

UMC OBS Unit EHR Workflow

FYI: Enoxaparin Indication

Wednesday, June 6^th a required indication field will be added to enoxaparin orders.  This will assist Pharmacy during the verification process to  understand the medication intent and will display in the MAR for Nursing during administration.

FYI: IVIG Indications

Powerform - Documenting Lab Results From Other Facilities

Powerforms for documenting lab results from another facility are being introduced and will replace some existing forms. Results documented on these forms will display in the patient flowsheets in Powerchart and are readily identified as coming from an outside source. The name of the facility that processed the lab is a required field and the form cannot be completed without this field. The forms are similarly named "Outside Lab..." followed by the type of results that the form entails (CBC, Chem, FOB, HIV Screen, etc).

Lab results that are not available on these forms will continue to follow the same process previously defined by your clinic (i.e. scan into chart, reviewed by provider, etc).

These forms can be found in your Ad Hoc folders begining May 23, 2018.

Powernote - Blood Pressure Screening Requirement - Refer to PCP or Alternate Provider

New Powerform - Documenting Eye Exams From Outside Sources

Deceased Patient Alert

Beginning May 8^th, 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