Be PreparedHED AND HEO/WIZ DOWNTIME

Saturday May 12, 2012 at 700pmTill approximately

Sunday May 13, 2012 at 12 Noon

Downtime for: Order Entry (HEO/WIZ), Nursing Documentation (HED),

Nursing Med Administration System(Admin_Rx)

Systems not down: StarPanel, Medipac, Accudose, Inpatient and ED Whiteboard.

HED AND HEO/WIZ DOWNTIME

Impact of the extended downtimeRoles and responsibilities – educator/unit

leadership MR/AA and sssWorkflow/timelines – getting ready for

downtime, processes during downtime, and recovery from downtime

Supplies/ Forms needed for downtimeManaging Admissions, Discharges and

Transfers

WHAT YOU’LL LEARN

All orders will be written and processed manually Look up orders prior to DT in starpanel Use paper Physician Order Sheet (POS) Use Transfer Order Sheet for transfers

and as reference for orders prior to DT

All documentation will be on paper Paper MAR DT Flowsheets OPC manually updated w/ orders

IMPACT

Admission Hx can be in starpanel but will not generate any orders ( immunizations,etc)

Accudose will be in override and only have order prior to DT

To recover from downtime any ongoing orders will need to be entered into HEO/WIZ Pharmacy enters medications Nurses enter non medications

IMPACT

THIS IS A REALLY BIG DEAL

Staff not familiar with manual processes for such an extended time.

Many have not ever used manual forms and will need training

BOTTOM LINE

Educator/ Unit Leadership• Design &

implement plan to educate/ re-educate nursing staff

• Assure MR scheduled for entire DT

• Review RN staffing for DT and recovery and schedule additional staff prn

• Touch base with all staff working during DT to assure they are knowledgeable

AA/MR

• Order Supplies ( black pens, paper, POS, Home Care Instruction Sheets, labels)

• Print Forms from Edocs

• Stock DT kits- assure all unit specific flowsheets needed for extended dt are printed

• MR to attend MR training session

CAPS/SSS

• Resource to unit educator/leadership re: DT Preparation and DT Processes

• Assist with educations/ re-education

• Communicate w/ providers re: DT processes

• SSS Web site w/ resources needed

• Update Edoc DT forms

ROLES & RESPONSIBILITIES

Computer Talk: Gettn’ Ready for Downtime SessionsRegister in LMS

Attendance is Mandatory for 1 MR and 1 Leadership person from each Unit

4/27 730-830 VCH B319 & 407 Oxford house5/3 1930-2030 VCH B3195/5 1930-2030 in 407 Oxford house5/1 730-830 VCH B319 & 407 Oxford house5/8 730-8300 VCH B319 & 407 Oxford house

GETTN’ READY FOR DOWNTIME SESSIONS

MR meetingsStaff meetings/ unit boardsSmall groupsCharge nurse meeting1 on 1 with those working the weekendPostersShare the powerpoint – feel free to use/ modify for

your area

EDUCATE OTHER STAFF

Weeks prior to dt: educate and

get supplies

Sat May 12 : Place on charts DT POS,, print

labels, place DT req @ desk

Sat May 12 1700: retrieve Phm generated MARS, print TOS place on chart,

Print OPCSat May 12

1900- HEO/WIZ , HED and Admin

Rx Down- use DT processes.

Sun May 13 0700- shift

change: print OPC & update

with orders since DT, initiate new DT flowsheets and Fall risk Flowsheet

Sunday May 13 Noon- Recovery from Downtime-

enter orders/ enter data in

HED/Admin Rx

TIMELINES

Replenish k it A l l k i ts should conta in:

Laminated Downtime Checklist; Physician Order Sheet (POS)- E-Procurement ORDER ASAP Nursing Downtime Flowsheets- EDOCS (Appropriate to unit- gen care, ICU, ED for VUH and

VCH, NICU, VPH; Downtime Falls Flowsheet (revised 2012) EDOCS Medication Administration Records (MARs)- EDOCS Downtime Requisitions ( revised 2012)- EDOCS VCH Patient Discharge Instructions (MC 4085); VUH Patient Discharge Instructions (MC 2418)

COPY CENTER: ORDER ASAP Braden Skin Risk Assessment Guidelines EDOCS

Other documents that might be needed: ICU Blood Gas DT Req ( new) EDOCS Insulin Drip Downtime Guidel ines ( new) EDOCS Nurse Administered Heparin Drip Protocol ( new) EDOCS Downtime Restraints Flow sheet EDOCS and pol icy – pol icy manual Complex wound flowsheet PCA/ Epidural Policies – Pol icy manual Assessment Guidel ines VUH and VCH EDOCS

DOWNTIME KIT

Order Copier PaperOrder Black PinsOrder Patient Labels Increase Staffing

PREPARING FOR DOWNTIME

Place Phm Fax # on

Fax Machine

VUH – 7a-7p 39879VUH – 7p-7a 31640VCH – anytime – 66402VPH – pharmacy rounds during day,VPH – 7p-7a – 31630

Early Day shift Saturday Morning For pts. not being discharged by 5p,Medical receptionist will

Place Physician Order Sheets (POS) in blue charts TWO per chart, with patient labels attached on all three pages, DO NOT ADDRESSOGRAPH

Print 2 Downtime Flowsheets for each patient place labels, DO NOT ADDRESSOGRAPH

Print 2 Fall Risk Assessments for each patient place labels DO NOT ADDRESSOGRAPH

Print 30 labels for each patient and place in chart Print downtime reqs and place in convenient location at

desk Place black pens at nurses station

PREPARING FOR DOWNTIME SAT MAY 12 DAY SHIFT

1700 Saturday MR Checks printer to assure has paper ( paper MARS will be

generated by pharmacy) MR Retrieves MARs from designated printer & distribute. 

Prints to as follows: CCT on each unit, VUH on south side, VCH on B pods, MCN on each unit)

MR prints Diet List MR prints “Overview of Patient Care” (OPC) and Transfer Order

Sheet (TOS) & distributes RN addresses outstanding Inpt Whiteboard (Inpt WB) indicators

while information stil l current( VAP, Falls) RN saves monitor/vent data to DAS before start of downtime.

DAS will not receive data from these systems during the downtime so any values that need to be documented during this time will need to be manually entered on downtime forms.

For units that have centralized charts, MR place charts at patient rooms

PREPARING FOR DOWNTIME SAT MAY 12 1700

Charge Nurse identifies all patients with restraints and contacts provider to renew orders for all pt with restraints

Charge Nurse identifies all pt with potential transfer or discharges and contacts provider to enter orders/ generate discharge letter before dt

RN documents Planned Priorities and Nursing Summary on all patients in HED

Night Shift WILL NOT do Priority Problems or Nursing Summary during downtimeRN transcribes cumulative Intake and Output for their shift on

the 7p-7a downtime flowsheet

Ensure OPC and Transfer Order Sheet are printed (MR to Print)

PREPARING FOR DOWNTIME SAT MAY 12 1700

Orders Provider/ RN writes orders on paper Physician Order Sheet and give to MR

or RN for processing.  print & sign name, write pager # on all orders 1 set of orders per page Use ONLY BLACK INK and press hard ( going thru 2 copies) Any Verbal/ telephone orders require a read back to the provider and will require co-

signature by provider MR Alerts RN of any STAT orders MR Fax  copy of each POS to Pharmacy-

VUH – 7a-7p 39879 VUH – 7p-7a 31640 VCH – anytime – 66402 VPH – pharmacy rounds during day, VPH – 7p-7a – 31630

I f Scanning, MR scans POS MR transcribes new, modified, & discontinued orders to the paper MAR MR completes  DT requisit ions for labs, anci l lary depts & blood bank (one

requisit ion per dept)  and cal ls to inform of order or sends order to anci l lary department. Complete a DT req for future occurrences of anci l lary orders that are scheduled during the downtime.

DOWNTIME SAT MAY 12 1900 DOWNTIME BEGINS

Downtime Orders

Orders ( cont)MR updates Diet list with any diet ordersMR denotes “DT” next to ongoing orders that will need to

be entered once the system comes back upMR Pull out desk copy of written physician order sheet

and places at nurses’ station to assist with tracking of orders during downtime – ie CXR in am, O2 at 2l/m , Albuterol treatment q6h

RN checks StarPanel e-MAR for previous med admin times & verifies schedules are correct on paper MAR

RN’s verify transcription is correct & signs MAR For units with real time scanning: MR scans physician

order sheet, highlights document and places back in the blue chart and place back at the patient bedside

RN writes new orders on OPC or for large number of orders can make copy of DT Physician order sheet

DOWNTIME SAT MAY 12 1900 DOWNTIME BEGINS

Downtime Orders

DOWNTIME SAT MAY 12 1900 DOWNTIME BEGINS

Documentation• RN/CP document interventions on manual

flowsheets  and Meds on paper MARs.   (consider need for additional flowsheets for restraints, complex wounds etc and print from Edocs)

• For New Admissions, complete Nursing Admission History in Starpanel but RN writes a protocol order on the paper physician order sheet for any protocol generated flu and CPAP orders.  Positive screens for ancillary departments will be communicated via ancillary dashboards and will not require an order.

MR Round at least Q4h during DT Checks for any missed orders Restocks with DT order sheets as needed

12Midnight – MR assures printer is stocked with paper in prep for printing

of next day’s MARS

0100-0200 MAR’s printed by pharmacy, MR place in Blue Charts , and

Notify RN RN compares and verified Sunday’s MAR with Sat’s MAR and

makes any corrections. Alert Pharmacy to Downtime Downtime Downtime any schedule changes

DOWNTIMENIGHT SHIFT SAT 5/12- SUN 5/13

•Complete Admission Hx in Starpanel- write protocol order for pnuemovax of CPAP prn

•Make copy of admission orders since OPC will not have ordersAdmission

•Discharge Orders are written but prescriptions can be generated via RxStar in Starpanel

•Use Home Care Instruction sheet if patient letter is not generated or is incomplete

•Document discharge instruction in narrative portion of DT flow sheet

Discharge

•Provider uses Transfer Order Sheet ( TOS) to denote transfer orders – lines thru any orders to discontinue, denotes modifications to orders and writes new orders on blank lines. Dates/times and signs TOS.

•MR faxes TOS to pharmacy and processes orders per DT procedures.

Transfer

ADMISSION/ DISCHARGES/ TRANSFERS

SPECIAL CONSIDERATIONS

Orders RN to enter in HEO/WIZ any ongoing non pharmacy orders non-medicat ion Pharmacy to enter in HEO/WIZ any ongoing pharmacy orders

PROVIDERS SHOULD NOT ENTER ANY ORDERS THAT WERE WRITTEN DURING DOWNTIME. This is to avoid duplication of orders. Restraint Orders Renewed

Orders completed during downtime should not be entered in HEO/WIZ. Providers to cos ign on paper any verba l , te lephone or protocol orders wr i t ten on

physic ian order sheets dur ing downt ime.  Ongoing orders in it ia ted dur ing downt ime wi l l be entered in HEO/WIZ after downtime and can be e lectronica l ly co -s igned.  

Documentation RN to enter in HED

Last set of vital signs Documentation for foleys and IV inserted or discontinued and wounds initiated or ended Downtime Start and Stop time on Asmnt/Interventn Tab Cumulative Intake and Output for Saturday and Sunday

Example of Back time for Saturday’s Cumulative from paper flowsheet, (3/12/2012, 0645). Will need to subtract what was charted from 7a-7p on 3/12 in HED from 24 hour cumulative from the paper flowsheet. Sunday’s cumulative will be the current cumulative from the paper flowsheet

RN to confirm meds in Care Organizer us ing paper MAR- carefu l ly checking schedules and in forming Pharmacy of schedu le changes v ia care organizer

In Admin Rx, RN notes overdues and document as “a l ready g iven-see MAR” i f administered & charted dur ing DT                             

RECOVERY FROM DOWNTIME(APPROXIMATELY NOON SUNDAY MAY 13)

RN’s Continued HED

Admin Rx, medications with outstanding schedule need to be addressed

Asmnt/Interventn Tab, document start of downtime and end of downtime.

RN Enters Cumulative Intake and Output for Saturday and Sunday Example of Back time for Saturday’s Cumulative from paper flowsheet,

(3/12/2012, 0645). Will need to subtract what was charted from 7a-7p on 5/12 in HED from 24

hour cumulative from the paper flowsheet. Sunday’s cumulative will be the current cumulative from the paper flowsheet.

Restraint Orders renewed Priority Problems with goals back time to morning shift.

Complete at end of shift Planned Priorities and Nursing Summary.

WHAT TO DO AFTER DOWNTIME

(APPROXIMATELY NOON SUNDAY MAY 13)

Approximately 1700 Sunday, MR’s will after HEO/HED have been up and stable for several hours.

Remove and Discard all unused downtime documents with patient labeled attached; place any unlabeled dt documents in DT kit.

Remove Transfer Order Sheets

For units with real time scanning, MR will scan documents in to EMR Downtime flowsheets Downtime POS (physician order sheets) that were missed TOS (transfer order sheets) that were missed- may discard if no

orders denoted on TOS Re-locate charts per unit protocol back to location for scanning to shredder and discard to shredder

RECOVERY FROM DOWNTIME SUNDAY MAY 13 1700

SSS will have staff on site making rounds prior to downtime Sat 5/12, during downtime and during recovery from downtime.

Watch your fax machine for updates re: status of the downtime and for detailed instructions.

Update will also be sent out via charge nurse pager and via the starpanel banner.

Contact the Help Desk 343-4357 if help is needed.

SUPPORT DURING DOWNTIME