Category Archives: ICU

Be Prepared: ORCHID Downtime Scheduled Sunday, July 10 at 9pm

ORCHID is undergoing its first major upgrade this coming weekend, which will require downtime.  That means the EHR across DHS will not be available for normal orders, documentation, and results review.  Downtime is scheduled to start Sunday, July 10 at 9pm and end Monday, July 11 at 5am.

What do you need to know?  Depending on your clinical duties, please review the following.  I will be available Sunday night to ensure appropriate procedures.

If you are caring for inpatients, prepare beforehand and ensure recovery is accurately performed first thing Monday morning.

If you are working during downtime, review and be ready to perform downtime procedures (e.g. for order entry and admissions) and recovery procedures.

If you are returning to Monday outpatient, ORCHID should be up and running.

Two important resources:

 

Timeline

Preparation:

  • Sunday Afternoon – Prepare for downtime by prepping patients list, placing electronic orders, and completing daily documentation.
  • 17:00 – Finish placing electronic medication orders (as best as possible)
  • 19:00 – Finish placing electronic laboratory orders (as best as possible)

Downtime:

  • 21:00 – Downtime starts. Follow downtime procedures, and use designated 724Access workstations to review patient charts (read only access)
  • 21:30 – Level 1 724Access is available on all ORCHID workstations for chart review (read only access)

Recovery:

  • 05:00 – ORCHID goes live with upgrades. Begin Recovery.
  • Monday Morning – Ensure recovery is completed, e.g. electronic back-entry of uncompleted orders, verification of back-entry, back-entry of notes.

 

PREPARATION

  • Orders
    • Place medication orders by 17:00 if possible.
    • Place laboratory orders (including AM labs for the next day) by 19:00 if possible.
    • Continue electronic order entry up until downtime at 21:00.
  • Patient Lists
    • Print your sign-out and/or patient list before 21:00.
  • Notes
    • Sign daily notes by 21:00. For uncompleted notes, make a back-up copy, and sign the note during Recovery.

DOWNTIME

724Workstation

  • Chart Review & 724Access
    • 724Access allows you to access patient charts with information from the last 10 days and upcoming 3 days only. Check your email for the generic username and password. A 724Access workstation is located in each inpatient nursing unit and ED pod.
    • Other ORCHID workstations will have special Level 1 724Access starting 21:30. Log in with your own username and password.
  • New Vitals, I/O’s, POCT Results, Medication Administration
    • These data will be recorded on paper by the nurse.
  • New Lab Results
    • STAT and Critical results will be called and/or faxed to the nurse. The nurse should verbally relay the result to you.
    • Other lab results will be printed and sorted in the Laboratory. To review the results, go to the 1st Floor Laboratory, enter with door code 24069, and search by patient name for a printout of your result.
  • New Radiology Results
    • New studies will be limited to STAT and Critical studies.
    • Reads may be limited to STAT studies and Critical results.  The Nighthawk is available for verbal communication.  Prelim reads/dictations will be placed in Synapse.  To review, open Synapse from your workstation desktop – don’t link to Synapse from ORCHID.
  • New Orders
    • All orders during downtime must be handwritten.  Please remember that all blocks of orders require your name, signature, date, time, and at least two patient identifiers (stickers with name, DOB, MRN).
    • Use designated order forms.  These are available from the OV Intranet > ORCHID Portal > Downtime Forms, or Intranet > Forms > OVMC > Medical Record Forms.
    • Place completed orders in the patient’s hard chart and place it in the designated orders bin/rack for the unit clerk/nurse to process (like old times!).  In the ED, place written orders in the designated bin in the ED pod. Be sure to alert the nurse and clerk about any STAT orders.
    • Keep track of placed orders because uncompleted orders will need to be re-entered electronically during recovery! Nonessential orders (e.g. orders that do not need to be carried out during downtime) can likely wait until recovery.
    • TIPS on handwritten orders: Use a pen with blue or black ink and medium thickness. Write clearly and legibly for others to read. If you make an error, use a single strikethrough to cross-out the error AND sign-date-and-time the correction. Avoid banned abbreviations.
  • New Documentation
    • Handwrite notes on physician Progress Note forms.  You must sign, date, and time all pages of notes. All pages must have patient identifiers (stickers).  Consider typing and saving your note in another place (e.g. Word), so that you can copy-and-paste your note into ORCHID during recovery.
  • New Admissions
    • Use the designated downtime General Admission form.  Follow procedures for placing new orders.  In the ED, place orders in the designated bin in the Pod for the nurse/clerk to process.
  • New Discharges
    • Limit discharges if reasonable.  Discharges require Patient Instructions (use the form) and the Discharge Order set.
  • Do not discard any written notes or orders. Leave them in the hard chart. These remain part of the permanent chart.

RECOVERY

  • Orders Placed During Downtime
    • For inpatients: Back-enter all ongoing/incomplete orders or changes to ongoing orders, except completed lab orders, completed radiology orders, or medications that were previously ordered on paper.  Orders that should be back-entered include the following:
      • Admit to Inpatient along with MED General Admit order set
      • Transfer order
      • Resuscitation status
      • Isolation status
      • Allergies
      • Diet
      • Restraints
    • The following will be back-entered by other services:
      • Medications (updated by Pharmacy)
      • Hold status (updated by Psychiatry)
      • Request for Admit from the ED (updated by the ED)
      • Place in Observation from the ED (updated by the ED)
  • Documentation Requiring Back-Entry
    • Back-enter all History & Physicals, Discharge Summaries, Ambulatory Provider Notes, and Procedure Notes electronically into ORCHID.
  • Vitals and I/O’s During Downtime
    • For downtime <4 hours, the nurse will back-enter these results
    • For downtime >4 hours, the nurse will back-enter at least the most recent results
  • POCT Results During Downtime
    • Results will be uploaded into ORCHID
  • Medication Administration During Downtime
    • The clinician who administered the medication should back-enter those meds into the MAR
  • New Orders and Notes
    • Resume normal workflows involving electronic order entry and documentation.
  • The recovery process must be completed within 24 hours!
  • Do not discard any written notes or orders. Leave them in the hard chart. These remain part of the permanent chart.

General Consents Show Patient Empanelment +/- Provider

Trying to figure out your patient’s primary care physician?

When your patient is admitted, under the Documentation section, look for a note type labeled Consents General. This may include a scanned document with identification of 1) if the patient is a DHS or non-DHS empanelled patient and 2) who that empanelment provider might be.

Use this information for discharge planning.  Remember, empanelled patients should follow-up with their empanelment provider, not in CCC-Post-Discharge Clinic (Clinic A).  CCC-PDC should be reserved for un-empanelled patients (call Clinic A for an appointment).

The “empanelment” provider listed in the patient’s banner bar is not reliable at this time.

The St. John Sepsis Module is Live

Recognize and treat sepsis early!

The St. John sepsis module detects patients with signs of sepsis using vitals and laboratory results.  When the screen is positive, the patient’s nurse will be alerted.  The nurse will then alert the provider.

It is up to the you as the provider to take action! Evaluate the patient and if the patient requires treatment for sepsis, start quickly.  Inpatients need antibiotics given within 1 hour of declaring sepsis!  Use the MED Sepsis Screening and Management Bundle order set to view guidelines and suggestions for management, including IV fluids and empiric antibiotic selection.  This order set will suppress alerts for a period of time.

Goals: *use the MED Sepsis Screening and Management Bundle

  • BLOOD CULTURES before antibiotics
  • LACTATE: Check it, and if >= 2.0, recheck within 4 hours!
  • IVF: At least 30cc/kg IV fluid bolus (about 2L) within 3 hours
  • Additional clinical assessment and orders as indicated to identify the source
  • Make the diagnosis and document: Use auto text (.sespsnotsepsis, .sepsisseveresepsis .sepsissepticshock)