Transcript Slide 1

How do I chart …
The Basic and Essential
Anesthesia Data?
The Basic and Essential Anesthesia Data
The College of Physicians & Surgeons of Ontario uses the
Anesthesia Peer Assessment Form to set the minimum
standard for Anesthesia record-keeping.
(Click
Here
to view the various sections of the form)
Whether using paper or electronic records, we need to
be sure we meet and exceed this minimum standard.
Over the years the paper record has evolved to include
many “prompts” to remind us about data entry. We are
comfortable with the paper record and have developed
efficient ways of completing it.
The electronic record has strengths and weaknesses.
No more mind-numbing vital sign data entry!
The challenge is to develop new workflow patterns for
data entry to make the e-record more complete than
the paper record ever was or could be.
The Basic and Essential Anesthesia Data
The MacroBar – WorkFlow Signposts
Marker: Anesthesia Case Start (OHIP billing)
Marker: Equipment Check
Marker / Reminder: Patient Assessment
Reminder: Assign ASA Level / Medical Team / Pt Wt-Height
Marker: Regional Anesthesia Start
Marker: General Anesthesia Start
Marker: Monitored Anesthesia Care Start
Marker: places
a symbol on
the timeline
Marker: Antibiotics–First Dose / Start Timer
Marker: End of Surgery / Confirm Procedure
Reminder: Fluid Balance / Final IV Bag Levels
Marker: End of GA / Emergence Events
Action: Transfer to PACU /SDCU / ICU
Reminder: Transfer of Care Note
Reminder: you
need to chart
something
Marker: Anesthesia Case Finish
Action: Discharge to non-SIMS unit – nurses do NOT use SIMS
(e.g. ICU/Endo Suite/Brachy Unit)
The Basic and Essential Anesthesia Data
Step 1: Get Anesthesia Manager OPEN
When the Anesthetist turns on the anesthesia machine,
the SIMS computer turns on automatically.
The SIMS computer will Auto-Logon – you do not log
into Windows with your TOH password.
Double-click the icon for SIMS-Perioperative Manager
and when prompted, logon with your SIMS password.
You will now see the Census List with the patients
listed: Surgery-Today
The ORs are listed
in numerical order –
Your patients are listed in
your OR alphabetically,
not by time!
Click Here for more
Help on opening
Anesthesia Mgr
The Basic and Essential Anesthesia Data
Step 2: Start the Anesthesia Manager SESSION
Find and highlight with a Left-Click of the mouse, your
first or next patient’s name
Click on the “START SESSION” button
Some important concepts:
- the whole patient record for the surgery – from SDA
or SDCU to the OR to PACU – is an ENCOUNTER
- the patient’s admission in SDA/SDCU is a SESSION
- to move from SDA/SDCU to the OR, the patient
must go through the TRANSFER zone
- to move the patient into the OR (and start charting)
you must pick up the patient from Transfer
and START A NEW SESSION
- patient leaves the OR for PACU => into TRANSFER
The Basic and Essential Anesthesia Data
For more detailed information,
take the Grand Tour….
Click Here for Help
on Navigating
Anesthesia Mgr
Click Here for Help
on Real-Time
Variables
The Basic and Essential Anesthesia Data
Step 3: Insert the Anesthesia Case START event (flag = S)
Left-Click the mouse on the START Macro button
Click Button to enter
Start Case time
Macro Bar
for workflow
Chevrons show when AM
started running this session
Yellow column
is current time
The Basic and Essential Anesthesia Data
Edit Event dialog appears –
either accept the current time
shown or edit the time.
We will change it to 20:50
and click OK
After clicking on the START button:
The Button is
depressed
TimeBox 20:50
shows the flag
symbol “S”
From the moment Anesthesia Manager is open, it is fully
operational and will capture any Vital Signs which appear on the
monitor or any action by the ventilator.
By clicking the Anesthesia Start macro button, you have set the
time for when you started the case. (for tracking purposes)
Note: You can set the Start Flag to before AM started – it is
very important to remember this when it comes to print
The Basic and Essential Anesthesia Data
Step 4: Chart the Equipment Check (flag = C)
Click on the
Equip Check
button
Note: Gas
Machine #
left blank
Time is
edited to
20:55
All these Equip Events
are entered with
one Click!
After clicking on the EQUIPMENT CHECK button:
Equip Check button is
depressed
TimeBox 20:55
shows symbol “C”
The Basic and Essential Anesthesia Data
To enter the Gas Machine # you need to display
the Events Log – click its icon on the ToolBar
Below is shown the Events Log with all the
Events so far.
To add a Comment you need to EDIT the Event:
Highlight by a mouse click and click Edit
or – Double-click the Event
The Basic and Essential Anesthesia Data
[TAB] from the Time field
or mouse click to the
Comment box;
Enter the Gas Machine #
Then [TAB] again to the
the [OK] button and
hit [ENTER]
The updated Events Log
now shows the Gas
Machine # in the Comment
column
The Basic and Essential Anesthesia Data
At this point you have everything ready to proceed with
your anesthetic case.
When you choose to document will be determined by your
personal choice and workhabits.
The WorkFlow buttons on the MacroBar are designed to
drop Bookmarks (Flags) on the TimeLine at the various
stages of your case. When it is convenient, you return to
these TimeBoxes with the Flags and complete the chart.
The Basic and Essential Anesthesia Data
Step 5: Documenting your Assessment of the Patient
The person giving the anesthetic must document
his/her own medical assessment of the patient.
The following scenarios are possible:
1. More than likely, your patient has had a recent visit
to the PAU and an MD Assessment is available in
Preop Manager, but done by someone else.
2. The Patient may have been assessed in the PAU or
SDCU by the Nurse only and the MD Assessment
needs to be done
3. The Patient has not been seen in the PAU or SDCU;
no RN or MD Assessment has been done
e.g. inpatient from ward
What needs to be done?
1. Check vOacis: Review the PAU visit MD Assessment
– OR2. Complete a new MD Assessment in Preop Manager
The Basic and Essential Anesthesia Data
Step 5: Documenting your Assessment of the Patient
If vOacis has a recent Preop Manager Assessment
complete with an MD Assessment done by someone else:
(either a PAU visit or a ward/ER Consultation)
- You need to document your own preop assessment in
Anesthesia Mgr – using the Preop Evaluation eventset
If vOacis has a recent Preop Manager Assessment without
an MD Assessment (i.e Nurse Assess only):
- You need to document your own preop assessment as
an MD Assessment in Preop Mgr – select the patient
from the “Surgery Today” census list
- Preop Mgr may have the MD Assess section “locked” use the Addendum section in this case
If vOacis has no recent Preop Manager Assessment:
- You need to document your own preop assessment as
an MD Assessment in Preop Mgr – select the patient
from the “Surgery Today” census list
The Basic and Essential Anesthesia Data
Step 5: Documenting your Assessment of the Patient
in Anesthesia Manager
Click on the “Pt Assess” button on the MacroBar
and edit the dialog Time field if needed
The symbol “P” appears as a Flag on the TimeLine
at the selected time
Pt Assess
button
The “Add Events” window pops up:
1. Select EventSet “A010_Preop Evaluation”
2. Check the Time field - edit if needed
Click Here to
Select
The Basic and Essential Anesthesia Data
Step 5: Documenting your Assessment of the Patient
Using the Event Set
A010_Preop Evaluation,
select events to
document what you
assessed
Click on each
Event as
appropriate
Bring the selected
Events over to the righthand panel, enter any
Comments required and
then click [OK]
We recommend that a
brief medical problem
list be entered as an
Anesth History comment
The Basic and Essential Anesthesia Data
Step 6: Chart the ASA Level and the Medical Team
Strictly speaking, the ASA level
goes with Preop Assessment.
Anesthesia Manager has placed
it in a grouping called:
DEMOGRAPHICS
We have a single Macro button
called ASA/Team which will
remind you to open up the
Demographics window.
It’s up to you to remember to
enter both items!
The Basic and Essential Anesthesia Data
Step 6: Chart the ASA Level and the Medical Team
Click this small
arrow to reveal
the drop-down
Clicking on ASA Level brings up the selection box
Use the drop-down box or hit the keyboard [DOWN ARROW]
repeatedly until the desired ASA Level is highlighted
The Basic and Essential Anesthesia Data
Step 6: Chart the ASA Level and the Medical Team
This window pops up when Medical Team is clicked
Don’t forget to
enter the rest
of the Team!
To select Elliott:
-Jump to the start of
the “E” names by
typing the letter “E”
-Either use the
[DOWN] arrow key
or the [PgDn] key
to reach the name
and hit [ENTER]
Use mouse to move
to a different box
When you click in the empty Anesthesiologist box
a drop-down of names appears.
Although you can select with the mouse by scrolling
down the list, using the keyboard is faster.
Tip: Remember the keystrokes for the next time
The Basic and Essential Anesthesia Data
Step 6: Chart the ASA Level and the Medical Team
Once the ASA/Team button has been used, it will
appear depressed in the MacroBar.
If you need to see Demographics again, use the
Demographics button at the bottom of the ToolBar
The Basic and Essential Anesthesia Data
An alternate way to access the sections in Demographics
Click Here
to return to
Flowsheets
Click Here
(may be a
long way
down)
The Basic and Essential Anesthesia Data
This is also a good time to enter the patient’s weight.
Unfortunately, you will need to remember the weight
from the Preop Assessment to then enter it.
Entering the Weight here will be useful later when you use
drug infusions based on weight. The weight will show up
automatically when the drug infusion window opens.
The Basic and Essential Anesthesia Data
Step 7: Bookmark on the TimeLine when Anesthetic
Technique begins
MacroBar
Workflow
Technique
TimeLine Flag Symbol
Regional
R
General
G
Monitored Care
M
This case is a combined
Spinal and General –
both RA and GA buttons
have been pressed
Flag Symbol “R”
for Regional
Technique
Flag Symbol “G”
for General
Technique
The Basic and Essential Anesthesia Data
Step 7: Bookmark on the TimeLine when Anesthetic
Technique begins
Hovering the mouse over the Anesthetic Technique buttons
shows Events which will be entered automatically for you
The Regional, General and MAC Start buttons register
a Reminder Event only - you need to specify the
Anesthesia Type when you document the events
In most cases, once your patient’s surgery is under way,
then you will return to the Bookmark to document.
The Basic and Essential Anesthesia Data
Step 8: Return to the “R”, “G” or “M” Technique Symbol
=> Document Events
Click in the TimeBox with
the Symbol “G” to
bring up the Add Events
window
In most GA cases
you can use
the Basic GA
event set
Correct time
already
entered
The Basic and Essential Anesthesia Data
Step 8: “R”, “G” or “M” Symbol => Document Events
These are
Reminders –
Don’t select!
Organized into
Sections with a
note for full list
Note the “Must Do” –
You need to select the
Anesthesia Type.
The Basic GA Set has
(G)_General Anesthesia
built-in, ready to select.
A complete list of the
Anesthesia Types is
in Event Set A001
The Basic and Essential Anesthesia Data
Step 8: “R”, “G” or “M” Symbol => Document Events
The Sections provided are:
-
IV Lines
Airway Management
Ventilation
Patient Position
Eyes
Add Equipment
Transport/End Activity
This Basic GA event set gives
you the most commonly used
items/events that you will need.
With everything in one list, you
will be less likely to forget to
document something.
Each Section has its own, more
detailed, list of choices for those
more specialized cases.
The Basic and Essential Anesthesia Data
Step 9: Document Anesthetic Technique Events
General Anesthesia
In many cases the
“Basic GA” Event Set
contains all the events
needed.
More detailed Event Sets
are available:
A050
A052
A054
A056
A058
–
–
–
–
–
ETT (oral)
ETT (nasal)
LMA
FOB Intubation
AW Complic’ns
and…
A150 – Thoracic SL ETT
A152 – Lung Isol’n DL ETT
The Basic and Essential Anesthesia Data
Step 9: Document Anesthetic Technique Events
Regional Anesthesia
The“Basic Spinal” Event
Set contains the events
commonly needed for
Spinal Anesthesia.
Other Event Sets include:
A060 – Reg’l Block Types
A062 – Epidural Block
A064 – Spinal Block
A066 – Upper Limb Blocks
A068 – Lower Limb Blocks
A070 – IV Reg’l (Bier) Blk
A072 – Head&Neck, Trunk
The Basic and Essential Anesthesia Data
Step 9: Document Anesthetic Technique Events
Monitored Anesthesia Care
The“Basic MAC” Event Set
contains the events
commonly needed.
Other Event Sets include:
A014 – Basic Eye
A080 – Anes-MAC
A190 – Eye Care Centre
A192 – Eye Institute
The Basic and Essential Anesthesia Data
Step 9: Document Anesthetic Technique Events
A detailed tutorial about
documenting Events is
available:
More detailed descriptions
about Technique-specific
Events are available:
Documenting Events
GA – Oral ETT
Spinal Anesthesia
Epidural Anesthesia
The Basic and Essential Anesthesia Data
Step 10: Document Fluids IN / OUT
The Flowsheet “Med Infusions & Fluids” has it all…
(The Anesthesia Summary Flowsheet can also be used)
“Fluids IN” refers to not only typical IV Fluids and Blood
Products but also IV Med Infusions (see Propofol above).
The Basic and Essential Anesthesia Data
Step 10: Document Fluids IN / OUT
There are many tasks to be done related to
Fluid Management:
-
starting an IV solution bag using gravity feed
running an IV on an infusion pump
documenting a “bag level”
finishing and starting a new bag
interrupting one solution to run another
discontinuing (stopping) an IV solution
tracking urine output / blood loss
Tutorials regarding Fluids are
available:
Intro to IV Fluids
Detailed Fluids IN/OUT
The Basic and Essential Anesthesia Data
Step 10: Document Fluids IN / OUT
It is helpful to keep the tally of Fluids IN / OUT up-to-date
at regular intervals.
Near the end of the case, you will want to do the final
“Bag Levels” so that the calculated Fluid Balance will be
accurate.
Opens
Fluid Balance
window
Bag Level
Button is a Reminder
Pops up
Fluid Balance
window
Click on this Button to
get a detailed
breakdown of the
Fluids given
The Basic and Essential Anesthesia Data
Step 11: Document Medications
Documenting Medications is one of the central activities in
recording an anesthetic.
-
AM opens with a “default” list of drugs
drugs are either given by “bolus” or “infusion”
drugs not found in the default list need to be Added
doses can be Entered, Modified or Deleted
drugs can be Discontinued
a running tally of drug dosages given
is shown in a Summary
A detailed tutorial about
documenting Medications
is available:
Documenting Meds
The Basic and Essential Anesthesia Data
Step 11: Document Medications
The way Anesth Mgr handles Medications is a bit odd.
Older versions supported Meds in two ways:
- bolus doses = Medication Flowsheet
- infusions (called “drips”) = Fluids Flowsheet
Later versions added Combination Meds:
- both bolus & infusions = Medication Flowsheet
It would be better if ALL infusions were together on the
Medication Flowsheet.
The Basic and Essential Anesthesia Data
Step 11: Document Medications
Single Drug Bolus
- row highlighted
Combo Bolus with preset
doses
Combo Infusion
- rates to be entered
The Default drug list in the
Medications Flowsheet is a
mix of single drugs and
combos.
Medications can be
Bolus or
Infusions
(look for /min or /h)
Medications can be
Single Drug or
Combinations
(look for multi-line
white box when 2 or more
drugs)
The Basic and Essential Anesthesia Data
Step 11: Document Medications
As an example, let’s use Propofol without any Lido mixed in.
The default list of drugs has plain Propofol as a bolus but the
infusion is a combo of Propofol + Lido.
We need to add a plain Propofol infusion.
If we go to the Fluids Flowsheet, Propofol is listed under
Other IVF. But if you hover the mouse over the Propofol
listed, you see it is actually the P+L combo.
AM displays the drug masses of combos in Medications but
shows the drug volumes in Fluids.
The Basic and Essential Anesthesia Data
Step 11: Document Medications
To add the “old-style” drip Propofol,
move the mouse pointer over the heading
Fluids IN and when the finger appears,
left-click.
A windows pops up for you to add a “Fluid” - in this case,
chose the Family called “General Anesthetic” and then see
what “Treatments” are available.
We want Propofol in
mcg/kg/min
Click on
[Add]
and then
[Cancel]
Update: We have standardized Propofol infusions to mg/kg/min
The Basic and Essential Anesthesia Data
Step 11: Document Medications
A Med Infusion (“drip”) shows up
in Green under a new heading for
General Anesthetic
By default the drug is displayed
by “Dose only”
By right-clicking, you can choose
to see both Volume and Dose
Now you can see the pump
rate on one line
and the dose on a 2nd line
This looks good but the Propofol bolus and infusion are on
different Flowsheets!
The Basic and Essential Anesthesia Data
Step 11: Document Medications
These are
Infusions
(/min)
The Combo icon
shows a “+”
with a pill bottle
This is
Bolus Propofol
+ Lido
An easy way to select Medications not listed when
Anesthesia opens is to use the Protocol Button.
A major advantage to Protocols is that we can list
bolus and infusions, both single drug and combos,
all in the same place.
Update: To avoid confusion on the Summary PrintOuts, most 1-drug
infusions (e.g. Vasopressors) will use the older “Fluid Drip” technique
until Picis can correct how the combo infusions are represented
The Basic and Essential Anesthesia Data
Step 11: Document Medications
When we Add Propofol as a 1-drug combo infusion,
this is what shows up in AM under Medications:
Now Propofol (plain)
bolus and infusion
are together
This is what we see when we add some
doses on the Medication Flowsheet:
When we switch to the Fluids Flowsheet,
the pump rate is entered automatically:
This looks perfect
on screen within AM
but on a printout
the rate is NOT
shown; instead you
see the mass of
drug given per time
column.
We hope Picis can
correct this soon.
The Basic and Essential Anesthesia Data
Step 11: Document Medications - Antibiotics
The Antibiotic First
Dose button pops up a
time window, then
puts an “A” on the
timeline and starts
a Timer (counts up)
When you have the time later, enter the antibiotic in the time
column with the symbol “A”
If it’s Cefazolin, it’s easy – it’s a default drug.
Otherwise you will need to Add the antibiotic first.
Two choices:
1. Use the Protocols – Anes-Antibiotics list 12 common ones
2. Click on Anti-Infectives on the Med Flowsheet
(this will list every antibiotic on TOH formulary!
Shortcut – type a few letters e.g. “v” pops up vancomycin)
The Basic and Essential Anesthesia Data
Step 12: End of Surgery / Update Procedure
With the last few stitches, mark
the End of Surgery with the
“End S” button
The Demographics window pops
up and you need to check the
listed Procedure and update if
necessary. (This is important in
Remote Locations – procedure
will NOT be there automatically)
The Basic and Essential Anesthesia Data
Step 12: End of Surgery / Update Procedure
Take a look at the Required Events box below
The only
events left are:
1.Finish Time
2. QA Indicator
All the others
have at least
one entry
The Basic and Essential Anesthesia Data
Step 13: Fluid Balance – Enter IV Bag Levels
Enter IV Bag / Blood Bag levels
Also Update Urine Output and
Estimated Blood Loss
Check in Fluid Balance window –
updates dynamically as you enter
data.
Step 14: Mark End of General Anesthesia (g)
The End GA button places the letter
(g) on the TimeLine for you and
automatically enters a group of
events appropriate for the end of a
typical GA.
If there are discrepancies with what
you want to record, you will need to
edit these events in PACU
The Basic and Essential Anesthesia Data
Step 15: Transfer to PACU / SDCU
The green PACU-SDCU-ICU button
begins a Transfer of the patient into the
“Transfer Zone”.
It is essential that your patient be
“transferred” or else the PACU/SDCU
will not be able to retrieve your
patient’s record!
You will be shown the Demographics screen
one more time, in case something missing
had slipped your notice.
The Basic and Essential Anesthesia Data
Step 15: Transfer to PACU / SDCU
Click [Transfer]
to proceed.
If you realize
you forgot to
chart something
click [Cancel]
The Basic and Essential Anesthesia Data
Step 16: Documentation in PACU / SDCU
Open the Patient in Remote View:
Important tip: The patient must have been admitted into
PACU or SDCU if you want to document in Remote View.
The Basic and Essential Anesthesia Data
Step 16: Documentation in PACU / SDCU
Patient in Remote View – note White ID band:
Use the Report button to open Add Events and
use A005_PACU-SDCU-ICU Report
to document QA Indicator & Transfer of Care
The Click on the Finish button to enter the
Anesthesia Case Finish time
The Basic and Essential Anesthesia Data
Step 17: Print the Anesthesia Record to vOACIS
While in Remote View, after the Finish button, the
Print Anesthesia Record pops up:
Make sure to choose the
Anesthesia record
You need to enter the
Anesthesia Start time
which probably is not
the same as the time
you opened the
session.
You need to look up the
Anesthesia Start time
before you click on the
Finish button!
The Start & End
times for data
to print shown
here are for the
PACU session
The Basic and Essential Anesthesia Data
Step 17: Print the Anesthesia Record to vOACIS
The Anesthesia Session times are now shown.
21:10 was the End of the
Anesthesia Session.
The Case Finish time in
PACU needs to be entered
here: 21:16
We need to add the
time in PACU until
Case Finish Time
if we want to
include the
Transfer of Care
events and the first
few vital signs
captured in PACU.
The Basic and Essential Anesthesia Data
Alternate Steps 16 & 17:
Patients who DO NOT GO to PACU / SDCU
If your Patient is in a Remote Location and will not be going
to PACU – you need to change the end sequence a little.
You need to complete the Report and Finish Time
BEFORE:
1. Clicking on the X-SIMS (Discharge) Button
2. Leaving your OR
You will need to Enter an estimated
Finish Time and use that time when
printing the Anesthesia Record
The Basic and Essential Anesthesia Data
Alternate Steps 16 & 17:
Patients who DO NOT GO to PACU / SDCU
This is the
DISCHARGE window.
Be very careful…
You cannot UNDO
a Discharge!
Remember:
Discharge is for
Patients who will not
be going to the main
PACU or SDCU
For ICU Patients, you
will Transfer first, then
start a session on the
ICU computer, enter
reports – then
Discharge
The Basic and Essential Anesthesia Data
Your
Electronic Anesthesia Record
is now