Transcript Slide 1

GBHN Order Sets
An effective solution to the complex
challenge of improving patient care and
safety
Agenda
Call for questions – to be answered at the
end of the presentation
Overview of partnership
Project Process
Demo of website
Sample order sets/protocols
Context: Massive Gap Between the
Possible and the Actual
Quality
 Misuse, under use, overuse on a massive scale:
Crossing the Quality Chasm 2001
Safety
 Medical error is common:
Institute Of Medicine Report on Error 2000
Variation in Care
 Variability in care not explained by patient
preferences or different disease patterns:
British Medical Journal 2002; 325: 961-964
Solution:
Order Sets a Clinical Decision Support Tool
A group of orders with a common functional purpose used by the
physician to create orders.
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Integrates knowledge into the care delivery process “knowledge
where the clinician needs it most”
Organizes clinical knowledge so it is easy to remember, easy to
use and has maximum benefit to the patient
Contain evidence-based and best practices
Source of education
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Can be used in paper or computerized ordering systems
Order Sets: Key Benefits
Safety
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Reduced transcription errors
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Reduced errors of omission
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Reduced errors in medication dosing
Quality
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Improved compliance with evidence-based and best practices
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Standardization of care
Efficiency
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Decreased time to write and process orders
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Reduction in physician call-backs
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Reduction in missed orders
Critical enabler for computerized practitioner
order entry
Current Status of Order Sets
Lack of Recognition of Order Set Importance
Order Set Design
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Often no standardized structure
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Structure is not modular
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Lack of integration with other processes/documents
Order set life cycle not well established
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No dedicated Order Set Committee at most hospitals
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Most often P+T/MAC based process, occasionally process is
distributed to the level of the health systems
Best practices often not scaled across departments
Lack of version control
No measurement of metrics
Each hospital has its own structure and approach to order sets
Order Set Project
2001: Order set development begins in ICU
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Rapid Cycle improvement of order set design
2002: Order set development in other departments
2003: Standardized order set format established
2004: Current Order Set Committee established
2006: Standardized order sets in use in every Health System
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Over 250 order sets currently in use
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Admission order set use > 90% in most health systems
Open Source Order Sets
Dedicated to improving healthcare in Canada by facilitating the use
of high quality, standardized evidence based order sets
Partnering with other Health Care Organizations to standardize and
improve the quality and safety of patient care
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Niagara Health System
Open Source Order Sets
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Provide a complete order set solution
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Save organizations time, money and reduce demand on limited
organizational resources
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Improve quality
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Local ownership and adaptation of tools
Open Source Order Sets
Standardized Order Set Design
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Standardized structure to order set content based on DAVID
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Rules of correct formatting at all levels of order set content
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Clear syntax of order set content
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Designed to anticipate CPOE
Modular Format
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Best practices are contained in functional groups
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Facilitates the spreading of best practices across different
order sets and across health systems
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Over 300 modules including many high value best practice
modules such as deep vein thrombosis prophylaxis, bowel
care, pain control, electrolyte management
Order Set Lifecycle
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Order Set Committee
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Interdisciplinary membership
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Robust methodology for development, approval,
implementation and maintenance
Open Source Order Sets
Large Library of Developed Content
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Over 250 order sets and clinical protocols
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Comprehensive interdisciplinary content
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Incorporation of real world experience
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Will grow to over 600 order sets in the next year
Order Set Web Page
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Web accessible data base to store library of order set content
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Order sets clearly organized, searchable by many different
criteria and relationships between order sets and clinical
protocols clearly established
Order Set Project Support
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On-site and remote support including physician, nursing,
pharmacy
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Goal is rapid knowledge transfer
Benefits
Save time
Save money
Improve the quality and safety of patient care
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Large improvements of easily measured metrics in short periods of
time
Improve order set design
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Increase order set use by physicians
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Increase the clinical impact of order set use
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Increase the standardization of best practices across the healthcare
system
Increase the knowledge base that can be used for order set
development
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Hospitals are no longer developing order set content in isolation
Improve the coordination of order sets with other order sets, documents
and processes
Improved coordination of health care delivery in Ontario
GBHN Order Set Project
First steps now being completed:
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Order Set Committee established – members:
Jessica Meleskie
GBHN, Chair
Sharon Musehl
Nursing, SBGHC
Lisa Laviolette
Nursing, GBHS
Michelle Scime-Benninger
Nursing, HDH
Trent Fookes
Pharmacy, GBHS
Greg Young
Laboratory, HDH
Dr. Randy Montag
HDH
Dr. Paul Eisenbarth
HDH
Dr. Lisa Roth
SBGHC
Dr. Roger Skinner
GBHS
Dr. Brendan Mulroy
GBHS
Pat Given
HIS, Order Sets
Susan Downs
HIS, Clinical documentation
Darlene Young
GBHN, Education/Utilization
Julia Metzger
GBHN, Administrative Assistant
Others as needed on an adhoc basis
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Meeting once a week to move project quickly into implementation
GBHN Order Set Project
First steps:
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Conversion of all of our current orders into the new modular format
Link directly from the GBHS Intranet, HDH Docushare, Icon on
SBGHC desktops
Beginning to merge our content with OSOS content
Next steps:
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Go live date – May 22 – first few order sets approved will go on the
website
Print-on-demand directly off website – 88 new printers being installed
this month across all GBHS sites where there have been issues
Will need a champion on each unit to remove of old order sets from
the units as we get new ones approved, replacement with new ones
(small volumes to ensure most up to date orders always being used,
print-on demand for low volume order sets)
Demo of Website
Initially see entire list of orders available
Click on name of document to print off and use
Search via key word at the top of the list, or click on “advanced
search” to search by many different parameters as can be seen on
the website
Can also see the entire library of Open Source Order Sets if click
on “Master OS Repository” on the left hand side
Will be releasing a memo each month with the new/changed
orders available on the website. Also releasing a newsletter as
necessary to update staff/physicians on project status
Involved with the Clinical Documentation project with Cerner to
build the order sets as developed into PowerOrders
NOTE: these do not replace the clinical pathways– they are
still available on the EBC website via the icon on the desktop.
They will be modified if necessary if the orders change, but
will still be used. The pathway orders will be available on both
sites – the EBC site as well as the Order Sets site
Sample: COPD Order Set
ADDRESSOGRAPH
Draft #3
GREY BRUCE HEALTH NETWORK
Page 1 of 4
Processed
SITE: _____________________
Chronic Obstructive Pulmonary Disease (COPD)
Order Set
Admit to __________: Dr _________________________to consult/assume MRP
Diagnosis: COPD:
with pneumonia________________________________
Isolation:
Contact
Droplet
Airborne re:____________________________
Comorbidities: a) ____________ b) _______________ c) _______________
Code Status:
________
________
________
Level 3 – All Care including CPR
Level 2 _______________________________________
Level 1 – Comfort Measures Only
NKA or: _____________________________________________
Allergies:
Family Physician:
Same as MRP, or __________________________________
Clinical pathway: ●Cerner Order for COPD Pathway
Consults: ___________________ Reason: __________________________
CCAC
Clinical Nutrition
Physiotherapy
Social Work
Discharge Planning
Occupational Therapy
Palliative Care Nurse
Pharmacy
Speech/Language Pathology
Respiratory Therapy (to teach regarding puffer use)
Diet:
Regular Diet
Regular Diet with NPO after 2400hrs
NPO
May take meds with sips if NPO
Energy Controlled Diet _____________kcal
Healthy Heart Diet
Other Diet: _____________________________________________
Activity:
AAT
Ambulate within 8h and TID
Vital Signs: ● Height & Weight on admission
● Intake and output x 24 hours
VS + O2 sats q4h x 24h, qid x24h then bid when stable
VS + O2 sats q4h
VS + O2 sats qshift
VS + O2 sats q _____h
Respiratory
O2 to keep SaO2 greater than 92%
02 ______L/minute via NP
COPD Patient: O2 to keep SaO2 88% - 92%
02 _______________________________
Patient Care
Tubes/Drains:
POC:
Foley Catheter
NG tube suction
POC Capillary Blood Glucose QID x 2 days
NG tube straight drain
POC Capillary Blood Glucose daily
Laboratory
On admission (if not already done in ER): (unless otherwise noted – via blood & routine)
● CBC
APTT, INR
● Lytes, Cr, Glucose
ABG
CPK, Troponin
Ca, Mg
ALT, ALP, Bili
AST
Sputum C+S
Blood C+S x 2 STAT
Urine R+M
Urine C+S
Physician’s Signature__________________________Date___________Time__________
C/1/GBHN/Med/-/COPD/MD/05-07/v1/-
Copyright © 2007 Grey Bruce Health Network
Kardex
COPD Order Set
May be printed on demand, or since it is fairly high volume, can
have 5-10 copies available printed on the unit
Physician will pull and write on the order set just like our current
orders
All orders have an admission header on them – where to admit,
diagnosis, isolation, comorbidities, code status, allergies, family
physician
Two types of orderables – open box is optional and must be ticked
before it is active; closed circle is an automatic order unless it is
crossed off
You will notice similar modules across all the order sets – same
choices on most of them, difference will be which ones are
automatic orders, and which ones are tick boxes. Many more
choices than we are used to, to be more flexible for patients with
multiple comorbidities.
COPD Order Set
If there is a clinical pathway, the next line will have the
order for the clinical pathway to be entered into Cerner
Next sections – Consults, Diet, Activity, vitals same as
current order sets we have seen in the past
Next section – Respiratory – will be a new category in
Cerner containing all treatments i.e. oxygen related to
respiratory
Patient care section – has subsections in it related to
nursing care – Tubes/Drains; Point of Care (POC)
Testing,
Laboratory, Diagnostic Tests, IV Solutions similar to our
current orders
COPD Order Set
Medication sections are divided up into
subcategories by type of medication:
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Antibiotics, Bronchodilator therapies, Steroid
therapies
PRN Medications – includes your Gravol, etc, as well
as refers to two protocols – Potassium Oral Dosing,
Bowel Routine
Smoking Cessation section, PRN Sedation section
Next sections are other protocols – diabetes related,
DVT prophylaxis protocol
All of these protocols are also available on the
website to follow if ordered.
COPD Order Set
All associated protocols can be found on the website for
reference
Documentation for the protocol – written “bowel care
protocol” on Kardex/Care Plan, and then tell pharmacy
when you are initiating the protocol and they will
document on the MAR sheet (GBHS). SBGHC, if a nurse
initiates a protocol, place protocol with med profile, add
“bowel protocol” to the med profile, and transcribe to the
MAR.
Some order sets will also have a new category called
“Communication Orders”. This is for orders such as “If
increased swelling or bleeding at the operative site,
notify physician”.
Questions