GBHN Order Sets An effective solution to the

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 n Misuse, under use, overuse on a massive scale: Crossing the Quality Chasm 2001 Safety n Medical error is common: Institute Of Medicine Report on Error 2000 Variation in Care n 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. n n 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 best practices Source of education n Can be used in paper or computerized ordering systems

Order Sets: Key Benefits Safety n Reduced transcription errors n Reduced errors of omission n Reduced errors in medication dosing Quality n Improved compliance with evidence-based best practices n Standardization of care Efficiency n Decreased time to write and process orders n Reduction in physician call-backs n 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 n Often no standardized structure n Structure is not modular n Lack of integration with other processes/documents Order set life cycle not well established n No dedicated Order Set Committee at most hospitals n 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

Trillium’s Order Set Project 2001: Order set development begins in ICU n 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 n Over 250 order sets currently in use n Admission order set use > 90% in most health systems

Open Source Order Sets Based on Trilliums award winning Order Set Project 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 n Niagara Health System Open Source Order Sets n Provide a complete order set solution n Save organizations time, money and reduce demand on limited organizational resources n Improve quality n Local ownership and adaptation of tools

Open Source Order Sets Standardized Order Set Design n Standardized structure to order set content based on DAVID n Rules of correct formatting at all levels of order set content n Clear syntax of order set content n Designed to anticipate CPOE Modular Format n Best practices are contained in functional groups n Facilitates the spreading of best practices across different order sets and across health systems n 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 n Order Set Committee n Interdisciplinary membership n Robust methodology for development, approval, implementation and maintenance

Open Source Order Sets Large Library of Developed Content n Over 250 order sets and clinical protocols n Comprehensive interdisciplinary content n Incorporation of real world experience n Will grow to over 600 order sets in the next year Order Set Web Page n Web accessible data base to store library of order set content n Order sets clearly organized, searchable by many different criteria and relationships between order sets and clinical protocols clearly established Order Set Project Support n On-site and remote support including physician, nursing, pharmacy n Goal is rapid knowledge transfer

Benefits of Partnering with OSOS Save time Save money Improve the quality and safety of patient care n Large improvements of easily measured metrics in short periods of time Improve order set design n Increase order set use by physicians n Increase the clinical impact of order set use n Increase the standardization of best practices across the healthcare system Increase the knowledge base that can be used for order set development n 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: n 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 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 n Meeting once a week to move project quickly into implementation

GBHN Order Set Project First steps: n n n Conversion of all of our current orders into the new modular format Link directly from the GBHS Intranet Beginning to merge our content with OSOS content Next steps (May 07): n n n Implementation – staff need to know how to access orders via website Print-on-demand directly off website – 88 new printers being installed this month across all GBHS sites Removal 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 to ensure staff/physicians are up to date on the latest changes 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 Power. Orders 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

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: n n n Antibiotics, Bronchodilator therapies, Steroid therapies Pain control – patient may be on Acute Pain Service or not – options are there for both 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, and then tell pharmacy when you are initiating the protocol and they will document on the MAR sheet. 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