Using Your EMR for More than Just Documenting

Using Your EMR for More than Just Documenting Stacey Ryan MSN RN, Manager Infection Prevention Barbara Malacaria MS RN CCRN, Nursing Director

Journey to Zero Harm and High Reliability • Leadership Commitment • Safety Culture which allows staff to speak up • Robust Process Improvement

Process Improvement Use of the EMR to support consistency with processes, help provide pertinent data to aid clinical decision making and to be able to highlight clinical data to drive early diagnosis. Our answer is SURVEILLANCE

…more that just for documenting The EMR is: • • • A complex collection of templates Integrated algorithms that guide practice A safety net for patients Able to identify current and future trends A tool that can be used to drive clinicians toward clinical diagnosis

SURVEILLANCE Ø Tool that works in the background of EMR Ø Helps with analysis and interpretation of data Ø Takes predetermined data elements and links them together for real-time actionable items Ø Updated in real time as new data is available Ø Uses tracking boards, status boards and surveillance boards.

Ways to Use Surveillance Ø Guide clinicians to add items to problem list Ø Link clinicians to best practice guidelines and order sets Ø Take discrete data elements to trend patient status Ø Link nursing interventions to surveillance metrics Ø Translate safety information to patient tracker boards

Oversight of Surveillance Project Ø Ø Ø Interdisciplinary Team Application Process Project Owner Approval process by Team members Monthly update on all projects

Projects Ø Malnutrition Indicator Ø Legal Guardian Indicator Ø Adult Early Warning System: vital signs monitor Ø Sepsis Indicator Ø Antibiotic Stewardship Ø PEWS: pediatric early warning

Sepsis – What is it? • • Sepsis is the body’s extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection you have triggers a chain reaction throughout your body. Without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death.

Sepsis Stats According to the Centers for Disease Control: • More than 1. 7 million adults in America develop sepsis each year • Nearly 270, 000 die as a result • 1 in 3 patients who die in a hospital have sepsis

Sepsis – Reducing Mortality • Goal-directed therapy for the early resuscitation of patients with sepsis significantly reduces overall mortality in patients with sepsis, if initiated within the first 6 hours of diagnosis, Critical Care Medicine, 2014 Oct 20; 18(5): 570.

Sepsis –Goal Directed Therapy SHBH built 4 Sepsis Order Sets to drive clinicians to take specific actions for patients on the Sepsis Continuum: • • SIRS [Systemic Inflammatory Response Syndrome] Sepsis Severe Sepsis Septic Shock These order sets are based on best practice standards and include diagnostic tests, antibiotics, fluid resuscitation guidelines, the use of vasopressors, and triggers for changing the patient’s level of care.

Sepsis –Goal Directed Therapy Challenges Identified: • Missed opportunities for ordering the sets early • Inconsistent utilization of the order sets

Sepsis Surveillance • Build a Sepsis Surveillance Module within the Electronic Medical Record [EMR] • Flag patients that sepsis is suspected based on vital signs and labs • Drive clinicians to take specific actions including use of order sets

Sepsis Surveillance Creating the Team: • • • Information Technology Physicians Nursing Leadership Pharmacy Infection Prevention/ID Laboratory Staff Education Front-line staff Quality Specialist ! y ar M t l u s i id n i l p i c

Sepsis Surveillance Unique to SHBH: • “Widen the net” of patients captured – expand criteria for inclusion • Added Procalcitonin levels to the algorithm • Attached antibiotic guidelines based on infection source, best practice guidelines, and local Antibiogram • Hardwire a re-evaluation period

Sepsis Surveillance How it works: • Patient “flagged” Sepsis in EMR • Nurse takes action(s) - Recheck vital signs, and notify provider • Provider takes action(s) - Place Sepsis Order Set - Enter an event note (documents on the problem list) - Re-evaluate (2 hours, 4 hours, or 24 hours if sepsis is ruled out)

Sepsis – Measuring Success • • Mortality trends Order set usage Length of Stay Discharge disposition

Sepsis – Next Steps • Identify severe sepsis earlier • Attempt to manipulate positive microbiology results into discreet data to include in surveillance • Explore the rapid turn around organism testing with blood cultures

Future Projects Ø Ø Ø Obesity flagging for BMI>30 Link Obesity flag to OSA assessment Narcotic Usage Monitoring of High Risk for OSA Post operative surveillance system

Thank You! We would like to thanks Chris Mitchell who is the Senior Systems Analyst and coordinator of the surveillance system in Meditech. cmitchell@signature-healthcare. org