adrian lio, austin health: using a clinical system to address the national safety & quality...
DESCRIPTION
Adrian Lio, Lead Pharmacist, Clinical Systems Project Group, Austin Health, VIC delivered this presentation at the 2013 Electronic Medication Management conference. It is Australia’s only conference to look solely at electronic prescribing and electronic medication management systems. For more information on the annual event, please visit the conference website: http://www.healthcareconferences.com.au/emedmanagementTRANSCRIPT
Using a clinical system to address
the NSQHS standards
• What the NSQHS standards mean in an electronic prescribing
environment
• How reports are extracted and presented
• Tangible benefits from data reporting
• Targeting quality improvement strategies
ObjectivesObjectives
• Major tertiary health provider in northeast Melbourne
• 3 campuses
– The Austin Hospital
– Heidelberg Repatriation Hospital
– Royal Talbot Rehabilitation Centre
• Major services
– Victorian Spinal Cord Service
– Victorian Respiratory Support Services
– Oncology Services
– Victorian Liver Transplant Unit
Austin HealthAustin Health
2011
Radiology orders
Pathology orders
e-Prescribing
Discharge Summaries
Results & Results Endorsement
2012
Inpatient medications
MAR
Fluid balance chart
724 Access
2013
Clinical Documentation
First Net
? Oncology system
? Device Integration
? Surgi Net
The Austin Health EMR JourneyThe Austin Health EMR Journey
Clinical System Chosen:
• 2011 – Phase One Implementation
– Single sign on to clinical applications
– Electronic Ordering Pathology and Radiology
– Electronic Ordering of Discharge Prescriptions
– Results reporting and tracking of Acknowledgment
– Clinical Decision Support
– Electronic Discharge Summaries
What is ‘Live’ now?What is ‘Live’ now?
• 2012 – Phase Two Implementation
– Replace the National Inpatient Medications Chart
– Inpatient medications
» Prescribe
» Verify and dispense
» Administer at bedside
– VTE & Allergies Documentation
– Fluid Balance Chart Documentation
– Nurse/Patient Care Orders
– Patient ID via barcode scanning
– Immunisation Documentation
– 724 ‘Downtime’ viewer
What is ‘Live’ now?What is ‘Live’ now?
• New national standards
– 10 national standards with an
additional nutrition standard for
Victoria
Governance
Partnering with Consumers
Healthcare Associated Infections
Medication Safety
Patient Identification & Procedure
Matching
Clinical Handover
Blood & Blood Products
Pressure Injuries
Deterioration in Acute Health Care
Falls
The National Quality Safety and Health StandardsThe National Quality Safety and Health Standards
• New national standards
– Effective January 2013
– The standards have 225 core actions which are deemed critical for
safety and quality
– In addition there are 33 developmental actions which aid in quality
improvement
– Each action assessed against a three point rating scale
» Not Met: Actions have not been achieved
» Satisfactorily Met: Actions required have been achieved
» Met with Merit: Actions required have been achieved with evidence
of a higher level of achievement
NSQHS – AccreditationNSQHS – Accreditation
• Self assessment
– Documenting and assessing evidence against each standard and
developing an action plan for those ‘Not Met’
– Self-assessment was conducted over July and August 2012 with key
stakeholders, CSUs and relevant clinical governance committees
NSQHS – Self-assessmentNSQHS – Self-assessment
NSQHS – Self-assessmentNSQHS – Self-assessment
Standard 4: Medication Safety
– Core Items Met: 10/31
– Developmental Items Met: 0/6
– Main areas of non-compliance:
» Auditing of Medication Management system
» Auditing of Medication Authorisation system
» Auditing of Decision Support Tools
» Auditing of Medication storage and distribution systems
» Auditing of High Risk medications
» Medication allergy and adverse drug reaction processes
• Electronic medication management system
– No more illegible orders
– Transparency in relation to medication administration
– Ability to build prescribing guidance
– Ability to enforce prescribing guidelines and policies
– Barcode scanning
– Closed-loop medication management
– Discern Analytics: Cerner Data Reporting Solution
» Data retrieval is fast
» Ability to extract data and export to a CSV file for further
manipulation
Advantages of CernerAdvantages of Cerner
• Build methodology addresses:
– Standard 4.2.2 : Action is taken to reduce the risks identified in the
medication management system
– Standard 4.4.2 : Action is taken to reduce the risk of adverse
medication incidents
– Standard 4.5.2 : Quality improvement activities are undertaken to
reduce the risk of patient harm and increase the quality and
effectiveness of medicines use
• Order Sentences with pre-built instructions
• Care Sets and Power Plans containing built in guidance
1. Standardised Ordering1. Standardised Ordering
Medication instructions: Ciprofloxacin
1. Standardised Ordering1. Standardised Ordering
Ordering: Glyceryl Trinitrate Patch
1. Standardised Ordering1. Standardised Ordering
Ordering: Exforge HCT
1. Standardised Ordering1. Standardised Ordering
Evidenced Based Information : ED Constipation Pathway
1. Standardised Ordering1. Standardised Ordering
Warfarin: Mandatory documentation of INR range
1. Standardised Ordering1. Standardised Ordering
2. Antibiotic Stewardship2. Antibiotic Stewardship
• Translating current antimicrobial prescribing
policy to an electronic system– Standard 4.1.1 : Governance arrangements are in place to support the
development, implementation and maintenance of organisation wide medication
safety systems
– Standard 4.1.2 : Policies, procedures and/or protocols are in place that are
consistent with legislative requirements, national, jurisdictional and professional
guidelines
– Standard 4.3.3 : Action is taken to increase the effectiveness of the medication
authority system
– Standard 4.4.2 : Action is taken to reduce the risk of adverse medication
incidents
– Standard 4.5.2 : Quality improvement activities are undertaken to reduce the
risk of patient harm and increase the quality and effectiveness of medicines use
• To promote appropriate and proper prescribing of antimicrobials
• Multiple methods at achieving this:
– Specialised Care Sets and order sentences including time offsets
and drug level reminder tasks
– Discern Alert
– Discern Analytics reports for ID Physicians and Pharmacist
2. Antibiotic Stewardship2. Antibiotic Stewardship
• Care Sets contain the ability to include prescribing guidance and
information
• Ability to combine medications, pathology and radiology orders in
one ordering window
• Ability to incorporate time off-sets on orders to facilitate drug
level monitoring
2. Antibiotic Stewardship – Care Sets2. Antibiotic Stewardship – Care Sets
2. Antibiotic Stewardship – Care Sets2. Antibiotic Stewardship – Care Sets
2. Antibiotic Stewardship – Care Sets2. Antibiotic Stewardship – Care Sets
• Austin Health’s ‘Good Antimicrobial Prescribing Practice (GAPP)’
policy required custom build in to Cerner.
• Currently using an online approval system (IDEA3S) to generate
approval numbers based on selection criteria
• On paper
– approval number is written on the drug chart
– Required before administration but not always followed
• In Cerner
– Creative use of Discern Alert
– Cannot proceed with order unless approval number is documented
in appropriate field
2. Antibiotic Stewardship – Discern Alert2. Antibiotic Stewardship – Discern Alert
2. Antibiotic Stewardship – Discern Alert2. Antibiotic Stewardship – Discern Alert
2. Antibiotic Stewardship – Discern Alert2. Antibiotic Stewardship – Discern Alert
2. Antibiotic Stewardship – Discern Analytics2. Antibiotic Stewardship – Discern Analytics
• Custom reports can be run out of Cerner through a program
‘Discern Analytics’
• Able to retrieve data quickly and in real-time
• Export to Excel (in ‘csv’ format) provides ability for further
manipulation
2. Antibiotic Stewardship – Discern Analytics2. Antibiotic Stewardship – Discern Analytics
2. Antibiotic Stewardship – Discern Analytics2. Antibiotic Stewardship – Discern Analytics
2. Antibiotic Stewardship – Discern Analytics2. Antibiotic Stewardship – Discern Analytics
3. VTE and Allergy Recording Alerts3. VTE and Allergy Recording Alerts
• Various alerts in place related to VTE Risk,
Treatment and allergy recording
– Standard 4.4.2 : Action is taken to reduce the risk of adverse
medication incidents
– Standard 4.5.2 : Quality improvement activities are undertaken to
reduce the risk of patient harm and increase the quality and
effectiveness of medicines use
• Replicates requirements of the National Inpatient Medication
Chart
• Opens when opening a patient profile or ordering for the patient
3. VTE and Allergy Recording Alerts3. VTE and Allergy Recording Alerts
Patient with no allergies or VTE risk assessed
3. VTE and Allergy Recording Alerts3. VTE and Allergy Recording Alerts
Allergy documentation screen (inc. Height and Weight)
3. VTE and Allergy Recording Alerts3. VTE and Allergy Recording Alerts
Power Form for prescribers to document VTE Risk assessment
3. VTE and Allergy Recording Alerts3. VTE and Allergy Recording Alerts
3. VTE and Allergy Recording Alerts3. VTE and Allergy Recording Alerts
Power Plan to guide ordering of medications
3. VTE and Allergy Recording Alerts3. VTE and Allergy Recording Alerts
Alert: High Risk VTE documented but overdue task
3. VTE and Allergy Recording Alerts3. VTE and Allergy Recording Alerts
Alert: High Risk VTE documented but no VTE Prophylaxis
• Quality report of assessment of VTE Risk
– Standard 4.2.2 : Action is taken to reduce the risks identified in the
medication management system
– Standard 4.5.1 : The performance of the medication management
system is regularly assessed
• Created by Department of Health
• Current report builds a snapshot of patients’ VTE Risk Assessment
• Can run report filtered by ward location, medical unit and date
admitted and date discharged or current inpatients over a
specified period
4. VTE Risk Assessment Report4. VTE Risk Assessment Report
• Built using custom CCL (Cerner Command
Language) reports
– CCL provides possibilities for querying and reporting on any data
from Cerner.
– CCL allows a programmer to retrieve data from the database and
display it in a way the user requires
– Current Process: A request is submitted by one of the health
organisations and a specification sheet is drafted.
– Specification sheet details the logic required for inclusion and
exclusion of data as well as details about fields that are presented
4. VTE Risk Assessment Report4. VTE Risk Assessment Report
• VTE Risk Assessment Inclusion criteria:
– Patient registered to the specific facility and/or location
– Encounter status: Cancelled encounters are excluded
– Can select between patients who were:
» Admitted and Discharged between a date range
» Had active encounters within a date range
4. VTE Risk Assessment Report4. VTE Risk Assessment Report
4. VTE Risk Assessment Report4. VTE Risk Assessment Report
4. VTE Risk Assessment Report4. VTE Risk Assessment Report
4. VTE Risk Assessment Report4. VTE Risk Assessment Report
• Excel report retrieves:
– Name of patient, UR number, ward location, medical unit
– Admission Date/Time and Discharge Date/Time
– First Date/Time of documented VTE Risk
– Details of initial documentation of VTE Risk (High risk, Low risk etc.)
– Most recent Date/Time of documented VTE Risk
– Details of most recent documentation of VTE Risk (High risk, Low
risk etc.)
– Total number of patients evaluated
– Total number of patients with VTE Risk assessment documented
5. Allergy Report5. Allergy Report
• Allergy Key Performance Indicator Report
– Standard 4.4.2 : Action is taken to reduce the risk of adverse
medication incidents
– Standard 4.5.1 : The performance of the medication management
system is regularly assessed
– Standard 4.7.1 : Known medication allergies and adverse drug
reactions are documented in the patient clinical record
– Standard 4.7.2 : Action is taken to reduce the risk of adverse
reactions
5. Allergy Report5. Allergy Report
• Allergy Key Performance Indicator Report
– Retrieves Patient’s name, ward location and medical unit
– Patient inclusion criteria:
» If patient has no allergy recorded
» If the patient ‘s allergies have been modified or updated after 24
hours since admission
� Note: If the patient had pre-existing allergies that was updated within 24
hours of admission, the patient will not qualify for the report but will be
counted in statistics at the end of the report. If a patient has ‘No Known
Allergies’ but not reviewed within 24 hours, the patient will qualify for
the report
» Patients have been admitted greater than 24 hours
5. Allergy Report5. Allergy Report
5. Allergy Report5. Allergy Report
Footer section of Allergy KPI report:
• Excel version also available
– Retrieves similar columns but extra column with ‘Meds Prescribed’
section for that patient
6. Medication Administration Reports6. Medication Administration Reports
• Using Discern Analytics
– Ability to do reports on Medication Administration events
– Allows deeper investigation into medication administration tasks
» Retrieves all administrations for an orderable(s) over a period of time
» Can display when a dose a administered
» Can display the dose that was documented as given (as opposed to
looking at the order detail display line)
» If a task was ‘Not Done’ and the reason selected
» Allows investigation into trends, usage statistics and identification of
errors
» Can look at current events as well as retrospective analysis
– Incredible advantage due to speed of access to information
6. Medication Administration Reports6. Medication Administration Reports
• Examples:
– Report on Clexane Administration
times
» Hospital policy change to make
Clexane administration times at 8am
» Further excel manipulation allowed the
report to look at percentages of
administrations outside the scheduled
times and filter by ward location
6. Medication Administration Reports6. Medication Administration Reports
• Examples:
– Report of medication administrations that were ‘Not Done’
» Local project looking at definitions of ‘Nil Oral’ and ‘Fasting’
» Report from Cerner allowed analysis of whether current practices are
appropriate
– Report on fentanyl patch administrations
» Review of ‘STAT’ (Once-only) administrations of fentanyl patch
» Led to implementation of Fentanyl patch removal tasks
– Report for high-risk drugs
» How often Naloxone is being used when looking at incidences of
opioid overdose
» Use of IV morphine on the wards
» High-dose insulin usage rates
ConclusionConclusion
• Implementation of Cerner has opened many
possibilities for improving practice
– Various tools to help translate current policies to an electronic
environment
– Specialised dosing instructions allows standardised dosing
– Allows quick, real-time access to data through the use of Discern
Analytics and custom built CCL reports
– Reports provides evidence for supporting the new NSQHS
• Future directions:
– Further implementation: Medication reconciliation
– More advanced reporting tools