GBHN Order SetsGBHN Order Sets

An effective solution to the complex An effective solution to the complex challenge of improving patient care and challenge of improving patient care and

safetysafety

AgendaAgenda

Call for questions – to be answered at the Call for questions – to be answered at the end of the presentationend of the presentation

Overview of partnershipOverview of partnership

Project ProcessProject Process

Demo of websiteDemo of website

Sample order sets/protocolsSample order sets/protocols

Context: MContext: Massive Gap Between the assive Gap Between the Possible and the ActualPossible and the Actual

Quality Quality Misuse, under use, overuse on a massive scale:Misuse, under use, overuse on a massive scale:

Crossing the Quality Chasm 2001Crossing the Quality Chasm 2001

SafetySafety Medical error is common:Medical error is common:

Institute Of Medicine Report on Error 2000Institute Of Medicine Report on Error 2000

Variation in CareVariation in Care Variability in care not explained by patient Variability in care not explained by patient

preferences or different disease patterns: preferences or different disease patterns:

British Medical Journal 2002; 325: 961-964British Medical Journal 2002; 325: 961-964

A group of orders with a common functional purpose used by the A group of orders with a common functional purpose used by the physician to create orders.physician to create orders.

Integrates knowledge into the care delivery process “knowledge Integrates knowledge into the care delivery process “knowledge where the clinician needs it most”where the clinician needs it most”

Organizes clinical knowledge so it is easy to remember, easy to Organizes clinical knowledge so it is easy to remember, easy to use and has maximum benefit to the patient use and has maximum benefit to the patient

Contain evidence-based and best practicesContain evidence-based and best practices

Source of education Source of education

Can be used in paper or computerized ordering systemsCan be used in paper or computerized ordering systems

Solution: Solution: Order Sets a Clinical Decision Support ToolOrder Sets a Clinical Decision Support Tool

Order Sets: Key BenefitsOrder Sets: Key Benefits

SafetySafety Reduced transcription errorsReduced transcription errors Reduced errors of omissionReduced errors of omission Reduced errors in medication dosingReduced errors in medication dosing

QualityQuality Improved compliance with evidence-based and best practicesImproved compliance with evidence-based and best practices Standardization of careStandardization of care

EfficiencyEfficiency Decreased time to write and process ordersDecreased time to write and process orders Reduction in physician call-backsReduction in physician call-backs Reduction in missed orders Reduction in missed orders

Critical enabler for computerized practitioner Critical enabler for computerized practitioner order entryorder entry

Current Status of Order SetsCurrent Status of Order Sets

Lack of Recognition of Order Set ImportanceLack of Recognition of Order Set ImportanceOrder Set DesignOrder Set Design

Often no standardized structure Often no standardized structure Structure is not modularStructure is not modular Lack of integration with other processes/documentsLack of integration with other processes/documents

Order set life cycle not well established Order set life cycle not well established No dedicated Order Set Committee at most hospitals No dedicated Order Set Committee at most hospitals Most often P+T/MAC based process, occasionally process is Most often P+T/MAC based process, occasionally process is

distributed to the level of the health systemsdistributed to the level of the health systemsBest practices often not scaled across departmentsBest practices often not scaled across departmentsLack of version controlLack of version controlNo measurement of metricsNo measurement of metricsEach hospital has its own structure and approach to order setsEach hospital has its own structure and approach to order sets

Order Set ProjectOrder Set Project

2001: Order set development begins in ICU2001: Order set development begins in ICU Rapid Cycle improvement of order set designRapid Cycle improvement of order set design

2002: Order set development in other departments 2002: Order set development in other departments

2003: Standardized order set format established 2003: Standardized order set format established

2004: Current Order Set Committee established 2004: Current Order Set Committee established

2006: Standardized order sets in use in every Health System2006: Standardized order sets in use in every Health System Over 250 order sets currently in useOver 250 order sets currently in use Admission order set use > 90% in most health systemsAdmission order set use > 90% in most health systems

Open Source Order SetsOpen Source Order Sets

Dedicated to improving healthcare in Canada by facilitating the use Dedicated to improving healthcare in Canada by facilitating the use of high quality, standardized evidence based order sets of high quality, standardized evidence based order sets

Partnering with other Health Care Organizations to standardize and Partnering with other Health Care Organizations to standardize and improve the quality and safety of patient careimprove the quality and safety of patient care

Niagara Health System Niagara Health System

Open Source Order Sets Open Source Order Sets Provide a complete order set solutionProvide a complete order set solution Save organizations time, money and reduce demand on limited Save organizations time, money and reduce demand on limited

organizational resourcesorganizational resources Improve qualityImprove quality Local ownership and adaptation of toolsLocal ownership and adaptation of tools

Open Source Order SetsOpen Source Order SetsStandardized Order Set DesignStandardized Order Set Design

Standardized structure to order set content based on DAVIDStandardized structure to order set content based on DAVID Rules of correct formatting at all levels of order set contentRules of correct formatting at all levels of order set content Clear syntax of order set contentClear syntax of order set content Designed to anticipate CPOEDesigned to anticipate CPOE

Modular FormatModular Format Best practices are contained in functional groupsBest practices are contained in functional groups Facilitates the spreading of best practices across different Facilitates the spreading of best practices across different

order sets and across health systemsorder sets and across health systems Over 300 modules including many high value best practice Over 300 modules including many high value best practice

modules such as deep vein thrombosis prophylaxis, bowel modules such as deep vein thrombosis prophylaxis, bowel care, pain control, electrolyte management care, pain control, electrolyte management

Order Set LifecycleOrder Set Lifecycle Order Set Committee Order Set Committee Interdisciplinary membershipInterdisciplinary membership Robust methodology for development, approval, Robust methodology for development, approval,

implementation and maintenance implementation and maintenance

Open Source Order SetsOpen Source Order SetsLarge Library of Developed Content Large Library of Developed Content

Over 250 order sets and clinical protocolsOver 250 order sets and clinical protocols Comprehensive interdisciplinary content Comprehensive interdisciplinary content Incorporation of real world experienceIncorporation of real world experience Will grow to over 600 order sets in the next yearWill grow to over 600 order sets in the next year

Order Set Web PageOrder Set Web Page Web accessible data base to store library of order set contentWeb accessible data base to store library of order set content Order sets clearly organized, searchable by many different Order sets clearly organized, searchable by many different

criteria and relationships between order sets and clinical criteria and relationships between order sets and clinical protocols clearly establishedprotocols clearly established

Order Set Project SupportOrder Set Project Support On-site and remote support including physician, nursing, On-site and remote support including physician, nursing,

pharmacy pharmacy Goal is rapid knowledge transferGoal is rapid knowledge transfer

BenefitsBenefitsSave timeSave time

Save moneySave money

Improve the quality and safety of patient careImprove the quality and safety of patient care Large improvements of easily measured metrics in short periods of Large improvements of easily measured metrics in short periods of

timetime

Improve order set design Improve order set design Increase order set use by physicians Increase order set use by physicians Increase the clinical impact of order set useIncrease the clinical impact of order set use Increase the standardization of best practices across the healthcare Increase the standardization of best practices across the healthcare

systemsystem

Increase the knowledge base that can be used for order set developmentIncrease the knowledge base that can be used for order set development Hospitals are no longer developing order set content in isolationHospitals are no longer developing order set content in isolation

Improve the coordination of order sets with other order sets, documents Improve the coordination of order sets with other order sets, documents and processes and processes

Improved coordination of health care delivery in OntarioImproved coordination of health care delivery in Ontario

GBHN Order Set ProjectGBHN Order Set ProjectFirst steps now being completed:First steps now being completed:

Order Set Committee established – members:Order Set Committee established – members:

Jessica Meleskie Jessica Meleskie GBHN, ChairGBHN, ChairSharon Musehl Sharon Musehl Nursing, SBGHCNursing, SBGHCLisa LavioletteLisa Laviolette Nursing, GBHSNursing, GBHSMichelle Scime-BenningerMichelle Scime-Benninger Nursing, HDHNursing, HDHTrent FookesTrent Fookes Pharmacy, GBHSPharmacy, GBHSGreg Young Laboratory, HDHGreg Young Laboratory, HDHDr. Randy MontagDr. Randy Montag HDHHDHDr. Paul EisenbarthDr. Paul Eisenbarth HDHHDHDr. Lisa RothDr. Lisa Roth SBGHCSBGHCDr. Roger SkinnerDr. Roger Skinner GBHSGBHSDr. Brendan MulroyDr. Brendan Mulroy GBHSGBHSPat GivenPat Given HIS, Order SetsHIS, Order SetsSusan DownsSusan Downs HIS, Clinical documentationHIS, Clinical documentationDarlene YoungDarlene Young GBHN, Education/UtilizationGBHN, Education/UtilizationJulia MetzgerJulia Metzger GBHN, Administrative AssistantGBHN, Administrative AssistantOthers as needed on an adhoc basisOthers as needed on an adhoc basis

Meeting once a week to move project quickly into implementationMeeting once a week to move project quickly into implementation

First steps:First steps: Conversion of all of our current orders into the new modular formatConversion of all of our current orders into the new modular format Link directly from the GBHS Intranet, HDH Docushare, Icon on Link directly from the GBHS Intranet, HDH Docushare, Icon on

SBGHC desktopsSBGHC desktops Beginning to merge our content with OSOS contentBeginning to merge our content with OSOS content

Next steps:Next steps: Go live date – May 22 – first few order sets approved will go on the Go live date – May 22 – first few order sets approved will go on the

websitewebsite Print-on-demand directly off website – 88 new printers being installed Print-on-demand directly off website – 88 new printers being installed

this month across all GBHS sites where there have been issuesthis month across all GBHS sites where there have been issues Will need a champion on each unit to remove of old order sets from 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 the units as we get new ones approved, replacement with new ones (small volumes to ensure most up to date orders always being used, (small volumes to ensure most up to date orders always being used, print-on demand for low volume order sets)print-on demand for low volume order sets)

GBHN Order Set ProjectGBHN Order Set Project

Demo of WebsiteDemo of WebsiteInitially see entire list of orders availableInitially see entire list of orders availableClick on name of document to print off and useClick on name of document to print off and useSearch via key word at the top of the list, or click on “advanced 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 search” to search by many different parameters as can be seen on the websiteon the websiteCan also see the entire library of Open Source Order Sets if click Can also see the entire library of Open Source Order Sets if click on “Master OS Repository” on the left hand sideon “Master OS Repository” on the left hand sideWill be releasing a memo each month with the new/changed Will be releasing a memo each month with the new/changed orders available on the website. Also releasing a newsletter as orders available on the website. Also releasing a newsletter as necessary to update staff/physicians on project statusnecessary to update staff/physicians on project statusInvolved with the Clinical Documentation project with Cerner to Involved with the Clinical Documentation project with Cerner to build the order sets as developed into PowerOrdersbuild the order sets as developed into PowerOrdersNOTE: these do not replace the clinical pathways– they are NOTE: these do not replace the clinical pathways– they are still available on the EBC website via the icon on the desktop. still available on the EBC website via the icon on the desktop. They will be modified if necessary if the orders change, but They will be modified if necessary if the orders change, but will still be used. The pathway orders will be available on will still be used. The pathway orders will be available on both sites – the EBC site as well as the Order Sets siteboth sites – the EBC site as well as the Order Sets site

Sample: COPD Order SetSample: COPD Order Set

C/1/GBHN/Med/-/COPD/MD/05-07/v1/- Copyright © 2007 Grey Bruce Health Network

Processed

Chronic Obstructive Pulmonary Disease (COPD) Order Set Kardex

Page 1 of 4

GREY BRUCE HEALTH NETWORK

SITE: _____________________

Draft #3

ADDRESSOGRAPH

Physician’s Signature__________________________Date___________Time__________

________

________ ________

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

Allergies: NKA or: _____________________________________________

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% COPD Patient: O2 to keep SaO2 88% - 92% 02 ______L/minute via NP 02 _______________________________

Patient Care Tubes/Drains: Foley Catheter NG tube suction NG tube straight drain

POC: POC Capillary Blood Glucose QID x 2 days 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

COPD Order SetCOPD Order Set

May be printed on demand, or since it is fairly high volume, can May be printed on demand, or since it is fairly high volume, can have 5-10 copies available printed on the unithave 5-10 copies available printed on the unitPhysician will pull and write on the order set just like our current Physician will pull and write on the order set just like our current ordersordersAll orders have an admission header on them – where to admit, All orders have an admission header on them – where to admit, diagnosis, isolation, comorbidities, code status, allergies, family diagnosis, isolation, comorbidities, code status, allergies, family physician physician Two types of orderables – open box is optional and must be ticked 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 before it is active; closed circle is an automatic order unless it is crossed offcrossed offYou will notice similar modules across all the order sets – same You will notice similar modules across all the order sets – same choices on most of them, difference will be which ones are choices on most of them, difference will be which ones are automatic orders, and which ones are tick boxes. Many more automatic orders, and which ones are tick boxes. Many more choices than we are used to, to be more flexible for patients with choices than we are used to, to be more flexible for patients with multiple comorbidities.multiple comorbidities.

COPD Order SetCOPD Order Set

If there is a clinical pathway, the next line will have the If there is a clinical pathway, the next line will have the order for the clinical pathway to be entered into Cernerorder for the clinical pathway to be entered into CernerNext sections – Consults, Diet, Activity, vitals same as Next sections – Consults, Diet, Activity, vitals same as current order sets we have seen in the pastcurrent order sets we have seen in the pastNext section – Respiratory – will be a new category in Next section – Respiratory – will be a new category in Cerner containing all treatments i.e. oxygen related to Cerner containing all treatments i.e. oxygen related to respiratoryrespiratoryPatient care section – has subsections in it related to Patient care section – has subsections in it related to nursing care – Tubes/Drains; Point of Care (POC) nursing care – Tubes/Drains; Point of Care (POC) Testing, Testing, Laboratory, Diagnostic Tests, IV Solutions similar to our Laboratory, Diagnostic Tests, IV Solutions similar to our current orderscurrent orders

COPD Order SetCOPD Order Set

Medication sections are divided up into Medication sections are divided up into subcategories by type of medication:subcategories by type of medication: Antibiotics, Bronchodilator therapies, Steroid Antibiotics, Bronchodilator therapies, Steroid

therapiestherapies PRN Medications – includes your Gravol, etc, as well PRN Medications – includes your Gravol, etc, as well

as refers to two protocols – Potassium Oral Dosing, as refers to two protocols – Potassium Oral Dosing, Bowel RoutineBowel Routine

Smoking Cessation section, PRN Sedation sectionSmoking Cessation section, PRN Sedation section Next sections are other protocols – diabetes related, Next sections are other protocols – diabetes related,

DVT prophylaxis protocol DVT prophylaxis protocol All of these protocols are also available on the All of these protocols are also available on the

website to follow if ordered.website to follow if ordered.

COPD Order SetCOPD Order Set

All associated protocols can be found on the website for All associated protocols can be found on the website for referencereferenceDocumentation for the protocol – written “bowel care Documentation for the protocol – written “bowel care protocol” on Kardex/Care Plan, and then tell pharmacy protocol” on Kardex/Care Plan, and then tell pharmacy when you are initiating the protocol and they will when you are initiating the protocol and they will document on the MAR sheet (GBHS). SBGHC, if a nurse document on the MAR sheet (GBHS). SBGHC, if a nurse initiates a protocol, place protocol with med profile, add initiates a protocol, place protocol with med profile, add “bowel protocol” to the med profile, and transcribe to the “bowel protocol” to the med profile, and transcribe to the MAR. MAR. Some order sets will also have a new category called Some order sets will also have a new category called “Communication Orders”. This is for orders such as “If “Communication Orders”. This is for orders such as “If increased swelling or bleeding at the operative site, increased swelling or bleeding at the operative site, notify physician”. notify physician”.

QuestionsQuestions