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CDS Nursing Data Entry Workflow

Page history last edited by David A Collins 14 years, 8 months ago

CDS Nursing Data Entry Workflow

 

 

OVERVIEW:

  • Nursing staff to complete the VTE risk assessment
  • Nurse notification to physician on VTE risk
  • Physician gives prophylaxis orders based on risk to Nursing staff for entering electronically or submit as written orders for verification/dispensing

 

 

MODEL PRACTICES

  • Ensure buy-in from nursing leadership and staff on importance of nursing role in VTE risk assessment and prophylaxis
  • Ensure VTE risk assessment forms are part of patient assessment documentation, this could be for the entire patient population or could be driven off chief complaint documentation, problem lists, admitting diagnoses
  • Create tasks for nursing to complete VTE risk assessment in a timely manner, escalation process for Nurse managers, Unit managers to monitor timely risk assessment
  • Identify change in level of care or venue of care that may change patient's risk for VTE. Ability to notify nursing staff (Alert fatigue to be considered)
  • Provide feedback to nursing staff on process compliance

 

 

 

 

 

2.During Encounter/Episode Could be office visit or hospitalization.  Hospitalizations will begin and end with first and last steps, and include multiple passes through the steps        
Participants/Workflow step Goals General CDS Strategies Specific CDS Considerations Given Paper/Digital Tools Outcomes/Lessons Learned/Pearls Owners/Stakeholders Metrics  
               
Nurse & Patient/Intake Gather and document key data items to help inform/speed subsequent H&P, planning and reporting; VTE Risk Asessment, contraindications to VTE prophylaxis;
Provide initial education and communication to patient

 
 Patient self-assessment forms (if not completed pre-visit); nursing assessment forms/tools/references on key nursing data to gather (e.g. related to symptoms, meds, VTE risk assessment (with assignment of risk category), contraindications to VTE prophylaxis, etc.)
• Collect history of present illness and document
• Vital signs
• Other pertinent information
Paper: Structured documentation on paper, incorporated into documentation workflow    

Effectiveness of CDS interventions (financial and clinical)

 

 
      Digital:
• structured form included in nursing documentation system
• Link risk categories to recommendations for corresponding specific prophylaxis orders
• Provide alert if risk assessment not completed
  • Nurses have a role, whether gather data or act as a check/balance.  Nurse can asssist in gathering information to assist physician with information collection. 
  • Role of VTE assessment, i.e., identifying risk strata, should be completed by physician. CDS tools, paper or digital, should integrate VTE assessment.
  • Minimizing the number of workflow steps is optimal. Time parameters are necessary. 
  • Escalating notification from primary nurse to charge nurse provides check/balance, alleviates tasks to floor nurse.
  • Tasks, that are alerts, should be essential items, and completed tasks should not remain as noise.
     
      Specific CDS Considerations Given Paper/Digital Tools Outcomes/Lessons Learned/Pearls Owners/Stakeholders Metrics  
    Advocate Paper: Done by nursing at our non-live (2) sites.   

Nursing 

Physicians

   
      Digital:Online risk assessment tool completed by nursing within 8 hrs. of admission.  A task is automatically placed on the RN's "PAL" (patient activity list) upon admission of all patients >18 yrs. old.  It is "past due" if not completed within the 8 hrs.   A second task is also automatic to contact the physician with the risk assessment score within 12 hrs. of admission.  As above, delayed tasks become "past due".

High level of risk assessments being completed.  Physicians were resistant to completing an assessment form. 

Risk assessments should also be performed upon change of venue or status, e.g. medical admit goes to surgery or to ICU-currently not in place.

[Does change in venue trigger the nursing task?  NO Is this for every single patient?  Potential alert-fatigue issue? WILL BE CONSIDERED, HOWEVER IMPORTANT UPON CHANGE OF VENUE TO EITHER INITIATE OR D/C PROPHYLAXIS CHANGE.]

VTE alert given to physicians who have not ordered any prophylaxis whether contacted by nursing or not, upon opening chart

Nursing 

Physicians

High level of risk assessments and notification completed.  However, appropriateness of prophylaxis may be inadequate.   
      Hybrid:        
    CHOP Paper: Risk assessment tool is incorporated into the nursing admission intake paperwork.  Nurses will assess patients 14 years or older. On the paper, there are 14 risk conditions that must be evaluated in order to assign patients as either 'at risk' or 'at high risk'.   The risk assignments remains in the patient record. 
  • A clear guideline for risk categorization is critical.

  • Nurses are critical and effective partners in the initiate assessment process - the assessment checklist does not take that much time.  good feedback for the most part. 

  • The assessment tools must be readily available and ready for data entry, otherwise, it will not get done (i.e. nurses tend not to actively seek out the forms unless it is an official part of the chart)

  • Accountability process is needed to drive compliance

  • Children above 14 years old appears to be at greater risk than younger (data not yet published).

  •  

  •  

Nursing

Physician 

  • risk assessment compliance study underway..appears high.
  • Tracking # of at risk patients underway but for children, difficult to assess because more difficult to assess the existence of subclinical thrombus in chidlren
  • Discharge education and scheduled follow up appt tracked.
 
      Digital: VTE prophylaxis cinical practice guidelines are on the hospital intranet, but in a passive state.  VTE prophylaxis order sets containing mechanical prophylaxis that nursing staff can order (to be co-signed later by physician).  Work underway for electronic version of nursing risk assessment tool that can be linked to point of care prophylaxis order reminders.  Work underway to add additional phrophylaxis orders into existing ordersets identified to be often used for at risk patients (i.e. pre-op orders).
  • Nursing initiated orders are effective in getting at risk patients the proper prophylaxis
  • The application of passive vs active reminders has been a debate, particularly when busy workflow is involved. 
    • It appears that the decision is based upon - patient risk degree, nursing and MD workload, and effectiveness
    • To help us assess, we have been engaged in QI tools such as ' mini PDSA cycles' and FMEAs  in other hospital areas, that we hope to use here.
  •  
    Improvement is temporally related to project activities and tapers off between activities.
    To hard-code practices into daily routine, it is necessary to insert continuous prompts at the point of care
    Buy-in from and a sense of responsibility by front-line clinicians positively impacts the use of VTE prophylaxis
    Identifying stakeholders is critical for success
     

Nursing

Physician 

 

- usage of nurse initiated mechanical prophylaxis orders is high 

% of at risk patients receiving VTE prophylaxis has increased significantly (shown by control chart)

 
      Hybrid: no process to connect the paper and digital, except thru workflow engineering (no electronic process)        
    HealthEast Paper: Used at one of our hospitals (LTAC).  Nurses complete an assessment of calf and respiratory symptoms.  Will notify the physician of positive findings.  Also documents education.
Paper is being completed but notification of the physician may not be happening reliably.  Can only track this by paper audit.  Documentation of is also not happening reliably.
Nursing: VTE site team and site nurse practice.  Assessment has not been measured.  Education at the LTAC last month was 100%
Goal of 100% of the education documentation of patients discharged on coumadin or lovenox 
 
     

Digital: At three of our hospitals nurses have a templated form in their intake assessment which allows for documetation of calf and respiratory symptoms and also has a check box indicating that the physican has been notified.

Education screen includes the elements that the nurse needs to do to educate the patient and allows for the documentation of it there.

To our knowledge, nurses are completing this.  Not sure there is an audit of completeness.  There is no hard stop for either risk or education documentation.  There is no flowsheet assembling risk factors collected by the nurse into one location for ordering providers. System VTE multidisciplinary team 

Assessment runs between 80-90%.  Education at the hospitals last month was 40 - 50%

Greater than 100% completion of the assessment of all patients and 100% of the education documentation of patients discharged on coumadin or lovenox. 

 
      Hybrid:        
    MH Paper: We are in the same position as THR. We have different processes at different facilities. We are using assessment forms that are placed in the patient chart so that the physcian can complete it. But there is no mandate for the physician to complete it. Since we are doing our pilot project with the electronic risk assessment tool, we haven't gone down the road of reassessing our system process yet, but will be doing that in the near future         
      Digital: At two of our community based hospitals, we are doing a pilot project with our vendor provided electronic risk assessment tool. This tool gives the user the ability to complete the risk assessment and based on the assessment provides recommended orders for prophylaxis. The user can order directly from within this tool. This tool is only being used by physicians. We have nursing staff identifying all patients within 16 hours that do not have their VTE risk assessment completed and then contacting the physician to have it completed within the first 24 hrs of admission
  • Since not all of our physicians are doing CPOE it was hard to get all the physicians to use this tool 
  • Getting the nurse to contact the physicians about VTE risk assessment was a huge culture change
  • Important to give feedback to the physicians to let them know how they are doing with the tool
  • Content may not satisfy all specialty needs
  • Physicians, Nursing, Performance Improvement teams 
  • Percentage of all inpatients that have the electronic risk assessment completed
  • VTE risk categories
  • VTE prophylaxis orders based on risk category 
 
      Hybrid: We are going in the direction of completely electronic based on our pilot project with the electronic tool        
    Orlando Paper:Currently no formal VTE risk assesment is being conducted.         
      Digital: No Current process.  Plans in place to include VTE risk assessment into nursing admission documentation being evaulated by risk.nursing leadership.  Once done, will use nursing risk assessment to drive alert to prescribers for high risk patients and include VTE risk score on data review  dashboard areas in the CIS        
      Hybrid:  Physician documentation is the only piece of the puzzle still on paper for us.  This is why we will need to use nursing documentation to generate risk assessment.        
    THR Paper: Currently, at our 13 entities, we have varied processes for VTE risk assessment.  Some hospitals have formal risk assessment tools and some do not and of those that do, some are completed by nursing and some are intended for physician completion, but no facilities mandate completion of the forms.  This is currently being reevaluated at a system level by a task force.         
      Digital: No formal risk assessment tool built in to CareConnect.  Order sets include condition or procedure specific guidance in this regard        
      Hybrid:  No process to connect the paper and electronic format at this time.  Some of the paper assessment forms are intended to become part of the chart (HSW) and some are not(PHD).         
               
Participants/Workflow step Goals General CDS Strategies Specific CDS Considerations Given Paper/Digital Tools Outcomes/Lessons Learned/Pearls Owners/Stakeholders Metrics  
Physician & patient/ H&P and plan Gather data regarding all key markers of underlying condition and response to treatment (including key items for reporting).  With patient, generate context-specific, evidence-based, best-practice care plan • Condition specific reference information reinforcing key data to gather (may be same as documentation templates, below)

• Context-specific recommendations on evidence-based management plan (including educational material to optimize patient participation)

Validate and/or complete VTE risk assessment<</body>