GBHN Order Sets

1. GBHN Order Sets An effective solution to the complex challenge of improving patient care and safety

2. 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

3. Context: Massive Gap Between the Possible and the Actual Quality • Misuse, under use, overuse on a massive scale: Crossing the Quality Chasm 2001 Safety • Medical error is common: Institute Of Medicine Report on Error 2000 Variation in Care • Variability in care not explained by patient preferences or different disease patterns: British Medical Journal 2002; 325: 961-964

4. Solution: Order Sets a Clinical Decision Support Tool • A group of orders with a common functional purpose used by the physician to create orders. • 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 and best practices • Source of education • Can be used in paper or computerized ordering systems

5. Order Sets: Key Benefits • Safety • Reduced transcription errors • Reduced errors of omission • Reduced errors in medication dosing • Quality • Improved compliance with evidence-based and best practices • Standardization of care • Efficiency • Decreased time to write and process orders • Reduction in physician call-backs • Reduction in missed orders • Critical enabler for computerized practitioner order entry

6. Current Status of Order Sets • Lack of Recognition of Order Set Importance • Order Set Design • Often no standardized structure • Structure is not modular • Lack of integration with other processes/documents • Order set life cycle not well established • No dedicated Order Set Committee at most hospitals • 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

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

8. 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 • Niagara Health System • Open Source Order Sets • Provide a complete order set solution • Save organizations time, money and reduce demand on limited organizational resources • Improve quality • Local ownership and adaptation of tools

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

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

11. Benefits • Save time • Save money • Improve the quality and safety of patient care • Large improvements of easily measured metrics in short periods of time • Improve order set design • Increase order set use by physicians • Increase the clinical impact of order set use • Increase the standardization of best practices across the healthcare system • Increase the knowledge base that can be used for order set development • 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

12. GBHN Order Set Project • First steps now being completed: • 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 • Meeting once a week to move project quickly into implementation

13. GBHN Order Set Project • First steps: • Conversion of all of our current orders into the new modular format • Link directly from the GBHS Intranet, HDH Docushare, Icon on SBGHC desktops • Beginning to merge our content with OSOS content • Next steps: • Go live date – May 22 – first few order sets approved will go on the website • Print-on-demand directly off website – 88 new printers being installed this month across all GBHS sites where there have been issues • 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 (small volumes to ensure most up to date orders always being used, print-on demand for low volume order sets)

14. 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. 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 PowerOrders • 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

15. Sample: COPD Order Set

16. 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.

17. 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

18. COPD Order Set • Medication sections are divided up into subcategories by type of medication: • Antibiotics, Bronchodilator therapies, Steroid therapies • 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.

19. COPD Order Set • All associated protocols can be found on the website for reference • Documentation for the protocol – written “bowel care protocol” on Kardex/Care Plan, and then tell pharmacy when you are initiating the protocol and they will document on the MAR sheet (GBHS). SBGHC, if a nurse initiates a protocol, place protocol with med profile, add “bowel protocol” to the med profile, and transcribe to the MAR. • 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”.

20. Questions