The First Consult Ordering System

The First Consult Ordering System Presented by Marjorie Lazoff, MD Medical Editor, Information Development Margaret Trexler Hessen, MD FACP Medical Editor, New Content Allan Brewer, MD Deputy Editor David R. Goldmann, MD Editor-in-Chief, First Consult

Table of Contents Slide Disclaimer 3 Introduction 4-15 Case 1 (Presentation) Acute Headache, long workup 16-57 Case 2 Ambulatory Diabetes/Comorbidities 58-77 Case 3 Ambulatory Screening/Prevention, +evidence 78-94 Case 4 Admission Community Acquired Pneumonia, variations 95-115 Case 5 Acute Abdomen, variations 116-124 Case 6 Acute Rapid Atrial Fibrillation, +evidence 125-132 Case 7 Intra-hosp Hypotension 133-142 Case 8 Post-op Total Knee Replacement 143-153 Case 9 Acute Restraints +documentation 154-162 Summary 163 Design Features Key 164

Disclaimers • Please, do not subject any living thing to what we have created here! The management pathways and evidence presented in these cases were created solely to illustrate the principles and use of FC’s ordering system. • Much of the evidence cited here has been cut-and-pasted without full attribution, unlike FC’s usual practice. • The following slides and cases were created to provide examples only and are not intended to represent a fully populated, finished product.

An Orderly Solution The First Consult Ordering System will: • Provide evidence and clinical information for MDs at point-of-ordering. • Use FC’s evidence, medical topics, and editorial workflow for content development and updating, including a peer review process that will help establish professional credibility within the medical community. • Allow for a variety of order entry strategies, depending on patient needs and MD style. • Permit Elsevier staff to consult with individual hospitals to create customized order sets quickly and efficiently, one-time or as a continuing service. Order sets can also be customized for groups of patients, such as pregnant women or common comorbidities. • Allow individual physicians to create and save their own order sets “on the fly.” • Empower institutions to provide MDs with customized support at point-of-ordering, to help ensure best practices and maximize patient safety. • Be purchasable as a system or individual components. • Integrate with other Elsevier products and Smart Content.

FC Orders Are Organized According to Patient Location • ER • Ambulatory: doctor’s office, clinic • Acute: in-patient ward • ICU: customize to include other units • Surgical: customize to specialties or add pre-op and post-op • Psychiatric • Many other possibilities: Pediatrics, Chronic care, Subspecialties

Each Location Has Two Complementary Groups of Orders • Shell orders: Database of all common orders in the location • Orders pertaining to the most common and important conditions seen in that location • Divided into familiar categories (labs, medications, etc.) • Evidence sets: Orders that are supported by the evidence and/or quality measures for physicians to consider in individualizing patient care • Grouped into conditions within each location • Includes only orders supported by quality evidence; not the same as the most important orders • Different evidence set for same condition in different locations (eg: acute DM, ICU DM, ambulatory DM)

AMB ERACUTE ICU SURG PSYCH ACUTE SHELL: ADM GEN LABS RAD PROC CONS MEDS TX D/C OTHER AMB ER ACUTE ICU PRE-OP SURG PEDS D/CER SHELL: GEN LABS RAD PROC CONS MEDS TX OTHER ACUTE EVIDENCE SETS ACUTE MI CEREBROVASCULAR ACCIDENT CHANGE MENTAL STATUS CONGESTIVE HEART FAILURE DIABETES ENCEPHALOPATHY GASTROINTESTINAL BLEED HEMOPTYSIS HYPOTENSION MAP PNEUMONIA MENINGITIS PANCREATITIS PULMONARY EMBOLUS SARCOIDOSIS SEPSIS SUPRAVENTRIC TACHYCARDIA TOXIC MEGACOLON TOXICOLOGY TOOLBOX ORDER SETS FC ACUTE CLEAR ACCEPT

Four Additional Features • Final Review: Screen customized by the institutions to provide a final opportunity for physicians to change, adjust or keep an order before accepting. (See slides 111, 161, 162) • Did You Forget?: Screen that is automatically generated whenever an expected order was not entered. (See slide 132) • Customized Order Sets: Our basic framework is different from the traditional Order sets, but our service will allow for hospitals to work with Elsevier to create institution-specific Order sets. (See next 2 slides) • Like Evidence sets, the customized Order sets will be specific to a condition within a location • Unlike Evidence sets, the customized Order sets will list the most common orders whether or not they are evidence-based • Comments: Potential for interactivity similar to that planned for FC topics. (Not shown on slides)

AMB ERACUTE ICU SURG PSYCH ACUTE SHELL: ADM GEN LABS RAD PROC CONS MEDS TX D/C OTHER AMB ER ACUTE ICU PRE-OP SURG PEDS D/CER SHELL: GEN LABS RAD PROC CONS MEDS TX OTHER ACUTE EVIDENCE SETS ACUTE MI CEREBROVASCULAR ACCIDENT CHANGE MENTAL STATUS CONGESTIVE HEART FAILURE DIABETES ENCEPHALOPATHY GASTROINTESTINAL BLEED HEMOPTYSIS HYPOTENSION MAP PNEUMONIA MENINGITIS PANCREATITIS PULMONARY EMBOLUS SARCOIDOSIS SEPSIS SUPRAVENTRIC TACHYCARDIA TOXIC MEGACOLON TOXICOLOGY TOOLBOX ORDER SETS FC ACUTE CLEAR ACCEPT

AMB ERACUTE ICU SURG PSYCH ACUTE SHELL: ADM GEN LABS RAD PROC CONS MEDS TX D/C OTHER AMB ER ACUTE ICU PRE-OP SURG PEDS D/CER SHELL: GEN LABS RAD PROC CONS MEDS TX OTHER ACUTE ORDER SETS ACUTE MI CEREBROVASCULAR ACCIDENT CHANGE MENTAL STATUS CONGESTIVE HEART FAILURE DIABETES EPILEPSY GASTROINTESTINAL BLEED HYPERTENSION HYPOTENSION MAP PNEUMONIA MENINGITIS PANCREATITIS PULMONARY EMBOLUS PULMONARY HTN SEPSIS SUPRAVENTRIC TACHYCARDIA TIA UREMIA TOOLBOX EVIDENCE FC ACUTE CLEAR ACCEPT

To begin… .

AMB ER ACUTE ICU SURG PSYCH AMB ER ACUTE ICU PRE-OP SURG PEDS D/C Welcome to First Consult Ordering System • Click on one of the above locations • Log onto system as physician • Select patient • On the screen that follows, select either that location’s general orders (“the Shell”), or topic-specific evidence-based orders (“the Evidence”) 5. At any time, you can • go back and forth between an Evidence set and its Shell orders • go back to another Evidence set within the category • Select another location and use those Shell and Evidence orders • At any time, you can click Review to view/cosign/edit/delete entered orders • For an order to be entered into the system, click Accept

AMB ERACUTE ICU SURG PSYCH AMB ER ACUTE ICU PRE-OP SURG PEDS D/C Welcome to First Consult Ordering System • Click on one of the above locations • Log onto system as physician • Select patient • On the screen that follows, select either that location’s general orders (“the Shell”), or topic-specific evidence-based orders (“the Evidence”) 5. At any time, you can • go back and forth between an Evidence set and its Shell orders • go back to another Evidence set within the category • Select another location and use those Shell and Evidence orders • At any time, you can click Review to view/cosign/edit/delete entered orders • For an order to be entered into the system, click Accept

AMB ERACUTE ICU SURG PSYCH AMB ER ACUTE ICU PRE-OP SURG PEDS D/C Which ER physician will be placing orders? • Brewer, Allan MD • Goldmann, David MD • Hessen, Margaret MD • Lazoff, Marjorie MD • Teich, Jonathan MD CLEAR ACCEPT

AMB ERACUTE ICU SURG PSYCH AMB ER ACUTE ICU PRE-OP SURG PEDS D/C Which physician will be placing orders? • Brewer, Allan MD • Goldmann, David MD • Hessen, Margaret MD l Lazoff, Marjorie MD • Teich, Jonathan MD CLEAR ACCEPT

Use Case #1: Long Day’s Headache into Night • 24 yo male presents to ER after experiencing a sudden severe headache (HA) and neck pain while lifting weights that morning. Pain quickly improved but his girlfriend insisted that he go to the ER anyway. • History unremarkable, review of systems negative. • Patient appears comfortable, vital signs stable, and exam including neurological is wholly unremarkable.

Assessment Acute headache, resolving; high suspicion for subarachnoid hemorrhage (SAH)

First Orders • Log onto system within a location and identify physician • Begin ordering: • Select and Accept Patient from list • Automatically brings up “Home Page” with Shell toolbar and Evidence sets • Select Headache (HA) under ER Evidence set and review whether there are evidence-based orders appropriate for this patient

AMB ERACUTE ICU SURG PSYCH AMB ER ACUTE ICU PRE-OP SURG PEDS D/C Current ER patients: • Bale, Christian • Firth, Colin • Gere, Richard • Leo, Melissa • Portman, Natalie CLEAR ACCEPT

AMB ERACUTE ICU SURG PSYCH AMB ER ACUTE ICU PRE-OP SURG PEDS D/C Current ER patients: • Bale, Christian • Firth, Colin l Gere, Richard • Leo, Melissa • Portman, Natalie CLEAR ACCEPT

AMB ERACUTE ICU SURG PSYCH ER SHELL: GEN LABS RAD PROC CONS MEDS TX D/C OTHER AMB ER ACUTE ICU PRE-OP SURG PEDS D/CER SHELL: GEN LABS RAD PROC CONS MEDS TX OTHER ED EVIDENCE SETS ACUTE ABDOMEN ACUTE MI ANKLE INJURIES APPENDICITIS CAP PNEUMONIA CHANGE MENTAL STATUS DIABETES KETOACIDOSIS ECTOPIC PREGNANCY HEADACHE HEMOPTYSIS KNEE INJURIES MENINGITIS SINUSITIS TOXICOLOGY TOOLBOX ORDER SETS FC ER CLEAR ACCEPT

Workup • A quick look through the ER HA Evidence orders shows that there are several evidence-based tests in the workup of SAH that are appropriate for this pt. • The tests are ordered, in the appropriate sequence.

AMB ERACUTE ICU SURG PSYCH ER SHELL: GEN LABS RAD PROC CONS MEDS TX D/C OTHER AMB ER ACUTE ICU PRE-OP SURG PEDS D/CER SHELL: GEN LABS RAD PROC CONS MEDS TX OTHER ER HEADACHE EVIDENCE 1/3 General • Migrane-type HA >72 hrs, give 250-500 cc D51/2 NS prior to neuroleptic administration and observed for potential orthostatic hypotension and acute extrapyramidal side effects. (ICSI 2009) Labs • ESR if pt >50 yo to r/o TA (ISCI 2009) Radiology m CT head no contrast (1) pt with HA and new abnl findings on neuro exam and/or suspicion of serious intracranial process (Level 2 ACEP 2008, ISCI 2009) OR (2) acute head trauma with sz (ISCI 2009) m CT head with contrast (1) any new sudden-onset severe HA (Level 2 ACEP 2008) OR (2) consider in HIV+ pt with new type of HA (Level 2 ACEP 2008) • MRI (with and without gad) if HA and sz without h/o head trauma (ICSI 2009) or SAH (Level 2 ACEP 2008) REMEMBER Urgent (not stat) neuro imaging study if >50 yrs with new HA and normal neuro exam (Level 3 ACEP 2008) TOOLBOX FC TOPIC REVIEW CLEAR ACCEPT

AMB ERACUTE ICU SURG PSYCH ER SHELL: GEN LABS RAD PROC CONS MEDS TX D/C OTHER AMB ER ACUTE ICU PRE-OP SURG PEDS D/CER SHELL: GEN LABS RAD PROC CONS MEDS TX OTHER ER HEADACHE EVIDENCE 1/3 General • Migrane-type HA >72 hrs, give 250-500 cc D51/2 NS prior to neuroleptic administration and observed for potential orthostatic hypotension and acute extrapyramidal side effects. (ICSI 2009) Labs • ESR if pt >50 yo to r/o TA (ISCI 2009) Radiology l CT head no contrast (1) pt with HA and new abnl findings on neuro exam and/or suspicion of serious intracranial process (Level 2 ACEP 2008, ISCI 2009) OR (2) acute head trauma with sz (ISCI 2009) m CT head with contrast (1) any new sudden-onset severe HA (Level 2 ACEP 2008) OR (2) consider in HIV+ pt with new type of HA (Level 2 ACEP 2008) • MRI (with and without gad) if HA and sz without h/o head trauma (ICSI 2009) or SAH (Level 2 ACEP 2008) REMEMBER Urgent (not stat) neuroimaging study if >50 yrs with new HA and normal neuro exam (Level 3 ACEP 2008) TOOLBOX FC TOPIC REVIEW CLEAR ACCEPT

AMB ERACUTE ICU SURG PSYCH ER SHELL: GEN LABS RAD PROC CONS MEDS TX D/C OTHER AMB ER ACUTE ICU PRE-OP SURG PEDS D/CER SHELL: GEN LABS RAD PROC CONS MEDS TX OTHER Richard Gere General Labs Radiology CT head no contrast Lazoff Procedures Consults Medication Treatments Other DELETE REVIEW SAVE ACCEPT

Accepting Orders • Orders must be Accepted before they are entered into the system • After placing an order, the physician can click the: • Accept button, to enter the order(s) • Save button, if interrupted or otherwise needing to return to orders at a later time • Review button, to bring up a list of all orders, with Pending orders highlighted. The physician may Clear all, or Delete specific items (similar to an online shopping cart system) before Accepting. • This system allows a physician to Accept or Review each order as placed, or place orders quickly and Review/Accept at the end, or any combination

Workup • CT head without contrast: normal

AMB ERACUTE ICU SURG PSYCH ER SHELL: GEN LABS RAD PROC CONS MEDS TX D/C OTHER AMB ER ACUTE ICU PRE-OP SURG PEDS D/CER SHELL: GEN LABS RAD PROC CONS MEDS TX OTHER ER HEADACHE EVIDENCE 2/3 Procedure (w/labs, meds) REMEMBER to CT or MRI before LP in adult pts with HA who exhibit signs of incr ICP (Level 3 ACEP 2008) • LP (1) r/o SAH in pt with negative non-contrast CT (Level 2 ACEP 2008) OR (2) to r/o meningitis (ISCI 2009) Consultation • Neuro consult if continued suspicion of SAH despite normal CT head and LP (ISCI 2009); alternatively, if CT, LP and opening pressure normal pt can be d/ced home with good f/u (Level 2 ACEP 2008) CONSIDER Neuro consult when (1) dx can’t be confirmed (2) warning signals present (3) HA occurs with frequency and duration sufficient to impair QOL (4) pt has failed to respond to acute remedies or is in status migrainosus (ISCI 2009) TOOLBOX FC TOPIC REVIEW CLEAR ACCEPT

AMB ERACUTE ICU SURG PSYCH ER SHELL: GEN LABS RAD PROC CONS MEDS TX D/C OTHER AMB ER ACUTE ICU PRE-OP SURG PEDS D/CER SHELL: GEN LABS RAD PROC CONS MEDS TX OTHER ER HEADACHE EVIDENCE 2/3 Procedure (w/labs, meds) REMEMBER to CT or MRI before LP in adult pts with HA who exhibit signs of incr ICP (Level 3 ACEP 2008) n LP (1) r/o SAH in pt with negative non-contrast CT (Level 2 ACEP 2008) OR (2) to r/o meningitis (ISCI 2009) Consultation q Neuro consult if continued suspicion of SAH despite normal CT head and LP (ISCI 2009); alternatively, if CT, LP and opening pressure normal pt can be d/ced home with good f/u (Level 2 ACEP 2008) CONSIDER Neuro consult when (1) dx can’t be confirmed (2) warning signals present (3) HA occurs with frequency and duration sufficient to impair QOL (4) pt has failed to respond to acute remedies or is in status migrainosus (ISCI 2009) TOOLBOX FC TOPIC REVIEW CLEAR ACCEPT

Workup • An LP is ordered. • In addition to the spinal fluid studies automatically generated with the LP procedure order for SAH, the physician decides to also order a CBC and blood glucose...

Workup • While very appropriate labs for a HA workup, a CBC and blood glucose will not be found within the ER HA Evidence set since there is no quality evidence supporting their use. • Instead, these labs are accessible under ER Shell/Labs, along with all the other common ER lab work for all ER conditions. • There is no need to navigate, since the ER Shell toolbar is ever present.

AMB ERACUTE ICU SURG PSYCH ER SHELL: GEN LABS RAD PROC CONS MEDS TX D/C OTHER AMB ER ACUTE ICU PRE-OP SURG PEDS D/CER SHELL: GEN LABS RAD PROC CONS MEDS TX OTHER ER SHELL LABORATORY Chemistry: q Basic Metabolic q Comprehensive Metabolic q Cardiac enzymes q Toxicology screen (blood and urine) q Other q Urinanalysis (dip and cell count) q Other Hematology: q CBC c diff q PT, aPTT q Other Microbiology: Cultures qBloodqSputumqUrineqPleuralqPeritonealqJointq CSF qOther Stain qGramqWrightqOther ______ TOOLBOX FC ER REVIEW CLEAR ACCEPT

AMB ERACUTE ICU SURG PSYCH ER SHELL: GEN LABS RAD PROC CONS MEDS TX D/C OTHER AMB ER ACUTE ICU PRE-OP SURG PEDS D/CER SHELL: GEN LABS RAD PROC CONS MEDS TX OTHER ER SHELL LABORATORY Chemistry: n Basic Metabolic q Comprehensive Metabolic q Cardiac enzymes q Toxicology screen (blood and urine) q Other q Urinanalysis (dip and cell count) q Other Hematology: n CBC c diff q PT, aPTT q Other Microbiology: Cultures qBloodqSputumqUrineqPleuralqPeritonealqJointq CSF qOther Stain qGramqWrightqOther _______ TOOLBOX FC ER REVIEW CLEAR ACCEPT

Results • Evidence order set results: • LP with CSF examination: normal, 1-2 RBC/HPF • Shell order set results: • Basic metabolic: normal • CBC w/diff: normal

??? • What to do now? • Return to ER HA Evidence orders, looking for evidence to guide next steps in the workup...

AMB ERACUTE ICU SURG PSYCH ER SHELL: GEN LABS RAD PROC CONS MEDS TX D/C OTHER AMB ER ACUTE ICU PRE-OP SURG PEDS D/CER SHELL: GEN LABS RAD PROC CONS MEDS TX OTHER ER HEADACHE EVIDENCE 1/3 General • Migrane-type HA >72 hrs, give 250-500 cc D51/2 NS prior to neuroleptic administration and observed for potential orthostatic hypotension and acute extrapyramidal side effects. (ICSI 2009) Labs • ESR if pt >50 yo to r/o TA (ISCI 2009) Radiology m CT head no contrast (1) pt with HA and new abnl findings on neuro exam and/or suspicion of serious intracranial process (Level 2 ACEP 2008, ISCI 2009) OR (2) acute head trauma with sz (ISCI 2009) m CT head with contrast (1) any new sudden-onset severe HA (Level 2 ACEP 2008) OR (2) consider in HIV+ pt with new type of HA (Level 2 ACEP 2008) • MRI (with and without gad) if HA and sz without h/o head trauma (ICSI 2009) or SAH (Level 2 ACEP 2008) REMEMBER Urgent (not stat) neuroimaging study if >50 yrs with new HA and normal neuro exam (Level 3 ACEP 2008) TOOLBOX FC TOPIC REVIEW CLEAR ACCEPT

??? • Evidence supports either a stat consult, an MRI, or discharge home with good follow-up • The physician clicks on the links to the guideline and/or graded systematic review (red), to review the evidence personally and see how it applies to his patient

Direct Link to Evidence Workup serious intracranial process: “The first investigation is a computed tomography head scan without contrast. If there is no evidence of a subarachnoid hemorrhage, a lumbar puncture should be performed. If both studies are normal and the suspicion of subarachnoid hemorrhage is still high, a magnetic resonance imaging with and without gadolinium should be obtained. Neurological consultation is indicated and further tests for consideration include magnetic resonance angiogram and magnetic resonance venogram.” Edlow JA, Panagos PD, Godwin SA, Thomas TL, Decker WW, American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med 2008 Oct;52(4):407-36. [91 references]

? • Before ordering yet another test, the physician brushes up on SAH by reading First Consult

Order Set Links to FC

Decision • After reading FC, the physician remains concerned about this patient. He decides to follow ACEP’s clinical statement recommendation and order an MRI. • The physician can enter the MRI order in one of three ways: • Using the HA Evidence set • Using ED Shell/Radiology, since an MRI is a common ER test nowadays • Using the hospital’s default Radiology link (not shown here), which commonly lists every imaging study available in the hospital

Decision • The physician likes to use the Evidence set, since the indication (Acute Headache) and urgency (stat) will be automatically displayed on the radiology order slip.

AMB ERACUTE ICU SURG PSYCH ER SHELL: GEN LABS RAD PROC CONS MEDS TX D/C OTHER AMB ER ACUTE ICU PRE-OP SURG PEDS D/CER SHELL: GEN LABS RAD PROC CONS MEDS TX OTHER ER HEADACHE EVIDENCE 1/3 General • Migrane-type HA >72 hrs, give 250-500 cc D51/2 NS prior to neuroleptic administration and observed for potential orthostatic hypotension and acute extrapyramidal side effects. (ICSI 2009) Labs • ESR if pt >50 yo to r/o TA (ISCI 2009) Radiology m CT head no contrast (1) pt with HA and new abnl findings on neuro exam and/or suspicion of serious intracranial process (Level 2 ACEP 2008, ISCI 2009) OR (2) acute head trauma with sz (ISCI 2009) m CT head with contrast (1) any new sudden-onset severe HA (Level 2 ACEP 2008) OR (2) consider in HIV+ pt with new type of HA (Level 2 ACEP 2008) n MRI (with and without gad) if HA and sz without h/o head trauma (ICSI 2009) or SAH (Level 2 ACEP 2008) REMEMBER Urgent (not stat) neuroimaging study if >50 yrs with new HA and normal neuro exam (Level 3 ACEP 2008) TOOLBOX FC TOPIC REVIEW CLEAR ACCEPT

Disposition • The MRI is negative. • But since suspicion for an SAH remains high, the patient is not discharged. A consult is ordered, as recommended by the American College of Emergency Physicians (ACEP).

Disposition • In this hospital, the appropriate consult for an SAH is Neurosurgery, not Neurology as recommended by ACEP. • The ER HA Evidence orders are customized to the hospital’s practice, so the ER physician will only see Neurosurgery in the HA Evidence orders. • The Neurology consult will remain available under ER Shell/Consults.

The First Consult Ordering System