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Epic Primer: Phases of Care. The concept, the reality.

Right now, we write orders, and somehow, they seem to get done appropriately. We do specify what needs to be done and when to do it, but sometimes, we don’t worry about that.

Who does worry about it? Who ensures that orders get followed appropriately?

Our nurses, pharmacists and other team members do.

When we use Epic, things will change. Epic will need to “know” whether to act now, or later, or in a particular place. For instance, day-after-day, patients on the ward can have orders written that get carried out right then and there. But a patient from the ward (or home) can need preoperative, operative, postoperative, and then ward or ICU orders. Those orders need to be specified for the correct place and time. In general, because much can be standardized, the phases can be (and already are – hooray!) specified in standardized order sets; however, we have to be aware that it is important to “attach” our orders to the phases of a patient’s care. For instance, we may want to check the bilirubin the morning before the patient gets her ERCP, so the blood test should be attached to that procedure and specified as “pre-procedure”.

This process is not just important for surgeons – it will need to be a big part of any procedural specialty. As well, since any patient in any place in HHS may have procedures or timed orders, it is important that we all know how to specify how orders are placed and carried out. The details behind-the-scenes are not important – thank goodness, others have already put that in place for us. We just need to use it properly. Here are a couple of scenarios that show what we do now, and how it will change (and be more transparent and accountable – i.e., reliable) in Epic.

Scenario 1 –NOW

While rounding on Saturday, Dr. Marcaccio scribbled two pre-op orders for the patient who was going to have her operation on Monday and raised the flag for the clerk to process the orders before heading out for a relaxing game of curling, (Hey, it’s cold. Golf is a no-go.)

Later, the clerk picked up the chart and transcribed the order into the Kardex, marked the order in the chart as transcribed and, realizing that neither order had to be acted on right now, put everything away.

The yellow, duplicate copy of the orders went to pharmacy. The pharmacy struggled to read the order as there were some dark creases through the text, but after a bit, they got what it was. The pharmacist thought it was appropriate to hold the anticoagulant as it was a treatment-level dose. She also noted that Dr. Marcaccio wanted an Octreotide injection ready for Monday morning. To be super ready, she sent up the Octreotide to the ward, marked to be administered in pre-op, as ordered by Dr. Marcaccio.

On the night shift, the nurse looking over the patient’s chart saw the order in the Kardex. Nothing to do about that right now, however, on handover Sunday morning, that night- nurse relayed to the Sunday day -nurse that this patient would need to have a nighttime medication held, and would he please pass this on.

The day-nurse told the patient that her anticoagulant would be held that night, and also made the Sunday night-nurse aware at report. The Sunday night-nurse held the meds, noted that in appropriate places in Meditech and on paper and also reported that at handover on Monday morning.

The Monday day-nurse made sure that this was marked on the paper form that accompanied the patient to same-day surgery (SDS). As he reviewed the chart that morning, he also realized that the Octreotide needed to be given in SDS and that the medication had already been prepared and sent to the ward. He attached the Octreotide dose to the patient’s chart and sent it to be administered in SDS.

The nurse in SDS checked the chart, noted that the anticoagulation had been held as ordered, and that the Octreotide needed to be given to the patient 1 hour prior to the OR. She administered the drug. The patient said “Ow”.

Scenario 2 – A BETTER FUTURE

In July, Dr. Marcaccio happened to be rounding on a Saturday again and had to prepare another patient in a similar manner. He opened the chart in Epic, brought up the standard order set and checked the orders. The Octreotide order was checked and was already specified in the phase of care as “pre-procedure”. He wrote one additional order to hold the anticoagulant on Sunday night. He then hurried out to play 9 holes of golf, confident that the patient’s care was organized and documented in one place for all to see and work with.

The Octreotide order automatically flowed to Pharmacy reports so that it would be available in SDS for the operation on Monday.

The nurse on the ward noted that the pre-op orders had been placed and that the anticoagulant needed to be held on Sunday – since the orders were easily visible in Epic, all the nurses saw it as they checked the chart.

The Sunday evening nurse ensured the anticoagulant was held as ordered.

The SDS nurse could see that the anticoagulant had been held last night as ordered. She released the pre-procedure orders when the patient arrived in Same Day. She administered the octreotide that was due to be given in SDS. This patient said “Ow”, too.

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