Tips & Tricks COMPASS Orders Improvements 11/11/14

Transcription

1 Tips & Tricks COMPASS Orders Improvements 11/11/14 Newborn CPOE Implementation for Newborns admitted to the Mother Baby Units at SMCA, UMCB, SMCW, SNW, SMCH and SSW Go-Live: December 2, 2014 Available Newborn Order sets Key Points of SMDO Newborn Admission 1. SMDO means Standing Medically Delegated Orders. 2. Comments at top of SMDO Newborn Admission order set: Note The SMDO is good for 24 hours. The admitting Pedi/Neo/NNP must sign the SMDO orders in their Message Center AND place a single Admit to order within 24 hours. Tips & Tricks Page 1

2 3. The Communication Order on the SMDO is NOT the official Admit to order. The official Admit to order cannot be part of an SMDO. 4. The Pedi/Neo/NNP must enter the single Admit to order within 24 hours of birth. The NNP must send the order to be co-signed by the Pedi or Neo. The Admit to order can also be entered by the nurse as a telephone order. Complete Required Fields 5. Carefully read the Notify Provider orders that call for immediate notification of the newborn s admitting Pedi/Neo/NNP. The nurse will initiate the SMDO at the time the newborn encounter is created, but he/she will immediately notify the Pedi/Neo/NNP of the indicated condition (s) when present. Tips & Tricks Page 2

3 6. Medication Orders: Note special instructions related to Newborn Meds 7. The following Newborn Protocols are embedded in the SMDO Newborn Admission order set with defined criteria indicating when the nurse or medical provider should select them. Tuberculosis Protocol Newborn Herpes Simplex Virus (HSV) Newborn Protocol Group B Strep (GBS) Protocol Newborn Hypoglycemia Protocol Newborn Positive Direct Coombs Protocol Newborn Ex: The nurse is entering the admission orders on a newborn whose mother has gestational diabetes. The nurse will click on the Hypoglycemia Protocol Newborn order box. This will open the Hypoglycemia Protocol Newborn order set. Carefully read all orders and notes on any embedded order sets. Click on the Return to SMDO Newborn Admission box once all orders and notes have been reviewed. Tips & Tricks Page 3

4 Once back to the SMDO Newborn Admission order set, continue the ordering process. Key Points of SMDO Newborn Discharge 1. The Discharge Newborn order set is a stand-alone PowerPlan. It is no longer a phase of the Newborn Admission orders. 2. The Pedi/Neo/NNP will enter and initiate the orders when the newborn is ready for discharge. Tips & Tricks Page 4

5 Process Implications Placement of initial admission order set: As soon as the newborn has a COMPASS encounter, the nurse who is responsible for the newborn during transition will initiate the SMDO Newborn Admission order set. This could be the L&D nurse or a specific transition nurse depending on your site. o NOTE: If present, the attending Pedi/Neo/NNP may also enter this order set. They would use the same SMDO Newborn Admission orders. Type SMDO Newborn in orders search box. The nurse will assign the SMDO Newborn Admission orders to the Pediatrician, Neonatologist or Neonatal Nurse Practitioner who is responsible for the newborn s care at the time the order set is placed. Q: What communication type will the nurse use? A: SMDO. SMDO orders are sent to the medical provider for signature. Q: When will the nurse order the newborn protocols that are applicable to the baby? A: At the time the SMDO Newborn Admission order set is entered if the criteria for these protocols are present at the time of delivery. The orders for the nurse to initiate these protocols are included in the SMDO. Tips & Tricks Page 5

6 Q: What if I initiate the Admission order set and forget to select necessary protocol(s)? A: Click on the SMDO Newborn Admission order set and click the View Excluded icon. This will bring back the check boxes for orders not selected initially. Choose the necessary protocol(s). Continue to use SMDO as the communication type. 1. View Excluded Icon Process for ordering Positive Direct Coombs order set. Q. The orders to initiate the Positive Direct Coombs order set if the infant has a positive direct coombs is part of the SMDO Newborn Admission order set. I will not have the results from lab at the time the Admission order set is entered, however. How will this order set be ordered when needed? A: The nurse will follow the same steps using the View Excluded icon as outlined above. Since these orders are included in the SMDO, the nurse will choose SMDO as the communication type so the orders can be signed by the Pedi/Neo/NNP. Process for ordering Cord Blood Hold or Cord Blood Work-Up Q: How will the Cord Blood Hold or Cord Blood Work-up order be entered? A: The SMDO Newborn Admission order set contains a Lab Instruction order that is default checked and provides the parameters for when the nurse is to order Cord Blood Work-up or Cord Blood Hold. Both the Work-up and Hold orders are included in the SMDO Newborn Admission, but are NOT pre-checked. The nurse MUST select the appropriate lab order based on the set criteria. Notification to Pedi/Neo/NNP of newborn s birth: Q: When will the Pedi/Neo/NNP be notified if the infant does NOT meet criteria for immediate provider notification? A: Each unit will follow its current notification process for newborns that do NOT fit any Notify Provider stipulations as stated on the SMDO. Tips & Tricks Page 6

7 Q: When will the Pedi/Neo/NNP be notified if the infant DOES meet criteria for immediate provider notification? A: The nurse will notify the Pedi/Neo/NNP during the infant s transition period. The nurse will still order the SMDO as soon as the infant s encounter is in COMPASS (this can precede notification of the pedi). At the time the PEDI/Neo/NNP is notified, the nurse may obtain and enter a telephone Admit to single order. Regardless of whether the Pedi/Neo/NNP needs to be notified immediately or via the normal process for the unit, the Pedi/Neo/NNP is required to place a single Admit to order as well as sign the SMDO orders via Message Center within 24 hours of birth time. The NNP will send the Admit to order to the Pedi/Neo for cosignature. Nurses will need to monitor for the presence of the Admit to order as well as the signing of orders so they can notify providers when the end of the 24 hour timeframe approaches. Q: How can I tell if the SMDO orders still need to be signed? A: In COMPASS, the Pedo/Neo/NNP will see outstanding orders that need to be signed by looking at their key to Message Center. On the orders page, orders that still need to be signed by the provider will have a caduceus icon displayed in the Notifications section of the order. Additional orders needed after entry of SMDO Newborn Admission: The Pedi/Neo/NNP will enter any necessary single orders or order sets electronically in COMPASS. Nurses can enter telephone orders as needed. The Newborn order sets exist as stand-alone order sets. The nurse must notify Pedi/Neo/NNP to obtain telephone orders for any necessary order sets aside from those located in the SMDO Newborn Admission orders. Newborn Documentation: Q: Will there be a change to how nurses and Pedi/Neo/NNP document their care and assessments of newborns? A: No. Nurses will continue to document Newborn care and assessments in COMPASS Both Nurses and Pedi/Neo/NNP will continue to document on the Newborn History & Physical Record paper duplicate form. Pedi/Neo/NNP will continue to document progress notes on paper. Tips & Tricks Page 7

8 This paper duplicate form will continue to be utilized by nurses and Pedi/Neo/NNP Discharge of Newborn: Pedi/Neo/NNP and Nurses will continue to use the Depart Process. Not using at this time. Notes remain on paper. Pedi/Neo/NNP must complete Probs & Dx Pedi/Neo/NNP initiates Discharge Newborn Pedi/Neo/NNP only complete if applicable* Pedi/Neo/NNP must complete Nursing and Pedi/Neo/NNP shared task Nursing completes as needed Nursing must complete Nursing N/A for newborns Nursing completes as needed Nursing and Pedi/Neo/NNP Sign & Close when exiting Depart. Nursing will print document. *Med Rec is only required if the newborn is discharged with an Rx. Tips & Tricks Page 8

9 Appendix A Process for signing SMDO Newborn Admission orders if the wrong medical provider was assigned the orders during order entry. If the nurse assigns the wrong medical provider when entering the SMDO Newborn Admission, the correct provider will need to be notified so that the orders can be signed. The correct provider will NOT be able to sign these from Message Center as these orders were not originally assigned to them. The correct Pediatrician, Neonatologist or Neonatal Nurse Practitioner can sign the orders from the orders page using the following process: 1. Go to the newborn s Orders page. Click on Orders under the View section of the page. 2. Look for orders with the caduceus icon displayed in the Notifications section of the order. 3. Holding down the control key, left click on each order that has the caduceus icon displayed. Click anywhere EXCEPT on the order name that is in blue text. 4. Once all orders with the caduceus icon are selected, Right click and choose Cosign (No Dose Range Checking). 5. A Co-signature box will pop-up. Click Cosign. Tips & Tricks Page 9