adrian lio, austin health: using a clinical system to address the national safety & quality...

Using a clinical system to address

the NSQHS standards

• What the NSQHS standards mean in an electronic prescribing

environment

• How reports are extracted and presented

• Tangible benefits from data reporting

• Targeting quality improvement strategies

ObjectivesObjectives

• Major tertiary health provider in northeast Melbourne

• 3 campuses

– The Austin Hospital

– Heidelberg Repatriation Hospital

– Royal Talbot Rehabilitation Centre

• Major services

– Victorian Spinal Cord Service

– Victorian Respiratory Support Services

– Oncology Services

– Victorian Liver Transplant Unit

Austin HealthAustin Health

2011

Radiology orders

Pathology orders

e-Prescribing

Discharge Summaries

Results & Results Endorsement

2012

Inpatient medications

MAR

Fluid balance chart

724 Access

2013

Clinical Documentation

First Net

? Oncology system

? Device Integration

? Surgi Net

The Austin Health EMR JourneyThe Austin Health EMR Journey

Clinical System Chosen:

• 2011 – Phase One Implementation

– Single sign on to clinical applications

– Electronic Ordering Pathology and Radiology

– Electronic Ordering of Discharge Prescriptions

– Results reporting and tracking of Acknowledgment

– Clinical Decision Support

– Electronic Discharge Summaries

What is ‘Live’ now?What is ‘Live’ now?

• 2012 – Phase Two Implementation

– Replace the National Inpatient Medications Chart

– Inpatient medications

» Prescribe

» Verify and dispense

» Administer at bedside

– VTE & Allergies Documentation

– Fluid Balance Chart Documentation

– Nurse/Patient Care Orders

– Patient ID via barcode scanning

– Immunisation Documentation

– 724 ‘Downtime’ viewer

What is ‘Live’ now?What is ‘Live’ now?

• New national standards

– 10 national standards with an

additional nutrition standard for

Victoria

Governance

Partnering with Consumers

Healthcare Associated Infections

Medication Safety

Patient Identification & Procedure

Matching

Clinical Handover

Blood & Blood Products

Pressure Injuries

Deterioration in Acute Health Care

Falls

The National Quality Safety and Health StandardsThe National Quality Safety and Health Standards

• New national standards

– Effective January 2013

– The standards have 225 core actions which are deemed critical for

safety and quality

– In addition there are 33 developmental actions which aid in quality

improvement

– Each action assessed against a three point rating scale

» Not Met: Actions have not been achieved

» Satisfactorily Met: Actions required have been achieved

» Met with Merit: Actions required have been achieved with evidence

of a higher level of achievement

NSQHS – AccreditationNSQHS – Accreditation

• Self assessment

– Documenting and assessing evidence against each standard and

developing an action plan for those ‘Not Met’

– Self-assessment was conducted over July and August 2012 with key

stakeholders, CSUs and relevant clinical governance committees

NSQHS – Self-assessmentNSQHS – Self-assessment

NSQHS – Self-assessmentNSQHS – Self-assessment

Standard 4: Medication Safety

– Core Items Met: 10/31

– Developmental Items Met: 0/6

– Main areas of non-compliance:

» Auditing of Medication Management system

» Auditing of Medication Authorisation system

» Auditing of Decision Support Tools

» Auditing of Medication storage and distribution systems

» Auditing of High Risk medications

» Medication allergy and adverse drug reaction processes

• Electronic medication management system

– No more illegible orders

– Transparency in relation to medication administration

– Ability to build prescribing guidance

– Ability to enforce prescribing guidelines and policies

– Barcode scanning

– Closed-loop medication management

– Discern Analytics: Cerner Data Reporting Solution

» Data retrieval is fast

» Ability to extract data and export to a CSV file for further

manipulation

Advantages of CernerAdvantages of Cerner

• Build methodology addresses:

– Standard 4.2.2 : Action is taken to reduce the risks identified in the

medication management system

– Standard 4.4.2 : Action is taken to reduce the risk of adverse

medication incidents

– Standard 4.5.2 : Quality improvement activities are undertaken to

reduce the risk of patient harm and increase the quality and

effectiveness of medicines use

• Order Sentences with pre-built instructions

• Care Sets and Power Plans containing built in guidance

1. Standardised Ordering1. Standardised Ordering

Medication instructions: Ciprofloxacin


Ordering: Glyceryl Trinitrate Patch


Ordering: Exforge HCT


Evidenced Based Information : ED Constipation Pathway


Warfarin: Mandatory documentation of INR range


2. Antibiotic Stewardship2. Antibiotic Stewardship

• Translating current antimicrobial prescribing

policy to an electronic system– Standard 4.1.1 : Governance arrangements are in place to support the

development, implementation and maintenance of organisation wide medication

safety systems

– Standard 4.1.2 : Policies, procedures and/or protocols are in place that are

consistent with legislative requirements, national, jurisdictional and professional

guidelines

– Standard 4.3.3 : Action is taken to increase the effectiveness of the medication

authority system

– Standard 4.4.2 : Action is taken to reduce the risk of adverse medication

incidents

– Standard 4.5.2 : Quality improvement activities are undertaken to reduce the

risk of patient harm and increase the quality and effectiveness of medicines use

• To promote appropriate and proper prescribing of antimicrobials

• Multiple methods at achieving this:

– Specialised Care Sets and order sentences including time offsets

and drug level reminder tasks

– Discern Alert

– Discern Analytics reports for ID Physicians and Pharmacist

2. Antibiotic Stewardship2. Antibiotic Stewardship

• Care Sets contain the ability to include prescribing guidance and

information

• Ability to combine medications, pathology and radiology orders in

one ordering window

• Ability to incorporate time off-sets on orders to facilitate drug

level monitoring

2. Antibiotic Stewardship – Care Sets2. Antibiotic Stewardship – Care Sets

2. Antibiotic Stewardship – Care Sets2. Antibiotic Stewardship – Care Sets

• Austin Health’s ‘Good Antimicrobial Prescribing Practice (GAPP)’

policy required custom build in to Cerner.

• Currently using an online approval system (IDEA3S) to generate

approval numbers based on selection criteria

• On paper

– approval number is written on the drug chart

– Required before administration but not always followed

• In Cerner

– Creative use of Discern Alert

– Cannot proceed with order unless approval number is documented

in appropriate field

2. Antibiotic Stewardship – Discern Alert2. Antibiotic Stewardship – Discern Alert

2. Antibiotic Stewardship – Discern Alert2. Antibiotic Stewardship – Discern Alert

2. Antibiotic Stewardship – Discern Analytics2. Antibiotic Stewardship – Discern Analytics

• Custom reports can be run out of Cerner through a program

‘Discern Analytics’

• Able to retrieve data quickly and in real-time

• Export to Excel (in ‘csv’ format) provides ability for further

manipulation

2. Antibiotic Stewardship – Discern Analytics2. Antibiotic Stewardship – Discern Analytics

3. VTE and Allergy Recording Alerts3. VTE and Allergy Recording Alerts

• Various alerts in place related to VTE Risk,

Treatment and allergy recording



– Standard 4.5.2 : Quality improvement activities are undertaken to

reduce the risk of patient harm and increase the quality and

effectiveness of medicines use

• Replicates requirements of the National Inpatient Medication

Chart

• Opens when opening a patient profile or ordering for the patient


Patient with no allergies or VTE risk assessed


Allergy documentation screen (inc. Height and Weight)


Power Form for prescribers to document VTE Risk assessment


Power Plan to guide ordering of medications


Alert: High Risk VTE documented but overdue task


Alert: High Risk VTE documented but no VTE Prophylaxis

• Quality report of assessment of VTE Risk

– Standard 4.2.2 : Action is taken to reduce the risks identified in the

medication management system

– Standard 4.5.1 : The performance of the medication management

system is regularly assessed

• Created by Department of Health

• Current report builds a snapshot of patients’ VTE Risk Assessment

• Can run report filtered by ward location, medical unit and date

admitted and date discharged or current inpatients over a

specified period

4. VTE Risk Assessment Report4. VTE Risk Assessment Report

• Built using custom CCL (Cerner Command

Language) reports

– CCL provides possibilities for querying and reporting on any data

from Cerner.

– CCL allows a programmer to retrieve data from the database and

display it in a way the user requires

– Current Process: A request is submitted by one of the health

organisations and a specification sheet is drafted.

– Specification sheet details the logic required for inclusion and

exclusion of data as well as details about fields that are presented


• VTE Risk Assessment Inclusion criteria:

– Patient registered to the specific facility and/or location

– Encounter status: Cancelled encounters are excluded

– Can select between patients who were:

» Admitted and Discharged between a date range

» Had active encounters within a date range



• Excel report retrieves:

– Name of patient, UR number, ward location, medical unit

– Admission Date/Time and Discharge Date/Time

– First Date/Time of documented VTE Risk

– Details of initial documentation of VTE Risk (High risk, Low risk etc.)

– Most recent Date/Time of documented VTE Risk

– Details of most recent documentation of VTE Risk (High risk, Low

risk etc.)

– Total number of patients evaluated

– Total number of patients with VTE Risk assessment documented

5. Allergy Report5. Allergy Report

• Allergy Key Performance Indicator Report



– Standard 4.5.1 : The performance of the medication management

system is regularly assessed

– Standard 4.7.1 : Known medication allergies and adverse drug

reactions are documented in the patient clinical record


reactions


• Allergy Key Performance Indicator Report

– Retrieves Patient’s name, ward location and medical unit

– Patient inclusion criteria:

» If patient has no allergy recorded

» If the patient ‘s allergies have been modified or updated after 24

hours since admission

� Note: If the patient had pre-existing allergies that was updated within 24

hours of admission, the patient will not qualify for the report but will be

counted in statistics at the end of the report. If a patient has ‘No Known

Allergies’ but not reviewed within 24 hours, the patient will qualify for

the report

» Patients have been admitted greater than 24 hours


Footer section of Allergy KPI report:

• Excel version also available

– Retrieves similar columns but extra column with ‘Meds Prescribed’

section for that patient

6. Medication Administration Reports6. Medication Administration Reports

• Using Discern Analytics

– Ability to do reports on Medication Administration events

– Allows deeper investigation into medication administration tasks

» Retrieves all administrations for an orderable(s) over a period of time

» Can display when a dose a administered

» Can display the dose that was documented as given (as opposed to

looking at the order detail display line)

» If a task was ‘Not Done’ and the reason selected

» Allows investigation into trends, usage statistics and identification of

errors

» Can look at current events as well as retrospective analysis

– Incredible advantage due to speed of access to information


• Examples:

– Report on Clexane Administration

times

» Hospital policy change to make

Clexane administration times at 8am

» Further excel manipulation allowed the

report to look at percentages of

administrations outside the scheduled

times and filter by ward location


• Examples:

– Report of medication administrations that were ‘Not Done’

» Local project looking at definitions of ‘Nil Oral’ and ‘Fasting’

» Report from Cerner allowed analysis of whether current practices are

appropriate

– Report on fentanyl patch administrations

» Review of ‘STAT’ (Once-only) administrations of fentanyl patch

» Led to implementation of Fentanyl patch removal tasks

– Report for high-risk drugs

» How often Naloxone is being used when looking at incidences of

opioid overdose

» Use of IV morphine on the wards

» High-dose insulin usage rates

ConclusionConclusion

• Implementation of Cerner has opened many

possibilities for improving practice

– Various tools to help translate current policies to an electronic

environment

– Specialised dosing instructions allows standardised dosing

– Allows quick, real-time access to data through the use of Discern

Analytics and custom built CCL reports

– Reports provides evidence for supporting the new NSQHS

• Future directions:

– Further implementation: Medication reconciliation

– More advanced reporting tools

adrian lio, austin health: using a clinical system to address the national safety & quality...

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