Ian Zunder & Bob ElliottSept – Oct. 2011

1

Update on SIMS

Talk Objectives

2

Highlight changesPointersIdentify common errorsReview key concepts

What’s newmyTOH has Preop Manager

3

Ward / ICU Consults

What’s newCubicle Computer with “LIVE” SIMS Apps

4

What’s comingiPad – myTOH / vOacis

5

What’s coming?

6

ICU autologin machinesvOACIS – new Census

“Surgery patients for tomorrow”Will be able to review your cases in one spot

rather than cutting MRN numbers from the OR schedule

Lab Interface

PrintoutChanges

7

Printout Changes

8

Printout Changes

9

Drug routes clearly identified

Prefix (Reg) used for Regional drugs

Combined Meds & Infusions

denoted by “>>”

Drug infusions in this section use RATE

Drug infusions in this section useMASS per Time Column

At this time, PICIS is not able to program the PrintOut so thatCombined Infusions appear in the Infusion section with a RATE

10

Printout Changes

The problem of Drug Infusion RATESUntil PICIS can fix the problem of Combo Infusions not showing upin the Printout as a RATE, we are going to use a PARTIAL work-around.

Single Drug Infusions will revert to the original PICISstyle as a FLUID (will appear OnScreen in greengreen)

Single Drug Infusion

as COMBO

Single Drug Infusionas FLUID

11

Printout Changes

The problem of Drug Infusion RATESSingle Drug Infusions:• will appear OnScreen in greengreen as a FLUID • can be selected in Protocols as before• will appear in the PrintOut in the INFUSION section• will appear as a RATE both OnScreen and in Print

Combo Drug Infusions (2 or more drugs):• will appear OnScreen in the MEDICATIONS section• will appear OnScreen as a RATE• will appear in the PrintOut in MEDICATIONS• will appear in Print as MASS per Time Column (usually 5 min)

Printout Changes

12

•Invasive pressures (in red) trended with non invasive pressures (same graph)

•Y-axis with BP incremental values of 20 rather than 40 (with grid on graph)

•SpO2 values documented as number in addition to histogram scale

Printout Changes

14

FFP has had bag levelled to zero

RBC paused – and levelled to zero

To get the proper display in the Printout – use Pause when bag finished

Data ArchivingWill be every minute by defaultData is (currently):

captured – q30secsdisplayed – currently q5min (NIBP is exception)archived (stored on server) – q5min

Data will be:captured – q30secsdisplayed – q5min in table / q1min in grapharchived – q1min

Rationale: In a Critical Event, will you remember to use Emergency Data to insert q1min data into record for archiving? Probably not...

15

Data ArchivingWill be every minute by default

Will you see anything different on-screen?

16

Art Line shown with RT Interval 5

min

Art Line shown with RT Interval 1

min

RT Interval can be set by clicking this

box

Tricks/Pointers Artifacts

Artifacts are a common problem with Anesthesia Information SystemsWhatever is on the monitor at

the precise moment when the AIMS is checking, gets recorded

You must be vigilant! Is an artifact in the graphical

trend captured in the “real time variables”?

If “YES”, this will appear on the printed record

If “NO”, this will NOT appear on the printed record

17

Artifacts How do you fix artifacts?

Correct the variableMemo the artifact

18

ArtifactsCorrect the Variable

19

1. Click on variable to be

corrected

3. Use the Comment field to document

“Artifact”

2. Input corrected value

4. Hit Enter button

Artifacts - Finding the Variable to Correct

20

At usual 5 min res, the artifact is seen on

Graph but not in Table

Switching to 1 min res, the artifact is now seen on both Graph & Table

ArtifactsMemo the Artifact

21

If you encounter morethan the odd artifact,(e.g. repeated electro-cautery interference)you will probably want toenter a formal Memo

Tricks/PointersLabeling IV Lines

Two IV lines running the same solutionHow do you keep track??? Label the line!!

22

Click on First IV Bagfor this IV line

Select alternate IV site

from Drop-down

Hover Pointer overIV Fluid to see IV Site

Tricks/PointersChanging the Rate for a Combo Infusion

23

Change Pump Rate using the rate from your pump

Switch from “Infusing”to “New Bag”

Now you can edit Dose

Tricks/PointersEliminating White Space

24

Tricks/PointersEliminating White Space

25

1. Right Click over any point of the Variables

Or on heading“Real-Time Variables”

2. Select the variables you want

to remove

3. Hit Remove 4. Hit “OK”

Tricks/PointersEliminating White Space

26

Tricks/PointersFinishing a Case before hitting the PACU

Normal ProcedureTransfer the patient off the

local workstation in the OR

In PACU, login to dedicated SIMS computer and locate the patient in Remote View

Complete PACU handover Report

Finish the Case and Print record

Logout

27

1

2

3

Tricks/PointersFinishing a Case before hitting the PACU

Modified Procedure Initially skip the Transfer

In the OR, document PACU handover Report and forward time the event

In the OR, document a Finish time and forward time the event When the Print dialogue box

appears, make sure that you forward time the “End Time” to capture the handover and the finish activity

Transfer the patient

Printout should be waiting for you on your arrival

28

1

2

3

4

•Can save time in high volume list

Anesthesia ManagerLaunching the Application

29

Wait until you see the eyes of the patient outside the ORA patient can only be active on 1 workstation at any

given time

If you “start session” on a patient NOT present outside the OR, this patient is not available to the nurses in the Preoperative area.

Anesthesia ManagerSelecting a Patient – Starting a SESSION

“Start Session” not availablePatient can only be “active” on one machine

Assume patient is active in Preop area until proven otherwise-how can you tell?

30

Anesthesia Manager Selecting a Patient – Starting a SESSION

31

•“Remote View”- Investigate

•Look for GA (Transfer)•Look for Event To OR in the log

•If patient is NOT in the Transfer zone, then contact Preop area•If patient IS in the Transfer zone, technical problem,

contact HELP Desk-SIMS technical pager

Anesthesia ManagerSelecting a Patient - MOR Default List & Emergency Patients

Patients on the Emergency List are initially NOT found on the Main Census List They are maintained on a “Waiting List” which we don’t have access to

Ward Clerk (or Nurse) moves patient onto the Main Census List when called for the OR

If you do NOT see your patient on the Main Census List, please ask whether the transfer from the Waiting List has occurred.

32

Anesthesia ManagerSelecting a Patient - MOR Default List

Occasionally, patient is on the Census list but not under the expected OR CIVEM01, CIVEMO2, CIVEMO3

Scan the list – right to the bottom!

33

• …OR - Sort the list by last name

•A Jon/Jane Doe will show up in a room as above using an alphanumeric name

Anesthesia ManagerSelecting a Patient - Satellite Default Lists

All workstations outside the Main OR (Civic or General Campus) have a generic pull down list (Lithotripsy at the Riv has a dedicated census)

CIV Dental - Admitted Today CIV Endoscopy - Admitted Today CIV Labour and Delivery - Active Patients CIV Medical Imaging - Admitted Today CIVMOR Surgery patients – Today (This is the DEFAULT) CIVMOR Surgery patients - Tomorrow CIVMOR Transfer patients ZZZ SIMS Version 2.2.7 A

34

Anesthesia ManagerFinding a Patient - Using MRN #

35

•Avoid unless absolutely necessary•Use the patient encounter # to help select the correct SIMS session -Encounter number is 12 digits

•Look for a Surgery Date and/or Booking

ID

Anesthesia ManagerLaunching the Application-Using MRN #

What happens if I pick the wrong SMS admission Anesthesia Manager won’t talk to OR Manager and the case will show up on a

System Admin census as not being complete.

What about Remote areas (Diagnostic Imaging/Endoscopy/Brachytherapy) These cases do NOT have a Booking ID Pick the most appropriate encounter/SMS admission

This is usually the encounter at the top of the screen search Date you choose should match the day of the procedure37

Anesthesia ManagerDemographics-System Bug

Demographic Screen does not match the active patient Known bug All information entered into the system will be archived and printed

CORRECTLY Exiting and re-starting Anesthesia Manager will resolve the

problem.38

Anesthesia ManagerDemographics-System Bug It is OK to quit application/power down-unplug computer

when a patient is ACTIVE on a local workstationAll data is uploaded and archived on the server (cloud) in 5

minute increments (soon to be 1 min) Rebooting the computer/Re-launching Anesthesia Manager

should bring up a text box identifying the patient active on the local machine and providing you with options

39

Anesthesia ManagerDemographics-Remote Areas

Demographics subsections are BLANK and need to be populated Labor and Delivery Dental Clinic Diagnostic Imaging Endoscopy Lithotripsy

40

Anesthesia ManagerDemographics-Remote Area Procedure

We are responsible for entering the procedure

41

Anesthesia ManagerDemographics-Remote Area Procedure

42

•All remote areas have cheat sheets

•Handful of keywords in any remote area will bring up the list of procedures

“Remote” – important!

“Cysto”

“Cesarean” (not “Caesarean”)

Anesthesia ManagerDemographics-Remote Area Procedure

43

1. Hit “Add”

2. Enter keyword

3. Find Now

5. Hit “Add”

4. Select Procedure

Anesthesia ManagerDemographics-Remote Area Medical Team

We are responsible for entering the medical team NO medical personnel (Anesthesia/Surgery) will be listed in Remote areas

44

Anesthesia ManagerDemographics-Remote Area Medical Team

All physicians practicing in remote areas will be listed in the pull down list Please inform a SIMS super user if a physician does NOT appear in the list

45

Macros Inserted into the program

because of the lack of visual prompts typical of a paper record

If followed, ensures (as best as possible) that important components of the record are NOT forgotten

46

Macros

Very important to use the “Start” icon Places the important Start-Time stamp (event) on the anesthesia record

(Can be done manually through Add Event – but why bother?)

System Admin checking to make sure that certain prerequisite information is on the record

47

Macros

You will be notified if “Anesthesia Start Time” is NOT documented

IMPORTANT OHIP NOTE:Make sure you enter a Anesthesia Start Time that is the same as

the Start Time you submit to OHIP

48

Macros

Only use the Start Icon ONCE! Above example – 1st click => incorrect Start Time of 21:20 entered

2nd click => tried to correct Start Time to 21:15 End result => SIMS will use the chronologically LAST Start

Time listed!

Proper way to correct => EDIT the time by double-clicking or Use the Edit Button

49

Incorrect Start Time entered

1st

Correct Start Time entered

2nd

Macros The events in this Event Set

(A010) are to be used to provide proof that the physician has reviewed a formal Preoperative Assessment/Consult Previously done in

Preoperative Manager-viewed in vOACIS)

It does NOT replace a formal Preoperative Assessment

50

Macros

Simply choosing events may not provide ample proof to having reviewed a Preoperative Assessment done by a colleague

“bullet points” in the Comments section suggest that you have reviewed the Preoperative Assessment or had a discussion with the patient

51

Macros These macros put markers on the timeline

(R, G, M) and indicate a “Start-Flag” in the log General Start Regional Start MAC Start

Provide a reference point for future entry of comments/drugs

They do NOT represent Anesthesia “Start Time”

They do NOT enter a specific “Anesthesia Type” for you

Reminder – Anesthesia Types start with:(G)_ or (R)_ or (C)_ or (M)_

52

Macros

You will be notified if “Anesthesia Type” is NOT documented. You should pick ONE-and-only-ONE Anesthesia Type! Admin reports will document if more that one type of

“Anesthesia Type” (including duplicates) have been entered

53

Macros

Don’t add events to the log using Macros if you have not performed the eventEg. “End GA” macro when a spinal anesthetic has been performedEg. “End GA” macro when a patient is left intubated

54

Event Log

Imperative that you check your event log at some point during every case Insure timeline makes

sense Delete inaccurate

entries

55

Protocols-Combined Medications

56

Extensive library of protocols, many of which contain combined medications and organized by:Major categories most commonly usedRegional anesthesia drugsAlphabetical by “Class”

For system purposes, a combination can contain 1-4 different drugs.Building in this fashion allows the drug to show up in both the

“medication” and “fluids” part of the electronic record

Combinations are primarily generic Bolus doses kept at 0 units Infusion doses kept at 0 units/hrExceptions are the most commonly used combinations (eg.

Fentanyl 250 ug/Lidocaine 200 mg)Exceptions are the most commonly used epidural/spinal

concentrations (eg. Bupiviaine 0.25% + Morphine/Fentanyl)

Protocols-Combined Medications

57

Don’t even Double-Click

Protocols-Combined Medications

58If this Box appears when choosing a Protocol,You are Editing the Protocol – CANCEL!

Protocols-Combined Medications

59

Do NOT enterANYTHING!

SIMS Help

60

FUNCTIONAL ISSUES-Super Users (working hours only)Civic Campus

Zunder Bryson Charapov

General Campus Elliott Gagne Szeto

TECHNICAL ISSUE-HelpDesk (14136)Password resetsNetwork connectivityPrinting problemsComputer related issues