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V i e w t h i s i s s u e o n l i n e a t :

SoarianUnder “Links”

Faith Regional IntranetUnder “Clinical”

www.frhs.orgUnder Education & Resources > For Healthcare Professionals > For Providers > Provider News

The Correct Patient Status: Getting it Right from the BeginningWe all know how important it is to get a patient into the correct status (inpatient versus observation) from the start of their stay at Faith Regional. In our current process there are many times we will see multiple and duplicate status orders in Soarian which makes it confusing for all involved. Remember, we cannot start billing until an appropriate status order is entered. To address these issues and the “bridging orders” a team of providers along with IT and Case Management have come up with a process that will be discussed briefly in this article.

Problems identified with the current process:

• Status orders are not being entered consistently.

• The admitting physician is not the one entering the status order.

• The ED physician is responsible for entering the status order even though they are not the admitting physician and they do not have admitting privileges.

• We currently have “bridging orders” and there is not a clear definition as to what this means.

• Status orders are frequently changed shortly after the patient goes to the bed tower. This should only be done when a patient’s medical condition changes and criteria is met for that change in status.

New Process:

• When a determination has been made that the patient needs to be admitted the ED physician will contact the admitting physician (or Hospitalist).

• The most beneficial way to ensure the patient is in the right status when they go to the bed tower is for the admitting physician to go to the ED when at all possible. If the physician cannot come to the ED, then they will have the conversation on the phone.

• When the case manager is present in the ED (they are available 7 days a week from 8am-6:30pm) they should be included in the conversation about the correct status and appropriate criteria should be reviewed.

UNMC Telehealth The second Tuesday of each month from 12:15 to 1:15 p.m.

Common Infections in the ElderlyJuly 11, 201712:15 - 1:15 p.m.Terrace View RoomPresenter: Muhammad Salmon Ashraf, M.D. | Associate Professor, Internal Medicine – Infectious Disease

CME OpportunityHow to Apologize to a PatientJune 20, 20174:00 - 5:00 p.m. 6:30 p.m. (for Physicians)Nebraska RoomPresenter: Brien Welch | Omaha attorney

Nominations for the 2017 Physician of the Year are being accepted now through November 1, 2017. All nominations must be submitted online at frhs.org.

FAITH REGIONAL HEALTH SERVICES

PHYSICIANO F T H E Y E A R

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• The ED physician will place the status order as a telephone order per the admitting physician when the physician is not present in the ED. If the admitting physician can come to the ER they will place their own orders. Orders can also be placed by the physician at home through remote access even prior to the patient being on the bed board. This would be preferred if possible (see link for instructions).

• If the admitting physician cannot place orders at the time the ED physician will place only the orders that are needed to get the care started (bridging orders) for that patient. These would include pain medication, order sets, and other medications needed. It will be up to the admitting physician to place any other orders beyond what is needed to get the patient’s care started.

More instructions and screen shots are below to help you with this new process. You can access the entire presentation by clicking here.

Please contact Laura Gamble (ext. 8319) or Kim Atkins (ext. 7597) if you have any questions.

Physician entering telephone orders for admitting provider.

ER provider can enter orders for another provider by using the fields at the bottom of the ordering screen to populate the other provider’s name and change the order source from written to telephone order with read back via the drop down.

The “Ordered by” field is changed by clicking on the ellipsis next to your name in the ordered by field. Another window opens which allows you to search for the appropriate provider

After selecting the physician’s name and clicking on add, the physician’s name will appear at the bottom of the screen.

When hovering over the new order, it displays the name of the provider that was selected in the ordered by field.

This is a monthly publ icat ion by Fai th Regional Heal th Serv ices Medical Staf f Serv ices2700 W. Nor folk Ave. , Nor folk , NE 68701

The Correct Patient Status: . . . continued from page 1

At any time we can actually see who entered the ordered by looking at the details or the history of the order. The “Entered by” is populated by whoever is signed into the computer and making the entry. The “Ordered by” is populated by your selection at the bottom of the ordering screen.

If you forget to change the name of the provider prior to entering orders, you can enter the information in the lower portion of the screen and then click on the icon for “Apply to Unsigned Orders” which is located right under the icon to sign the orders.

To access the Correct Status Order presentation - click here.

Documentat ion

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Physic ian Focus

This is a monthly publ icat ion by Fai th Regional Heal th Serv ices Medical Staf f Serv ices2700 W. Nor folk Ave. , Nor folk , NE 68701

Drug Shortage Alerts:

Emergency Syringes Intravenous emergency syringes are currently on shortage throughout the country. This includes 50% dextrose, epinephrine, and sodium bicarbonate.

Faith Regional is being affected by these shortages, and as a result the Pharmacy and Therapeutics Committee is recommending reserving sodium bicarbonate for critical care use only. Please see chart of alternative options for specific conditions below. It is anticipated that supply may not be restored until August 2017.

Indication Recommendation Key Points

Prevention of contrast-induced nephropathy

0.9% NaCl 1 mL/kg/hr for 6-12 hours before and 6-12 hours after procedureFor emergent procedures, 0.9% NaCl 3 mL/kg/bolus, followed by 1 mL/kg/hr for 6-12 hours after procedure

Use of sodium bicarbonate associated with mixed results; studies have differing therapeutic end points

Urinary alkalinization to enhance drug elimination

Optimal alternatives are agent specific

Evidence to support use of sodium bicarbonate is limited for most agents, with the best data in relation to enhancing elimination of high-dose methotrexate and aspirin

Oral sodium bicarbonate may be used

Rhabdomyolysis Aggressive resuscitation with 0.9% NaCl

Sodium bicarbonate offers no significant improvement over aggressive fluid resuscitation with 0.9% NaCl

Hyperkalemia (acute management)

• Insulin 10 units IV push + Dextrose 50% 50 mL (also on shortage)

• Calcium gluconate• Albuterol• Kayexylate

Sodium bicarbonate therapy has little use in the routine treatment of hyperkalemia unless severe metabolic acidosis is also present

Metabolic, respiratory, or diabetic acidosis

Sodium bicarbonate not recommended in patients with pH ≥ 7.15

Studies do not support that sodium bicarbonate enhances catecholamine effectiveness

Treat underlying shock/source of acidemia

Alternative buffers Sodium acetate may be considered as an infusion in select patients with severe acidemia

Sodium acetate cannot be used as IV push in emergency situations due to issues with hypotension and cardiac instability

************NOTE************Many studies have shown little/no benefit and perhaps harm from administration of sodium bicarbonate for rapid correction of academia accompanying cardiac arrest, and the latest ACLS guidelines published by the AHA do not recommend routine administration

References1. Amphastar (personal communications). February

17 and May 4, 2017. 2. Pfizer (personal communications). February 17,

March 13 and 21, April, 14, and May 3, 18, and 19, 2017.

3. Sodium Bicarbonate. In: Baughman VL, Golem-biewski J, Gonzales JP, Alvarez W, eds. Anes-thesiology & Critical Care Drug Handbook, 10th ed. Hudson, OH: Lexi-Comp; 1444 - 1447.

4. Sodium Bicarbonate. In: McEvoy GK, Snow EK, Miller J, eds. AHFS 2017 Drug Information. Bethesda, MD: American Society of Health-System Pharmacists; 2017:2852 - 2854.

5. Neavyn MJ, Boyer EW, Bird SB, Babu KM. Sodium Acetate as a Replacement for Sodium Bicarbonate in Medical Toxicology: a Review. J Med Toxicol. 2013;9:250-254.

6. Rouch JA, Burton B, Dabb A, et al. Comparison of Enteral and Parenteral Methods of Urine Alkalinization in Patients Receiving High-Dose Methotrexate. J Oncol Pharm Practice. 2017;23:3-9.

Pantoprazole (Protonix)

• Shortage of injectable pantoprazole anticipated to resolve in late June.

• All IV push orders for pantoprazole will be automatically substituted to famotidine (Pepcid) 20 mg IV q 12 hours if NPO or pantoprazole PO if patient able.

• Reserve injectable pantoprazole for patients with GI bleed.

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This is a monthly publ icat ion by Fai th Regional Heal th Serv ices Medical Staf f Serv ices2700 W. Nor folk Ave. , Nor folk , NE 68701

A Review of the Massive Transfusion Protocol for AdultsA massive transfusion is defined as the replacement by transfusion of 10 units of red cells in 24 hours and is the response to massive, uncontrolled hemorrhage. Massive transfusion involves appropriate amounts and types of blood components to be administered. Clinicians must have careful consideration of a number of issues including volume status, tissue oxygenations, management of bleeding and coagulation abnormalities, and changes in ionized calcium, potassium, and acid-base balance when a massive transfusion is needed. Cardiac surgery is the most common situation leading to massive transfusion with crystalloid fluids and packed red cells, followed by trauma, ruptured abdominal aortic aneurism, liver transplant, and obstetric catastrophes.

FRHS has a massive transfusion protocol (MTP) for adults with the purpose “to expedite the rapid restoration of circulating blood volume and the prevention of coagulopathies and other complications associated with hypovolemic shock.” The protocol applies to patients in OR, ED, OB and ICU when a patient’s entire blood volume is replaced within a 24 hour period or replacement of 50% of total blood volume within 3 hours. The attending physician or anesthesiologist will determine the need for MTP, place the order and the blood bank will be notified immediately by nursing staff or anesthesia. Once the MTP is initiated, the lab will prepare the transfusion packs and a designated runner will deliver them to the patient’s bedside. The packs will automatically be provided to the patient every 30-45 minutes until the attending physician or anesthesiologist deems the MTP be ceased. An order will be placed and the blood bank will be notified. The nurse will return any unused product to the lab via the runner.

The MTP packs are as follows:

1. Pack #1:a. 4 units of O negative uncrossmatched packed red blood cells unless ABO

type specific and/or crossmatched blood is availableb. 4 units FFP as availablec. 1 unit Platelet Pheresis (Single donor, unless platelet count greater than

100)

2. Pack #2:a. 4 units of packed red blood cellsb. 4 units FFp as availablec. 1 unit platelet pheresis (single donor)d. 10 units Cryoprecipitate upon discretion (unless fibrinogen greater than

150)

3. Repeat Pack 2 until Physician discontinues MTP

See the FRHS “Massive Transfusion Protocol or Adults” in Policy Stat for more details of the process as the above is merely a summary. Consider using the MTP when a patient will or potentially will be needing a larger than normal amount of blood product. This will expedite the transfusion administration and lab testing will be automatically ordered as described in the protocol.

For more information, go to https://frhs.policystat.com/policy/1523413/latest/

Best Pract ices

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