CPOE Implementation from a Nursing Perspective

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CPOE Implementation from a Nursing Perspective

• Harlow H. Sires, RN, MSN
• Clinical Informatics Specialist Highline Medical
  Center
• Burien, WA

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How I got here

• 1984 BSN University of Illinois, Chicago
• 1994 MSN University of Massachusetts, Boston
• 1996 Critical Care Clinical Specialist Staff
  Education

• 1998 2004 Apps Mgr (Reported to I.S.)
• 2004- 2006 Patient Services Clinical Systems
  Analyst (Reported to Nursing)
• 2006 President of NISCNE
• www.niscne.org

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• Main Campus
• Specialty Campus
• 184 Beds
• Planetree Philosophy

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Average Rainfall Seattle vs. Boston

• Boston Average Annual Rainfall
• 1,054 mm
• Seattle Average Annual Rainfall
• 944.6 mm
• Source www.mapsofworld.com

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Newton-Wellesley Hospital
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Newton-Wellesley Hospital

• Partners Affiliate
• 250 Beds
• 1 Pediatric Unit and 1 Special Care Nursery
• 1 Telemetry, 1 Med Oncology, and 1 Med/Surg
• Pediatrics and Maternal Child Health
• 1 Surgical Unit and PACU
• Psych (two divisions)
• Campus BOOMING with construction
• New ED and Surgical Center

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What I plan to share today

• Brief overview of MEDITECH MAGIC POM
  implementation at Newton-Wellesley Hospital
• Committee structure
• Rollout plan and motivation
• What our screens look like
• What worked for us and lessons learned
• The importance of a strong team approach and how
  to avoid silos
• Suggestions where to find Computer Nurses for
  future implementations

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Motivation

• Newton-Wellesley Hospitals ongoing commitment to
  patient safety
• Improve patient care
• JCAHO (ongoing Patient Safety Program)
• Pay-for-performance guidelines (Leapfrog)

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Committees

• CPOE Steering Committee
• Senior Staff, Physicians, I.T., Nursing,
  Education
• IS Steering Committee
• Directors, Physicians, Nursing
• Pharmacy CPOE Committee
• Pharmacists, Consultants, Nursing
• Nursing Practice CPOE Committee
• Physician Advisory Committee

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Project Team

• Project manager (full-time)
• Consultants (one full-, one part-time)
• Physician lead (part-time)
• Nursing lead (full-time)
• Pharmacy lead (full-time)
• Network/hardware representation
• Guests from upcoming units
• Project manager, physician and nurse lead, and
  CIO sat on CPOE Steering Committee

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Traditional physician orders

• Illegible
• Faxed to pharmacy (tube system or carried by hand
  before fax machines existed)
• Entered into computer by unit coordinator or RN
  (before computers requisitions)
• Pharmacy pages physician for clarification
• Orders sit on desk, flagged or un-flagged
• Cumbersome to review
• Competition for paper record

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Electronic Physician Orders

• Legible
• Instantaneously in receiving department
• Computer prompts MD of problems before the order
  is filed
• Orders can be accessed from anywhere
• Less competition for medical record

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Elements of CPOE

• Physicians enter orders in PCI (Patient Care
  Inquiry)
• Nursing Status Board (to take off the orders)
• Nursing views master list of physician orders in
  Order Management

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Adjusting to CPOE

• Nurses now exposed to more information
• Orders move quicker
• Second person cant access a patient when
  physician is writing orders on that patient
  (safety feature of software)
• Pharmacists spend less time paging physicians to
  clarify orders
• New signing off order paradigm

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Nursing CPOE Training

• Nurses learn differently than physicians
• Create basic training document and modify for
  each consecutive area
• Create fake user for each area in TEST with
  generic password
• Admit RN to into the test system (make everyone
  23 years old and 110 pounds)
• Enter standard order set on each nurse
• First hour of class observe
• Second hour of class hands on

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Rollout Sequence

• Pilot floor small controlled unit (Pedi) to take
  the software for a ride (October 22, 2004)
• Telemetry (March 22, 2005)
• Medical Oncology (May 17, 2005)
• Med/Surg (Ortho and Neuro Surg) and PACU (only
  Ortho and Neuro Surg)(June 21, 2005)
• Surgical floor and rest of inpatient PACU
  (September 13, 2005)
• ICU (October 18, 2005)
• Maternity (November 8, 2005)
• Special Care Nursery (January 2006)
• Psych (February 14, 2006)

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Preparing a unit for CPOE

• Ongoing physician training
• Prepare order sets related to service
• Recognize the culture of each floor
• As one floor goes LIVE, start prepping the next
  floor
• Weekly meeting with people who do grunt work
• 3 weeks before go-LIVE start Nursing training
• Connectivity testing for wireless access

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Go-LIVE Day

• Tuesday was our regular go-LIVE day
• Line up extra help in reserve
• Physician support and nursing support visible
• Have a notebook to communicate issues
• All patients who were admitted after 700 a.m.
  are put on CPOE
• Patients already admitted stay on paper
• This had challenges
• Didnt work on Psych due to LOS

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Go-LIVE day and the first week(s)

• Go-LIVE day is an anticlimactic day
• Prep yourself for Wednesday and Thursday!
• Be ready to quick fix things that couldnt be
  anticipated (Oh, we forgot to tell you..)
• Weekend warriors (staff changes)
• Separation anxiety from support staff starts on
  week three (We need to extend coverage, we are
  different from the other floors)

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Things to consider when scheduling coverage

• No magic formula that works for all floors
• Figure out times you will have high volumes of
  orders
• When do the physicians do rounds?
• Straight shift coverage vs. overlap
• Three weeks, round-the-clock coverage
• Double coverage weeks 1 2
• Single coverage week 3

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Coverage

• HUGE challenge in beginning of project
• Watch every area for stars and recruit them!
• Utilize as many staff people as possible People
  respect their peers
• Physician coverage and nursing coverage need to
  work together

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Sample Coverage Schedule
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What contributed to our success?

• Senior staff support
• Focused leadership
• Stellar communication between disciplines
• Well-orchestrated and documented rollout plan
  with change management philosophy at the center
• Learned from our mistakes and moved forward
  immediately
• Recognized excellence

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One Positive End Result!

• Order Clarification phone calls between
  Pharmacy and MD reduced by 80
• 2004 we tracked 2435 calls
• 2005 AFTER CPOE was 75 implemented 1267 calls
• January 2004 we tracked 272 phone calls
• January 2005 we tracked 213 phone calls
• January 2006 we tracked 19 phone calls
• February 2006 we tracked 10 phone calls

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Suggestions

• Change manage it or it takes over!
• Get as many staff SuperUsers as possible BEFORE
  you start
• Cross train nursing, physicians, and pharmacy
  support
• Pocket reference cards
• Make sure your support people are all on the same
  page! Learners need consistency!

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Suggestions to avoid silos

• Cross-pollinate your committees
• Invite lead pharmacist to floor meetings
• Nursing should attend Pharmacy meetings
• Show pharmacists how a nurse processes and views
  meds on the status board
• Show nurses how the physicians enter orders
• This is the most intense team effort youll ever
  encounter

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How you contribute as CNO

• Dont underestimate the power of being a role
  model
• Hold managers accountable for the success of
  computer implementations in their area
• Recognize excellence publicly and privately

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CNE Contributions (cont.)

• Be visible and show genuine interest in computer
  implementations
• Become familiar with and support your I.T.
  nursing staff (analysts, etc.)
• Computers are the future of Nursing and health
  care, send your nurses to conferences and pay for
  them to join local nursing informatics
  organizations

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Where to find future I.T. nurses?

• How did you get your job? Im frequently asked
  this question
• Theyre working in your
• ICUs
• PACUs
• Staff Education Department
• Nursing floors

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Questions Comments

• Harlow Sires, MSN
• hsires_at_highlinemedical.org
• harlowhsires_at_yahoo.com
• Work 206.431.5373 Ext. 5067
• Mobile [phone]