GBHN Order Sets

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• GBHN Order Sets
• An effective solution to the complex challenge
  of improving patient care and safety

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Agenda

• Call for questions to be answered at the end of
  the presentation
• Overview of partnership
• Project Process
• Demo of website
• Sample order sets/protocols

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Context Massive Gap Between the Possible and the
Actual

• Quality
• Misuse, under use, overuse on a massive scale
• Crossing the Quality Chasm 2001
• Safety
• Medical error is common
• Institute Of Medicine Report on
  Error 2000
• Variation in Care
• Variability in care not explained by patient
  preferences or different disease patterns
• British Medical Journal 2002 325
  961-964

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Solution Order Sets a Clinical Decision Support
Tool

• A group of orders with a common functional
  purpose used by the physician to create orders.
• Integrates knowledge into the care delivery
  process knowledge where the clinician needs it
  most
• Organizes clinical knowledge so it is easy to
  remember, easy to use and has maximum benefit to
  the patient
• Contain evidence-based and best practices
• Source of education
• Can be used in paper or computerized ordering
  systems

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Order Sets Key Benefits

• Safety
• Reduced transcription errors
• Reduced errors of omission
• Reduced errors in medication dosing
• Quality
• Improved compliance with evidence-based and best
  practices
• Standardization of care
• Efficiency
• Decreased time to write and process orders
• Reduction in physician call-backs
• Reduction in missed orders
• Critical enabler for computerized practitioner
  order entry

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Current Status of Order Sets

• Lack of Recognition of Order Set Importance
• Order Set Design
• Often no standardized structure
• Structure is not modular
• Lack of integration with other processes/documents
  
• Order set life cycle not well established
• No dedicated Order Set Committee at most
  hospitals
• Most often PT/MAC based process, occasionally
  process is distributed to the level of the
  health systems
• Best practices often not scaled across
  departments
• Lack of version control
• No measurement of metrics
• Each hospital has its own structure and approach
  to order sets

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Order Set Project

• 2001 Order set development begins in ICU
• Rapid Cycle improvement of order set design
• 2002 Order set development in other departments
• 2003 Standardized order set format established
• 2004 Current Order Set Committee established
• 2006 Standardized order sets in use in every
  Health System
• Over 250 order sets currently in use
• Admission order set use gt 90 in most health
  systems

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Open Source Order Sets

• Dedicated to improving healthcare in Canada by
  facilitating the use of high quality,
  standardized evidence based order sets
• Partnering with other Health Care Organizations
  to standardize and improve the quality and safety
  of patient care
• Niagara Health System
• Open Source Order Sets
• Provide a complete order set solution
• Save organizations time, money and reduce demand
  on limited organizational resources
• Improve quality
• Local ownership and adaptation of tools

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Open Source Order Sets

• Standardized Order Set Design
• Standardized structure to order set content based
  on DAVID
• Rules of correct formatting at all levels of
  order set content
• Clear syntax of order set content
• Designed to anticipate CPOE
• Modular Format
• Best practices are contained in functional groups
• Facilitates the spreading of best practices
  across different order sets and across health
  systems
• Over 300 modules including many high value best
  practice modules such as deep vein thrombosis
  prophylaxis, bowel care, pain control,
  electrolyte management
• Order Set Lifecycle
• Order Set Committee
• Interdisciplinary membership
• Robust methodology for development, approval,
  implementation and maintenance

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Open Source Order Sets

• Large Library of Developed Content
• Over 250 order sets and clinical protocols
• Comprehensive interdisciplinary content
• Incorporation of real world experience
• Will grow to over 600 order sets in the next year
• Order Set Web Page
• Web accessible data base to store library of
  order set content
• Order sets clearly organized, searchable by many
  different criteria and relationships between
  order sets and clinical protocols clearly
  established
• Order Set Project Support
• On-site and remote support including physician,
  nursing, pharmacy
• Goal is rapid knowledge transfer

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Benefits

• Save time
• Save money
• Improve the quality and safety of patient care
• Large improvements of easily measured metrics in
  short periods of time
• Improve order set design
• Increase order set use by physicians
• Increase the clinical impact of order set use
• Increase the standardization of best practices
  across the healthcare system
• Increase the knowledge base that can be used for
  order set development
• Hospitals are no longer developing order set
  content in isolation
• Improve the coordination of order sets with other
  order sets, documents and processes
• Improved coordination of health care delivery in
  Ontario

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GBHN Order Set Project

• First steps now being completed
• Order Set Committee established members
• Jessica Meleskie GBHN, Chair
• Sharon Musehl Nursing, SBGHC
• Lisa Laviolette Nursing, GBHS
• Michelle Scime-Benninger Nursing, HDH
• Trent Fookes Pharmacy, GBHS
• Greg Young
  Laboratory, HDH
• Dr. Randy Montag HDH
• Dr. Paul Eisenbarth HDH
• Dr. Lisa Roth SBGHC
• Dr. Roger Skinner GBHS
• Dr. Brendan Mulroy GBHS
• Pat Given HIS, Order Sets
• Susan Downs HIS, Clinical documentation
• Darlene Young GBHN, Education/Utilization
• Julia Metzger GBHN, Administrative Assistant
• Others as needed on an adhoc basis

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GBHN Order Set Project

• First steps
• Conversion of all of our current orders into the
  new modular format
• Link directly from the GBHS Intranet, HDH
  Docushare, Icon on SBGHC desktops
• Beginning to merge our content with OSOS content
• Next steps
• Go live date May 22 first few order sets
  approved will go on the website
• Print-on-demand directly off website 88 new
  printers being installed this month across all
  GBHS sites where there have been issues
• Will need a champion on each unit to remove of
  old order sets from the units as we get new ones
  approved, replacement with new ones (small
  volumes to ensure most up to date orders always
  being used, print-on demand for low volume order
  sets)

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Demo of Website

• Initially see entire list of orders available
• Click on name of document to print off and use
• Search via key word at the top of the list, or
  click on advanced search to search by many
  different parameters as can be seen on the
  website
• Can also see the entire library of Open Source
  Order Sets if click on Master OS Repository on
  the left hand side
• Will be releasing a memo each month with the
  new/changed orders available on the website. Also
  releasing a newsletter as necessary to update
  staff/physicians on project status
• Involved with the Clinical Documentation project
  with Cerner to build the order sets as developed
  into PowerOrders
• NOTE these do not replace the clinical pathways
  they are still available on the EBC website via
  the icon on the desktop. They will be modified if
  necessary if the orders change, but will still be
  used. The pathway orders will be available on
  both sites the EBC site as well as the Order
  Sets site

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Sample COPD Order Set

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COPD Order Set

• May be printed on demand, or since it is fairly
  high volume, can have 5-10 copies available
  printed on the unit
• Physician will pull and write on the order set
  just like our current orders
• All orders have an admission header on them
  where to admit, diagnosis, isolation,
  comorbidities, code status, allergies, family
  physician
• Two types of orderables open box is optional
  and must be ticked before it is active closed
  circle is an automatic order unless it is crossed
  off
• You will notice similar modules across all the
  order sets same choices on most of them,
  difference will be which ones are automatic
  orders, and which ones are tick boxes. Many more
  choices than we are used to, to be more flexible
  for patients with multiple comorbidities.

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COPD Order Set

• If there is a clinical pathway, the next line
  will have the order for the clinical pathway to
  be entered into Cerner
• Next sections Consults, Diet, Activity, vitals
  same as current order sets we have seen in the
  past
• Next section Respiratory will be a new
  category in Cerner containing all treatments i.e.
  oxygen related to respiratory
• Patient care section has subsections in it
  related to nursing care Tubes/Drains Point of
  Care (POC) Testing,
• Laboratory, Diagnostic Tests, IV Solutions
  similar to our current orders

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COPD Order Set

• Medication sections are divided up into
  subcategories by type of medication
• Antibiotics, Bronchodilator therapies, Steroid
  therapies
• PRN Medications includes your Gravol, etc, as
  well as refers to two protocols Potassium Oral
  Dosing, Bowel Routine
• Smoking Cessation section, PRN Sedation section
• Next sections are other protocols diabetes
  related, DVT prophylaxis protocol
• All of these protocols are also available on the
  website to follow if ordered.

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COPD Order Set

• All associated protocols can be found on the
  website for reference
• Documentation for the protocol written bowel
  care protocol on Kardex/Care Plan, and then tell
  pharmacy when you are initiating the protocol and
  they will document on the MAR sheet (GBHS).
  SBGHC, if a nurse initiates a protocol, place
  protocol with med profile, add bowel protocol
  to the med profile, and transcribe to the MAR.
• Some order sets will also have a new category
  called Communication Orders. This is for orders
  such as If increased swelling or bleeding at the
  operative site, notify physician.

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Questions