Doctors ICIP Training

[Pages:8]Doctors ICIP Training

1. Census (bedstate) screen

? Log into ICIP > stay on census o Review icons and keys at the top left.

o View Bed State for your ICIP unit. o View other ICUs on ICIP, see blue bar on left screen

SMH AICU / PICU / HH GICU / AICU and PICU Training units Note icons next to the name of patient, hover mouse over each ? Go to the Training unit > Add a test patient > open notes > go to Admission tab > Complete the mandatory fields in the Demographic form and Save Allergies / Critical care date & time / Weight / Patient Type

2. Flowsheet (FS):

Review the following on the ICU Chart: ? Obs Chart ? see chart sections on the left, single or double click on each ? Rows on the Flowsheet

o Contains assessments and observations o Contains picklist options o Note Infusions tab, look at the hourly obs fields o Look Medications administered and those pending. ? Totals & Balances > reset FS to show 24hr Fluid Chart

3. Documentation

a. Medical Notes Tab ? look at Tab sections ? from Admission to HowTo [blue bar left side] ? To add a document - via the icon, or right click on a previous one ? View previously saved documents

o Documents - once per admission stays at the top left side of the tab

o Documents- multiple entries during admission Is saved chronologically for LOS

Flowsheet

Tabs for Notes Flowsheet

all disciplines

Chart sections

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? Medical notes ? doctor's documentation - Medical notes tab - Problem & Diagnosis List - Procedure tab

Adults Once only per admission

? Medical Admission note ? at the top ? Problem & Diagnosis List ? at the top ? Procedure List ? at the top Daily docs ? saved chronologically ? Medical Review ? Handover ? Ward round ? ICU doctor Note - re-label these ? Consultants Reviews ? External reviews for visiting teams ?

each team has their own form

Procedures ? complete relevant configured doc for each procedure

Paeds Once only per admission

? Medical Admission note ? at the top left ? Problem & Diagnosis List ? at the top left

Daily docs ? saved chronologically ? Daily Medical review Handover is documented in the med review ? Asked to See - re-label these ? Consultants Reviews ? Ward rounds ? Visiting teams External reviews - PICU uses a generic form for all teams

Procedures ? same form is used for all procedures, re-label these for each procedure

As part of doctors' daily documentation and at the beginning of each shift: ? Review and update the Drug Prescription chart, the Problem & Diagnosis List and Procedure

List. ? Adults: update Major Event's field each shift to ensure this is current and reflects all changes. ? Paeds: update the discharge summary each shift.

b. Day Shift Documentation: AICU / GICU ? Each shift Update the Problems & Diagnosis. ? Review drug chart daily > discontinue prescriptions not being used especially infusions. ? AICU Handover am ? complete on the ward round ? night staff retrospectively adds this form in preparation for the WR. Some of the above data will default to the Med Rev document. Add a Medical Review for day shift review. Consultant ward round ? complete on each ward round. ? GICU Day shift ? use Ward Round document for the main day review. ? Both Adults **Update Major Events field each day in the med review or ward round to have a flow of all events for the Length of stay in ICU. This defaults to the discharge summary. ** ICU note added after main shift reviews. Re- label these to the content of discussion being documented ie handover, night review, Micro review or Referral to Haematology' etc.

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 Visiting teams - completes a speciality review ward round doc; the team should speak ICU team on any changes to care or requests. Family communication documented in Patient /Family Comm form ? ALL STAFF in Adults. Doctors, do not add family conversation in the medical notes. It gets lost and missed out. PICU ? Daily Med Review completed by the night team ? both day ward rounds are documented within this form. ? Any updates or events are documented in an Events/Asked to see form or Note-ICU doctor.

Re-label form as appropriate to the content of conversation.

c. Night shift: AICU /GICU ? If a patient is stable, no change and level 1-2, a full review is not required. ? Complete an ICU Note ? re-label document ? Review drug chart > discontinue prescriptions not being infused PICU ? Any updates or events are documented in an Events/Asked to see form. ? Night team to add Daily Med Review before 8am handover.

**Consultants for each unit have their own documentation**

d. Procedures > Procedure tab ? For all lines insertions, drains, intubations, etc complete an insertion form.

AICU, each form saved will default to the Procedure list. A doctors' log is generated from this. Insertions- lines, drains, tubes etc; Intubations /Tracheostomy etc ? PICU uses one generic form for all procedures; doctors please re-label the form each time to show the different insertions.

e. Problem and Diagnosis List > Medical notes tab ? Go to P&D list > right click on blank description field > New problem > click on Select Code tab >

enter a diagnosis in the search field > go to the coding system field and change SNOMED UK Diagnosis 2012 > Search. ? A list appear, choose an option > go to the Problem Description and edit information and add any patient history or ICU information, this will add to the patient's ICU story or history. ? Complete any other mandatory fields (with a red asterisk) > OK > save or go repeat the step to add other problems or diagnosis.

f. Death ? Update medical notes with events leading to death. ? Adults: Complete a Death Form in the Medical notes tab; review all sections and accept green data

> Save. This document is used for M&M hence default data.

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g. Other Speciality documents / Policy which may not be used often in Adults: (Doctors please review when you have time) ? Withdrawal of treatment ? complete an End of Life Care Plan (EOLC) > Save ? all documentation for Drs, Nurses and AHPs are to be entered in this form. ? Brain Stem Testing form ? Mental Capacity Assessment ? Physical restraint policy on the unit

**AICU / GICU: use the HowTo tab or the ICIP information folder in the Shared drive as an aide memoire on which document to use when**

h. Microbiology: AICU/GICU ? Doctors/Nurses document when samples are sent > FS > Vital Signs > `Micro sample sent' row ? Updated in the daily Medical Review ? Micro ward round daily > Microbiology FS > SOS > Antibiotics > General Cultures......... ? Reports, all results maps into reports from PAS for all 3 ICIP units. PICU ? Micro is currently documented on paper.

i. Admission ? Day or Night, PICU GICU AICU ? Prescribe at the bedside admission infusions after receiving handover for immediate use by nurses.

AICU to prescribe one of the admission drug Order Sets. ? In a timely manner, prescribe any antibiotics, steroids, speciality drugs, or medication the patient is

normally takes. These are non-urgent and can be done later. ? Complete Medical Admission form > Save ? Complete Problem and Diagnosis List > Save ? Complete a form for all Procedures in Procedure List > Save. ? Add medical review > Save ? Any reviews after - complete an ICU ? Note Doctor > re-label document. ? VTE and Bleeding assessments, we get audited on this and must therefore be completed on

Admission and 24hr post admission.

j. Re-admissions ? A readmission is considered a new admission rather than a cancelled discharge. ? We do not cancel a discharge to reuse the previous admission.

Add a new admission to ICIP: As some documentation can only be used once ie Drug prescription chart, Medical admission form, Problem and Diagnosis list etc, if a previous admission is reused this then causes too much confusion to reuse the previous set of ICIP notes. Previous documentation cannot be imported into a new admission and will have to be re-charted or copy + paste any free text entries. To copy/paste, open 2 ICIPs on the same PC to facilitate this. View previous admission can be viewed via the Visit History icon

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k. Transfers within SMH and HH AICUGICU ? Complete an ICU Transfer form ? discharge tab. The nurse transfers the current ICIP notes to the accepting unit. ? Use the documentation format of that unit. AICU PICU ? Transfer current admission to the accepting unit. ? Add relevant documentation for that unit. ? If a PICU patient is in AICU, the patient remains under the care of the paeds team and required minimum daily review form that team.

l. Discharge: AICU/GICU ? MDT Discharge Summary, doctors to complete Medical Review section first due to mandatory fields. ? Prescribe medications in Cerner ? The nurses will upload the notes into Cerner. PICU ? Complete discharge summary; via ICIP generate DS into a word document & save. ? PICU doctor to upload in Cerner. ? Ward doctor to prescribe medications in Cerner with the PICU doctor. ? The nurses will upload into Cerner the nursing documents only. The ward clerk will upload the medical notes.

4. Drug Chart tab / Prescribing: DO NOT SAVE ANY CHANGES IN THE LIVE UNIT

? Go to test patient > Admission tab > Demographic form, open form fill in Allergy, Patient Type & Body Weight ? important for prescribing on ICIP. Patient Type differentiate the prescriptions Adults/Paeds.

? Review these documents in Drug Chart tab, left side Note: Order Entry form > Direct Physician Entry for prescribing rights

a. Drug Chart Go to live unit > Drug chart > review format and the following in the Live Unit

DO NOT SAVE ANY CHANGES. ? Observe Allergy ? Patient Body Weight ? Name ? DOB, view in Order Entry & Demographic form ? Short cut to the drug chart sections, lower left column - 4 sections of the drug chart based on the

type of prescription frequency ? Prescriptions are in alphabet order in each sections ? Format / appearance of prescriptions. Uncluttered, clear and easy to read prescriptions. Keep all

prescriptions this way. ? Drug chart > within a prescription view the following

o Black symbols in right lower corner, a change has been made o Order / Other Instructions, green symbol o Pharmacy instructions / approval, tick

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o New or prescription changes, red flags o View Antibiotic Indication & Indication fields

o Overdue ? Modify a prescription (FY1s do not have prescribing rights)

Double click onto a prescription to open it > click on the Edit Chart icon to enable the mode of entry field and select Direct Physician Entry). Change the Schedule > Double click on frequency to view the list of options ? Discontinue a medication ? Right click > Discontinue > prescription crosses out, goes pink and moves to the end of that section ? Administer some medications, Drug Chart only ? tick admin field

o Record the fluid volume when a medication is given, such as Metronidazole o Change the time the drug is given and the actual dose o Go to another due dose and Withhold a medication > right click on pending dose > Held ? Deleted prescriptions move to the end of each section. ? **If changing a prescription formulation from IV to enteral or vice versa, delete the old and represcribe a new one; ie do not edit an existing IV prescription and change to Enteral as it will still contain IV information which doctors forget to delete.** ? Go to Discard > click all to discard changes.

b. Pharmacist & Pharmacy ? Open a prescription ? There are 3 fields at the end of the prescription for pharmacy and pharmacist entries. ? All prescriptions should be reviewed daily by the ICU pharmacist. ? Once a prescription is approved, a tick will appear at the end of a prescription. ? If a change is made after approval then the approval tick remains until the prescription is reviewed

the next office day.

c. Prescribing:

? Order Entry document or Enter New Orders icon?

? All prescribing occurs within this platform; this is a form like any other on ICIP, if the system does

not add this document automatically, the doctor should add it manually to the tab.

o View Mode ? this shows prescribing access

o To Prescribe, choose an option in fields 1 > 2 > 3 sequentially

o In Field 1 - Review Order Categories: Order Sets Drug Prescribing IV Drug Infusions Free Form

The prescribing categories are in a block text to differentiate from the rest of the listing which are used for prescribing.

PCA & Epidural

Crystalloids & Colloids

Blood & Products

o View Order Sets & Standard Order prescriptions

o View drug prescribing list

To prescribe GO TO YOUR TRAINING UNIT ADMISSION 6

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o Go to Drug Chart Tab > Order Entry form Prescribe an AICU admission order set- Click Field #1 > choose Order Sets Catalogue Wait for list of drugs and orders to generate Note all prescriptions will tick for prescribing > un-tick any not required. Review prescriptions; fill in any outstanding prescription information Save Other prescribing Click Field #1 > choose a catalogue Click Field # 2 > choose Medication > Field # 3 write your own prescription OR choose a Standard Order (SO) Check prescription and Instructions within Edit Dose and Frequency if required Enter an Indication ? especially if prescribing an Antibiotic or Steroids View Schedule Date / Time (of the first dose) > Prescribe a Stat dose if necessary If a medication is for a set period of time, within the prescription enter the Number of Days or Number of Administrations to stop ICIP generating a dose after the required time. This will automatically enter a Stop date/time in the prescription. Keep the default times of the prescription, these are set times used by the trust; prescribe a stat dose if a medication dose is required now for a new prescription. Based on the time of the stat dose, review the time of the schedule dose, this may need to be held if it is due too close to the stat dose. If there is no standard order in field #3 and the doctor has to write prescriptions, complete all relevant information normally added when prescribing on paper. Save

Actrapid Infusion ? AICU - There is a Sliding Scale set within the prescription; the scale can be edited within the prescription or add a separate Insulin Infusion form to the drug chart tab. ? HH GICU has their own protocol to follow.

Dietetics ? Adults - TPN is prescribed based on the Dietetics review, see TPN form in the Drug chart tab ? To start TPN out of hours use the Out of Hours bag until the patient is reviewed by dietetics the next working day. ? PICU ? PN is prescribed on the drug chart. ? Enteral Feeds & Sterile Water are not prescribed, these rows are added to the FS by the nurse.

Doctors - each shift............. ? Review drug chart daily > discontinue prescriptions not being infused ? Do not change prescription default times, prescribe STAT dose if required ? Do not leave un-used PRN prescriptions on the drug chart ? delete if not required i.e. PRN and infusion prescriptions. ? Keep up to date with MDT notes / reviews in the MDT tab

5. Prescribing Tasks for Doctors

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? Go to the AICU training unit test patient > Demographic Form > check allergies, body weight and patient type are saved.

? Prescribe the following and save:

AICU: Prescribe an admission Order Set > review prescriptions > change start times to time of admission Prescribe CVVHDF Order Set ? for filtered patients Prescribe IV Fluids, one standard order and one from scratch, add 40mmols K+ to 1L Nacl 0.09% Prescribe Infusions used on the unit, one standard order and one from scratch. Prescribe Colloids ? use SO and one from scratch. Prescribe several medications: Hydrocortisone, Furosemide, Tazocin ? Stat and Schedule doses. Complete indication fields for antibiotics and steroids. View schedule date/time at the end of prescription > mark and schedule doses as Held if close to Stat dose > Save. Prescribe one scheduled Medication retrospectively, ie atropine > change the time back to the time administration. Doctors please note: The nursing staff will not give a drug on a verbal order unless it and admission or emergency or peri-situations. Starting antibiotics, fluids, TPN, steroids are not emergencies.

6. Flowsheet, Intake, Infusion, Totals and Balances ? the obs are entered hourly in the FS ? Observe where and how these rows are displayed on FS. ? View changes in infusion rates / doses ? Observe Totals and Balances. Set a fluid balance to be achieved as necessary.

7. Review the following tabs: Reports, Labs, Nursing Doc, & MDT ? all MDT reviews lives in this tab but they can add a short note in the medical notes tab. On Adults, the MDT meeting once weekly, Tuesdays on AICU and Thursdays on GICU the form is saved in this tab.

8. AICU / GICU uses Family tab ? all family communication must be entered by all staff ? nurses, doctors & other AHPs.

9. Worklist ? leave this out if insufficient training time > to add jobs or reminders to the worklist: Drug chart tab > Order entry > choose an option in Lower case heading > complete order > save.

10. HowTo tab ? reference information on how and which documentation is used when.

11. Go to the Training unit > Delete test patient to `TEST data' > Close ICIP > Shut down PC.

12. Support to use ICIP - there is an ICIP information folder on the Shared drive with supports docs.

13. Downtime ? all 3 units goes back to paper ICU and drug charts, Cerner documentation for notes.

14. ICIP EMERGENCY DOWNTIME FOLDER: on an identified PC at the main station of each ICU, there is an emergency folder which saves a PDF copy of main documents for each patient. These PCs are: on PICU @ Nurses station; on AICU @ north station; GICU @ station 2.

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