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Extreme Makeover Order Menus & Order Sets
Brian Moore
Duane Mawhorter
Cathy Harrity
Section 1: Acute Coronary Syndrome
Welcome to Extreme Makeover, Order Menus and Order Sets. My name is Brian Moore. And we're
going to be having Duane and Cathy join us later.Again, welcome. Good afternoon, my name is Brian
Moore, Program Specialists and it's going to be hard to believe me but from the way my exact
pronunciation I'm from Big Spring, Texas. There’s not any drawl, so if you hear a "Y'all" or a "Yahoo" or
something just ignore it. And we'll go ahead get started.
At the West Texas VA Health Care System in Big Springs, Texas, we aren't the size that a lot of facilities
are so we depend a lot upon people to come up with ideas and to change them accordingly. What we
decided to do; one of the order sets, order minis that we came up with at our facility was the Acute
Coronary Syndrome.
Our facility is located in Big Springs, Texas. There are 55 Acute Care beds, four ICU beds, 40 Nursing
Home Care Unit beds. We serve about 62,000 veterans which is a quite large area. We're not a large
facility but we cover a lot. And we cover over 47 counties in both Texas and New Mexico.
The reason we decided to come up with the ACS order menu was to improve upon our current process
which was basically nothing. Wanted to insure the patients were seen properly and diagnosed
accordingly. And improve compliance; of course everybody wants to improve on performance
measures.
The order set, we wanted something that's going to prompt the clinicians through a series, make it
easiest for them to get through that process if they're not familiar with it or they've slept since then. It's
going to include the contraindications and some Killip Class and TIMI Risk score. And again, we basically
took this from somebody. I wish I could give that facility credit, but it's been a while and I can't
remember who it was.
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We initially met with the Chief of Staff and the Chief of Medicine and they handed me about 30 sheets
of screen captures and said: Here, do this.And I said: Yes Ma'am. We eventually included Urgent Care
nursing staff and other physicians as needed. Some of them brought in that specialty that they may
have studied or whatever. They brought that to us. We created the orders in CPRS. Had the Chief of
Staff and the Chief of Medicine review that. Make any suggestions. And we actually finished up by
completing the order menu and the order set.
What we've found was during the process that the menu that we received, there was actually an initial
cardiac menu that we had completed that they wanted everyone to look at. And it wasn't just ACS. It
didn't just include ACS. It included Cardiac Weight Based Heparin, Cardioversion, CHF Pathway, and all
these listed. So, while we were trying to do in ACS order set, we actually come up with and initial chest
pain evaluation which we'll take a look at first.
What we did was actually create a Cardiac order menu, right off the beginning. We included the ACS
Chest Pain in that. So the first option you're going to see under the Cardiac order menu is initial chest
pain evaluation.
So if we click on the initial chest pain evaluation, it's going to allow clinicians to pick and choose. Or
we're going to give them the option of using a order set.
The first thing you're going to see is it says: Click Here to Select ALL below for the Initial Evaluation.And
once they click that of course it's going to fire out the order set that we talked about. Or, if they do not
want to use the order set, if they're more comfortable by choosing individual orders, that's also
available to them. And I tried to go through and make those auto-accept as much as possible. As much
as they wanted to, so to make it even easier.
Once we go back to the initial Cardiac menu, this is of course is where we start the ACS order set that
we're going to look at. So, when the patient presents with the ACS Chest Pain, the initial orders have
been completed. We'll go ahead and start the ACS initial evaluation.
And what you'll notice on this menu, it is largely informative. There's not a lot of menus that fire off
from this initial. What you have to do is actually choose the diagnosis from looking at the diagnostic
criteria. So the first thing you're going to see is Click Here for Initial ACS Evaluation and that takes us to
that chest pain evaluation menu. We start with the diagnostic criteria. Down below where you see the
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diagnostic criteria it's going to give you what the STEMI High Risk is, the NSTEMI, the Unstable Angina
moderate risk, Unstable Angina low risk, and Stable Angina. They look at that, determine what the
criteria is and then they proceed through the appropriate menus. On the right-hand side, our Chief of
Staff wanted to get the Performance Measures out for them, just to remind them what they're really
doing, what they're trying to accomplish. So we listed the ACS Performance Measures on the right-hand
side.
So if they choose STEMI High Risk, it's going to take it to the STEMI High Risk menu within itself. And it's
going to always remind you at the top that the patient was seen in Urgent Care with a STEMI diagnosis.
And then the first thing we're going to list is the TIMI Risk Score and it tells you how to calculate that.
Originally, I had a link in there, it took you to a document, it was much nicer to look at, looked a whole
lot better, but they didn't want to have that extra click in and back out of that initial order so we decided
to put it on the menu itself. If you ever try to line up anything in an order menu, that's what you get.
But that's the best we could do. Then you continue down, it has a high risk score. If it's greater than
four, it actually tells you what you're going to do according to the Killip class which is on the right-hand
side. So you figure out what the TIMI Risk Score is and you go through the thrombolytic orders which is
located on the bottom right-hand side. We try to keep the orders always to the bottom right after all
the information is given.
So if you click on the thrombolytic orders, it takes you to the appropriate menu. It has some
contraindications, absolute contraindications and relative contraindications and it includes the
tenectoplase orders. So we try to keep it straight forward and getting them as much information as we
can.
The second option we had was the NSTEMI Unstable Angina. And again if you click on that...
...it takes you to it's own menu. Looks a whole lot like the original, but it's going to include the NSTEMI
orders.
And once you do the TIMI Risk and the Killip class, it takes you to the NSTEMI orders. You click on the
NSTEMI orders and you're going to get the individual orders or you can do the order set if you so
choose. And there's also some instructions on the right-hand side.
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The third option we have is the Unstable Angina which is a low risk.
And it takes you to the medications and instructions that are proprietary for an Unstable Angina.
The fourth option we have is the Stable Angina Low Risk.
Again, you're going to have the Stable Angina menu within itself. It's going to give you some instructions
and some outpatient orders as requested by the physicians.
Some of the feed back we have. They liked it. It was straightforward. It was easy to follow, lots of
instructions. They really liked that part of it. We actually presented it to VISN 18 Cardiac Care
Committee and they applauded it. They really liked the outcomes.
Section 2: Community Acquired Pneumonia (CAP)
And now what we do is go from something that was pretty complex to something that's a little more
simple, but it focuses on the same thing and that's Performance Measures. This is the Community
Acquired Pneumonia order set, order menu.
There was no process in place. We were spending a lot of money on drugs that were getting ordered
when they didn't need to be. So we needed to manage the cost for pharmacy. And again we wanted to
improve the compliance with the VA Performance Measures.
We met with the Chief of Staff again and Chief of Medicine concerning the order set. And we included
the pharmacists as necessary. We created the order set. We had the pharmacists look at it and make
sure that the appropriate medications were in there. And any suggestions or additional changes were
made and sent to us and we made those accordingly.
Now this one, unlike the other one, doesn't take from menu to menu. It is all right here in one place. So
the first thing you're going to look at is the initial orders. Any initial orders that are included with the
Community Acquired Pneumonia, you'll click on that. Or, down below it again, you'll see individual
orders if you'd rather do it that way. From there, it starts with the instruction process, the guidance.
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And we want to know if there's evidence of dehydration, they would tell you to place a peripheral IV.
Outpatient treatment of CAP, and then you have those orders. It tells you if the patient had antibiotics
within the last three months, consider using another antibiotic. And that's what we have available. On
the right-hand side, when the labs are available and the pneumonia score index has been calculated,
these are some of the things a physician is allowed to follow-up on. Whether they're going to be
discharged home, admitted or if there'll be outpatient flu vaccine, whatever needs to be done. And we
also let them know that the clinician needs to process the Tobacco Reminder. Then you have the
patients admitted with CAP, the actual admitting orders and then the initial blood culture that needs to
be drawn and then it kind of steps through to the next one, Plus one of the following. And then you
have your formulary alternatives down at the bottom. So we wanted to put it all in one location where
they could get to it and get the orders done quickly.
The feedback has been great. There's one convenient location. There's a complete process information
for the whole thing so they're able to look at one menu instead of going back and forth. And it meets
Performance Measures and we've consistently been in the green.
If you have any questions or comments, or whatever you may have--my counterpart in Big Springs is
Cheryl Justice and my name is Brian Moore. There's the e-mail links there so feel free to give us a call if
you have any questions.
Section 3: Improving the Efficiency of the Transplant Process
My name is Duane Mawhorter and I work at the Sonny Montgomery VA Medical Center in Jackson,
Mississippi, however, what I'm going to be presenting today was work that was done in Biloxi when I
worked down there. I accepted a position up in Jackson in May.
Little bit about Biloxi. These are all post Katrina figures. We lost a whole facility. So everything got kind
of down-sized; 40 Acute beds, 10 ICU beds, 101 Intermediate Care and Nursing Home beds, 20 mental
health, three CBOCs, they have four CACs, three CACs right now. Over 46,000 veterans served last year.
What I'm going to talk about this afternoon is -- I guess I got off my main slide there -- is improving the
efficiency of the transplant process. We had -- and you folks probably did too have -- something come
down nationally that this is the type of evaluations that were going to be done. Any transplant packets
that go in have to have a certain amount of information.
You folks remember the movie Jurassic Park. One of the things that I liked in there was the chaos
theory. Well, I think that was developed at the VA. We pretty much know that any thing that comes
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down to us nationally, if we leave it alone it's going to turn into chaos. Right? Because what do they
say: You've been to one VA, you've been to one VA. And so everybody has a different perspective to
how things are getting done. I believe myself -- I've been a CAC now for a little over seven years -- that
one of my primary purposes for what I do is to streamline and simplify processes for providers. They
have enough to worry about -- treating the patient with the panel sizes they have, the decreasing time
that they're having to see a patient -- to have to worry about computer programs. And that's one of our
primary responsibilities to help them get what they need to accomplish efficiently and get it done
correctly.Well we were having a big problem with the transplant. They came in nationally. There was
some nationally imported templates that came with it. And some paper sheets that said: This is what
you need to order. And we'll see an example of one of those a little later. Well, some of the lab tests
look ambiguous. Some of the lab tests were named different in our system than they were on that
sheet of paper. We had tests that were getting ordered in an untimely manner. They may expire for
some reason because the packet has to be done within a 90 day period. They have other things,
evaluations, that may also slow or even halt the process. We've had multiple tests run a patient that
simply wasn't a good candidate. You know, we'd never even get through it. But the tests were ordered
actually before the initial evaluation. So the Transplant Coordinator contacted me and said: We need to
try to do something to help fix this process.
From a patient stand-point, why did we do this? And this is just a few figures that I tried to dig out of
our Internet. And in the year 2000 -- 744 patients in the VA system were referred for organ transplants
and 264 of them got them. That's about at 35%. In 2005 we had 1,265 patients referred for transplants;
365 got them. If you go into the major organs such as like a liver transplant, 103 out of 500 got them.
So now we're down to 21%. So in the U.S. total last year, they say about 1,000 people died waiting for a
liver transplant. So we figure that anything that we can do to give one of our patients an edge. Now the
transplant process -- getting it approved -- isn't an exact science. Sometimes just getting there first may
be an edge that one of our patients might need to get the transplant.
From a facility standpoint, we've got dollar signs, right. The average transplant -- using a liver again, in
the United States -- last year cost about $235,000 for a liver transplant. Now, we only have a select few
facilities in our VA system that actually do the transplant of the organ, but there are a lot of costs for the
local facility in getting these packets made up. We've had packets that -- especially for the repeated
tests -- we've got time requirements on them. Maybe a patient isn't a good candidate. Or maybe even
the physician -- like we said -- the test looked like it was right but it wasn't right.
This is where we start. We tried to put everything where the physician, the provider, that was going to
be initiating this packet had a central location to go to. You notice that, we got them numbered; one,
two and three...
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...up at the top, it says: Before orders are placed on a patient. Click here to begin the process.And that's
the initial screening consult that goes to our transplant coordinator. This is very important because the
transplant coordinator can go in and view a patient's chart with a fresh set of eyes with no prejudice.
I'm a provider and I've got somebody that needs an organ across from me, I'm dealing with that person
and I'm looking just at that person, what needs to be done. The transplant coordinator -- who happened
to be a social worker -- can go through and look through that patient's chart and find little red flags. And
that's why we want him to start here first. We wanted doctor order $2,000, $3,000, $4,000 worth of lab
tests or X-rays and stuff before a patient actually gets an initial screening. Let's see if that patient is a
good candidate. What I had in the center there is what -- when you click on there, that opens up -that's the reason for request for the transplant screening. Just tells that transplant coordinator what
organ you're looking at, what the medical urgency is, and then you see the actual consult once it's been
dumped in.
Once a provider then gets the okay back from the transplant coordinator, the okay maybe, it's okay to
continue with this patient, but this patient needs to have six months of SIDU now, or some substance
abuse disorder or something or maybe a smoking cessation class. Something like that that shows up on
the patient. Or they may actually even -- for some reason -- refuse or deny this request at this time with
an explanation to the provider what needs to be done. But when the provider gets told: Okay, let's go
on to step number two.That's done through the consult process. Provider gets an alert that that
consult's been completed. Step number two are additional evaltuations that are required nationally -the mental health and dental consults. Now, the reason we had these come in number two before the
provider actually order tests is because of scheduling problems. Sometimes these actually take longer
to get scheduled. The evaluation is a very long evaluation. Well, not so much with the dental, but from
the mental health. They have to get time to see the patient and go through that evaluation, so we want
them to go through that next.
Down at the Gulf Coast Health Care System -- with the different CBOCS -- it was decided that the mental
health would actually -- whoever the patient was closest to -- they would designate a mental health
person at each one of those locations that would be doing these transplant evaluations. And so that's
what we actually did was create four separate, different consults that then alerted different providers
that a consult had been ordered. And then, over here on the right-hand side we also in the quick order
have our transplant coordinator's name put in there so she's alerted that these have been ordered. You
know, keeps her in the loop.
Once those evaluations have been done, because now, you can understand that the mental health
evaluation could put a speed bump or halt the process on this too. So once those are done, then the
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provider goes to number three. And that is the order set for the different individual organs. And each
one of these go to a different menu. We're going to just stay on the liver transplant and look at what
that menu looks like.
And up in the left-hand corner, we just have a little notice to the docs, to avoid any costly duplication of
tests, please check our health summary that we put on the reports tab. Make sure that you're not
duplicating any thing that's been done within the last 60 or so days. So if it's been done, we don't need
to order it again. I'll show you an example. We've got that on the reports tab. Underneath that -- right
there where it says Liver Transplant Order Set -- That is generic for every patient that's going to get a
liver transplant and these are the exact tests that the national has asked for. And then of course we add
underneath there an explanation, if the patient has had any history of drinking within the last two years,
they need three screens -- alcohol screens -- or if they've been smoking within the last two years, they
need three screens. So once again, that's something else that could take time that would slow the
process if we had something that then fell out of our time limits. On the right hand side, we have
different other areas to order if a patient follows any particular criteria. If the patient's under 50, they
don't need a scope. But if they're over 50 and had an abnormal scope or it's older than five years, then
they need another scope.
This is what our Health Summary looks like. And we just took everything that was on that national
requirement packet and put it here. If it's been done, it will show up for them.This is also an area where
our transplant coordinator would go to make sure that tests have been done.
I don't know if you can see this here, but this is the list of the liver transplant orders. And there's quite a
few and several of them are quite costly.
This is an example of what the hepatitis additional orders look like. The patient is hepatitis B positive
from the initial, then they need these additional orders placed.
Well we added also on this menu -- on each of them -- is a link to a website that we created. Like you
were talking earlier, the providers don't like it because it's a text order is the only way we can embed
that link. When they're done they have to click Cancel to get out of it.
This is what the Web site looks like, or did. I think it's been redesigned since I actually did this.
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On the left-hand side is all the check lists that come from national that needs to be done that a provider
can print out. In the center are a list of the mental health and the social worker guidelines. And also
what we added in there was, we had -- especially mental health providers -- we were having a problem
with going through this long evaluation and sitting at a computer with a patient and asking them all
these personal questions and putting them in the computer at the time. So what we did is we took that
evaluation. We took the national template, and created a word document that mirrored it. That they
could printout, put on a clip board, fill it in as they asked the questions and then later come back and fill
that in as an electronic document. But it would all be in order and it would all have the exact same
choices, checkboxes and everything that the national one had. And then on the right-hand side is a
sample doctor’s letter that needs to be as a cover letter with the packet that's sent in.
This is -- from the left hand side -- the liver transplant application checklist. This is what the doctor had
to work with initially. This is what needs to be ordered. And this is what we took our quick orders off of.
This is a copy of what the Word document looks like out of the mental health that we created for them
that they can just jot the notes down.
Feedback, well our transplant coordinator left; got another job. Actually, the new transplant
coordinator that came in was very, very happy with it from the standpoint that it also helped her learn
the process that had been established. That there was a process in place that she could come in and
continue with. The doctors liked it because they could go to one place. And even though they had to go
to that same place three different times, they at least knew where to go and order to go into. And there
was improved communications between the coordinator and the provider. You can imagine if you were
a patient and you're waiting to find out if you've gotten on that list and you're calling your provider.
You're provider's calling your transplant coordinator. Transplant coordinator's calling the CAC saying:
Have these been done? No.So, put it into an area where they all can see what's been done and what
needs to be done.
Here are a few references. The National Transplant Web site for the VA, the Gulf Coast Web site -- and
that goes to the transplant menu that we looked at. Gulf Coast coordinators -- Boots Brinkman, I put
her there but there's also Bunny next to her -- Bunny, Boots. I wanted to go by Bubba, but they said I
was born over the Mason Dixon Line so. And then, myself, I'm at Jackson.
Section 4: Prevention of Ventilator-Related Pneumonia
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Hi, my name is Cathy Harrity. I'm going to talk about three different order menus we've created at
Altoona. And the first is the Prevention of Ventilator-related Pneumonia.
And I work at the James E Van Zandt VA Medical Center in Altoona, Pennsylvania. We have 28 Acute
Care beds, four of which ICU beds, 40 Nursing Home Care Unit beds. We have two CACs and one
Computer Information Specialist who does most of our education.
And the reason we created this order menu was because of a new program called the VA Inpatient
Evaluation Center. And the purpose of the program is to improve ICU outcomes by measuring and
reporting ICU risk adjusted outcomes and implementing evidence based practices. And it's based on the
100,000 Lives Campaign but we weren't a part of that campaign.
Ventilator Associated Pneumonia is an airway infection that develops more than 48 hours after the
patient is intubated. And VAP is the leading cause of death amonth hospital-acquired infections.
VAP prolongs the time spent on the ventilator. It increases the ICU length of stay and it increases the
hospital length of stay after transfer from the ICU. It also adds an estimated cost of $40,000 to a typical
hospital admission.
And another reason we created this order menu was because we don't treat that many patients on
ventilators. So the order set became very important to prompt the physicians and nurses to order the
bundled components for each patient.
This was developed at Altoona through a Performance Measure team. So the Performance Measure
team was created and it's lead by our Infection Control Nurse, Jennifer Fouse. The team included a
hospitalist, nursing supervisor, the Chairperson of the Infection Control Committee, and a respiratory
therapist. And there were two consulting members -- our Chief of Staff and a pulmonologist.
The team reviewed past ventilator patients. And they noted that we had good outcomes and that many
of the bundled components were utilized. But we weren't 100% consistent in using the bundled
components.
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So the solution is the care bundle. And a care bundle is a grouping of best practices for a disease
process that individually improve care, but when applied together result in a substantially greater
improvement.
Our ventilator bundle components include the elevation of the head of the bed to between 30 and 45
degrees, a daily sedation vacation and assessment of the readiness to extubate, peptic ulcer disease
prophylaxis, deep vein thrombosis prophylaxis -- unless it's contraindicated.
The VAP prevention menu includes an order set that includes the initial vent orders, weaning
parameters, spontaneous breathing trial orders, sedation orders, sedation vacation orders and DVT
prophylaxis -- except the quick orders -- for medications.
It also includes the head of bed elevation orders and the oral care orders.
The menu includes the orders bundle, but it also includes them individually. It also includes inpatient
meds and the quick orders for the peptic ulcer disease prophylaxis.
And this is what our order menu looks like. And you can see we have the initial vent order and then the
bundle and then everything else is separate.
And this is the order for the initial vent order and this is sent to a printer in Respiratory Therapy.
And this is what the initial vent bundle looks like. And this includes the weaning parameters order and
the order to discontinue spontaneous breathing trial if certain parameters are met.
There's an order to return the patient to the previous vent settings if they fail the weaning. And then if
they tolerate it, there's an order for how long to continue.
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And these are the sedation vacation orders. And there's an order after the first 24 hours to hold the
sedation until the patient is calm and alert. If they become apprehensive, there's an order to resume
the sedation.
And these are the DVT orders. There's the TED support hose and range of motion exercise orders.
And this is the head of bed order and the oral care every two hours.
The menu also includes quick orders for specified meds. And if the physician needs to access other med
orders, there's the inpatient medications are also on here.
This isn't in use yet at Altoona. We worked over the summer to develop this. It has been reviewed by
our pulmonologist and our emergency room physicians.
And as I said, it's not in use, but they did provide positive feedback based on the content.
We don't have a success story yet, but we've had good outcomes based on our current process. But it's
anticipated with the implementation of this order set, it will result in improved outcomes.
And I've included a link to the 100,000 Lives Campaign, information on prevention of ventilator
associated pneumonia. And I've also included by outlook address and then our Infection Control Nurse's
out address.
Section 5: Outpatient and Inpatient Quick Orders
And next I want talk about our outpatient quick orders.
And this is a order menu we had created to enhance the disease specific orders previously created. And
we had quick orders created, but they weren't all on one order screen. So the providers said that this
would really help them to have them all in one place.
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So the new order menu included orders for diabetes, COPD, equipment, complex dosing and post liver
transplant.
And we placed it on our main outpatient menu and we called outpatient quick orders.
And this is what the menu screen looks like.
And the diabetes quick orders contain orders for meds, supplies, consults and nursing orders for
glucometer education and insulin self administration education.
For COPD quick orders, we included quick orders for pharmacy, tests, consults, and nursing orders.
For the equipment orders, this says inpatient equipment orders -- we actually use this screen for both
the inpatient and outpatient -- so this includes the equipment orders for Occupational Therapy
equipment, Wheelchair Clinic equipment, Physical Therapy equipment, Brace Clinic equipment, and
prosthetics requests. And then it also includes orders for pharmacy supplies.
The complex dosing order menu includes orders for prednisone, z pack, methylprednisolone, and
nicotine patches.
And then our post liver transplant orders. These are quick orders -- after the patient has had the liver
transplant -- these are the quick orders that the physician would order monthly and then it also provides
orders that he can order as needed.
Now I'm going to talk about our inpatient quick order menu.
And this was created for the same reason as the outpatient. They wanted everything all on one menu
so it was easier to locate.
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And it's also on our main menu -- inpatient order menu.
And this includes orders for the pleural fluid, cellulitis, isolation order screen, blood ordering screen,
equipment ordering screen and the nitropatch.
So the pleural fluid order set, it has the orders for the culture and smear.
The cellulitis includes various test orders, medication quick orders, and lab quick orders.
The isolation order screen has orders for contact precautions, enteric precautions, droplet precautions,
airborne precautions, and immunocompromised patient precautions and it also has an order to
discontinue isolation.
And the blood ordering screen includes orders for blood products and then labs -- certain labs -- Tylenol,
Benadryl.
This is the equipment order screen and it's the same as you saw is on the outpatient.
And the final thing we have on this order screen is an order set for nitropatch and removal of nitropatch.
And I've included contacts at Altoona -- Sue Reynolds, Mel Sharer and myself -- and those are our
Outlook addresses.
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