SCENARIO #7
SCENARIO TITLE: Emergency Room (ER) Results Retrieval
SCENARIO DESCRIPTION:
The patient is suffering from high fever, congestion, and sore throat. A family member takes
him to the emergency room at Bethesda Naval Hospital. Examination by the attending provider,
E.R. Physician, determines that the patient’s symptoms are consistent with the onset of
pneumonia. Using the AIS, E.R. Physician orders the necessary laboratory tests and radiology
procedures. Once all orders have been processed and resulted, E.R. Physician uses the AIS to
retrieve the patient’s laboratory and radiology results. At the same time, E.R. Physician uses the
AIS to retrieve the patient’s historical medication profile, and then orders the appropriate new
medication.
Scenario Story Identification:
Patient Condition: Pneumonia
Patient Attributes:
Sponsor’s service status: Active duty
Relationship to sponsor: Self
Condition severity: Emergency
Operational Environment Attributes:
Facility type: Teaching hospital
Facility location: National Capital Area
Facility status: Normal posturenondeployed, nonexpanded, nonmass casualty
(non-MASCAL)
Assumptions:
1.
The patient has been previously registered in the AIS, and a past medical history
is available.
2.
The patient’s eligibility has been verified by the ER desk clerk.
3.
The patient’s history and physical findings are entered electronically.
4.
The military treatment facility (MTF) possesses filmless digital radiologic image
capabilities.
5. All medical personnel have access to the AIS.
6. The AIS and all network connections are operational during the time of the scenario.
7. TRICARE is fully implemented.
8. The MTF is not using the pharmacy “bank teller” process.
SCENARIO STORY:
The patient, a 28-year-old male (active duty) presents to the Bethesda Naval Hospital ER
complaining of recent high-grade fever (103° F), sore throat, congestion, and a persistent cough
for the past two weeks. While checking the patient in, the ER technician uses the AIS to query
an enterprise-wide computer-based patient record (CPR), using the patient’s social security
number (SSN) to verify his identification. This procedure allows providers to view the patient’s
medical history, including previous test results, prescriptions, allergies, and immunizations. The
inquiry shows a history of childhood asthma, but no adult episode. The ER technician prints out
the essential emergency information and patient problem list and attaches them to the patient’s
chart.
The ER technician takes the patient’s vital signs and enters the findings of a 103.5° temperature,
pulse rate of 98, and respirations 22 into the AIS. These entries are then edited by the AIS, and
illogical values are flagged for correction.
The patient is immediately taken to an ER examination bed. Upon examination, the attending
physician, E.R. Physician, notices a rhonchus, a dullness to percussion at the left lung base, and a
slight wheeze; he also suspects the patient is dehydrated. The patient’s pharynx appears to be
red and inflamed, and tonsils are absent. Using the AIS, E.R. Physician logs on using a
protected password and identifies the patient in the AIS by using the patient’s SSN for
verification. He enters these findings into the patient’s CPR and then accesses the order entry
option. Indicating STAT priority, E.R. Physician places the following Laboratory orders:
Complete Blood Count (CBC) with Differential (DIFF) and a CHEM 7 panel. A Throat Culture
is also ordered, but with a routine priority since the system does not allow STAT priority for
procedures that cannot be immediately resulted. In addition, using the Radiology order type,
E.R. Physician requests a STAT Chest X-ray (PA and Lateral). Conjointly, the physician places
an order for a cardiopulmonary technician to take arterial blood gasses (ABG).
Upon activation of the order, labels are automatically generated in the ER. Specimens are
obtained, labeled, and sent to the lab. A cardiopulmonary technician takes the patient’s
specimen for the ABG. The patient is then sent to radiology. When he arrives at radiology, the
X-ray clerk retrieves the chest X-ray order and receives the patient, and an X-ray technician
takes the X-ray.
The laboratory clerk receives the patient’s specimens, logs them in, and accessions them. The
laboratory technician immediately processes the tests, and the results are transferred into the AIS
as soon as they are available. About 30 minutes later, while the patient is in Radiology, E.R.
Physician and the ER charge nurse receive an electronic notification of new lab results on their
desktop terminals. The results are also automatically sent to the ER printer as soon as they are
available. Using the AIS, E.R. Physician immediately accesses the lab results retrieval option
and identifies the patient. Results of the CBC/DIFF, ABG, and CHEM 7 are displayed
including the result values, normal ranges, specimen source, and high/low value indicators. The
result for the Throat Culture is still pending, but it will also be automatically printed once
completed, providing immediate notification to the ER Physician on duty. E.R. Physician opts
to sign off on the CBC and CHEM 7 results. He uses the electronic signature stored in the AIS.
Once the X-rays are completed, the Radiology technician transfers the electronic X-ray image
into the AIS. The physician accesses the radiology results retrieval option, identifies the patient,
views the chest X-ray image, and records an informal reading into the patient’s assessment/plan
section of the CPR. Later, the radiology transcriptionist enters the formal reading into the AIS,
and a text version of the clinical impression and result will be available to the physician through
radiology results retrieval.
The X-ray image indicates a posterior infiltrate with loss of left costophrenic. The lab result for
the ABG shows mild hypoxia, and the CBC shows increased white blood cell count. Creatinine
levels are 1.2 (just over the normal limit of 0.8–1.1). The doctor retrieves historical lab results
(shown in reverse chronological order), which show a creatinine level of 0.8. The doctor
suggests dehydration. In parallel, analysis of the lab results is consistent with the early stages of
pneumonia.
Before ordering any medication for the patient, E.R. Physician accesses the patient’s
medication profile. This step allows an ordering physician to determine whether any
outstanding active prescriptions or documented allergies could cause a conflict. The patient’s
profile indicates no active prescriptions, but does show a documented allergy against Penicillin.
E.R. Physician then accesses the order entry option and identifies the patient. Using the Rx
order type, E.R. Physician orders an Albuteral Inhaler, Guaifenesin, and inadvertently orders
Penicillin, despite the documented allergy on the patient’s profile. Before activating the
prescriptions, the doctor receives an electronic warning message indicating a documented allergy
against Penicillin. The doctor changes the Penicillin to Erythromycin and completes the
prescription orders. The doctor also places an ER local order for a one-liter half normal saline
intravenous fluid to be administered to the patient. Upon activation of the prescriptions, labels
are automatically generated in the outpatient pharmacy and the pharmacy technician is thereby
notified of prescriptions to be filled.
Before the patient is discharged from the ER, E.R. Physician provides instructions for taking the
prescribed medication and recommends quarters for 72 hours and a follow-up visit at sick call
the next day. Once the patient is discharged, he stops at the Outpatient Pharmacy to pick up his
prescriptions, and a family member takes him home. E.R. Physician can now check the
patient’s medication profile, and an “active” status will display next to each of the new
prescription orders.