Going forGoing forThe Big BangThe Big Bang

ChangeChangeAdam Black, RNAdam Black, RN

Joshua Feinstein, MDJoshua Feinstein, MDDiane MitchellDiane Mitchell

Wendy Scibielski Wendy Scibielski Wanda Taylor, RNWanda Taylor, RN

Melinda Tillman, RNMelinda Tillman, RN

University Of Texas Medical Branch

• We were the first Medical School in the UT We were the first Medical School in the UT system, founded 1891system, founded 1891

• In the past we “In the past we “Stopped for No StormStopped for No Storm” ” (Hurricane of 1900) but for Rita (2005) we (Hurricane of 1900) but for Rita (2005) we did a total evac (5 hospitals on campus – did a total evac (5 hospitals on campus – John Sealy, Waverly Smith Pavilion, John Sealy, Waverly Smith Pavilion, Rebecca Sealy, Children’s, and Hospital Rebecca Sealy, Children’s, and Hospital Galveston).Galveston).

More Statistics (FY ’07)

• Annual hospital admissions: 41,281 Annual hospital admissions: 41,281

• Annual ED visits: 54,592 Annual ED visits: 54,592

• Admissions from ED: 11,879Admissions from ED: 11,879

• Admit Rate 21.8%Admit Rate 21.8%

• Annual Clinic Visits: 682,294 Annual Clinic Visits: 682,294

• Telemedicine visits: Telemedicine visits: ≈ ≈ 35,000 35,000

ED Physical Plant Stats

• Square Feet: 90,000 (2.07 acres)Square Feet: 90,000 (2.07 acres)• Care areas: 4+ (Resuscitation, Main, Rapid Care areas: 4+ (Resuscitation, Main, Rapid

Treatment Area, Pedi, Emerging Infectious Treatment Area, Pedi, Emerging Infectious Disease (neg pressure), one area reserved Disease (neg pressure), one area reserved for “Clinical Decision Unit”for “Clinical Decision Unit”

• Terminals (current hardwired):44Terminals (current hardwired):44• Additional (supposed to be in 11/2007; Additional (supposed to be in 11/2007;

installed in 3/08):20 add’linstalled in 3/08):20 add’l• COWS – 5 now, 5 more to be corralledCOWS – 5 now, 5 more to be corralled• Does not count 4 tabletsDoes not count 4 tablets• Total: 78 terminalsTotal: 78 terminals

History: Epic in the ED

• Dec 2005Dec 2005– POE for Rad & Lab orders only using Sum04POE for Rad & Lab orders only using Sum04

• Dec 2006Dec 2006– Discharge Instructions, eMAR and Discharge Instructions, eMAR and

Imm/Injections using Sum05Imm/Injections using Sum05

• March 2007March 2007– Full cPOE, and conversion to Preference List Full cPOE, and conversion to Preference List

Composer using Sum05Composer using Sum05

• Aug 2007Aug 2007– Medication Reconciliation using Sum05Medication Reconciliation using Sum05

Scope of our project : EPIC• Eliminate patient tracking and nursing Eliminate patient tracking and nursing

documentation legacy system documentation legacy system • Application Build Scope Using Sum05:Application Build Scope Using Sum05:– Provide method of documentation for RN’s, PCT’s, Provide method of documentation for RN’s, PCT’s,

Care Manager’s, Patient Rep’s, ED CodersCare Manager’s, Patient Rep’s, ED Coders– Renumber and rename all rooms/beds/care areasRenumber and rename all rooms/beds/care areas– Trackboard, Manager, MapTrackboard, Manager, Map– ED Treatment teamED Treatment team

• Interface Build Scope:Interface Build Scope:– Waiting & Expected registration (No ADT)Waiting & Expected registration (No ADT)– Treatment team only in ED, not IPTreatment team only in ED, not IP

Scope of our project : Flow

• Improve discharged patient throughput Improve discharged patient throughput (i.e. reduced length of stay)(i.e. reduced length of stay)

• Reduce LWBSReduce LWBS

• Increase Staff and Patient satisfactionIncrease Staff and Patient satisfaction

• Make a complete change that is thought Make a complete change that is thought through and implemented (after ripping through and implemented (after ripping off 14+ years of bandages)off 14+ years of bandages)

How do I get there?

• Take I-45 South until you get about a Take I-45 South until you get about a mile off the coast…mile off the coast…

The Nation

The Region

Our Side of the Causeway

Closer Still

Successes con’t

Epic ApplicationEpic Application– Dedicated workflow super users and Epic Dedicated workflow super users and Epic

super users both on hand during go-livesuper users both on hand during go-live

– Overall staff acceptance positiveOverall staff acceptance positive• Users no longer working in two systemsUsers no longer working in two systems• Documentation mimics TNCC guidelinesDocumentation mimics TNCC guidelines• Workflow changes took the BIG hit in staff Workflow changes took the BIG hit in staff

satisfactionsatisfaction

– The Departmental Map!The Departmental Map!

Adam’s Map

Successes con’t

Epic ApplicationEpic Application– Better documentation of vital signsBetter documentation of vital signs• PCT’s like to stamp out red bells PCT’s like to stamp out red bells

– Staff strives to be compliant in Staff strives to be compliant in documentation despite no hard blocks- documentation despite no hard blocks- especially with Triage and Dischargeespecially with Triage and Discharge

– Since go-live, we have not experienced Since go-live, we have not experienced any substantial issues with system any substantial issues with system responsiveness or availabilityresponsiveness or availability

ChallengesTrainingTraining– Contract Staff training ongoingContract Staff training ongoing– ASAP build continued during trainingASAP build continued during training

• (plus) Student input was valued(plus) Student input was valued• (minus) Screens changed from class to class (minus) Screens changed from class to class

– Training of other Epic projects during same timeframeTraining of other Epic projects during same timeframe

Physical EDPhysical ED– Layout not designed for efficiency or PCs Layout not designed for efficiency or PCs

• Overcrowded workstationsOvercrowded workstations

– Building a wall on go-live day!Building a wall on go-live day!– Wireless connectivity Wireless connectivity

Challenges con’tASAP Application ChallengesASAP Application Challenges– IP NOT doing daily nursing documentationIP NOT doing daily nursing documentation• Therefore, ED utilizing LDA’s or I/O at this timeTherefore, ED utilizing LDA’s or I/O at this time

– Quality of nursing assessment documentationQuality of nursing assessment documentation• Assessment navigator vs ED Notes  Assessment navigator vs ED Notes 

– Hyperspace reports - too much scrollingHyperspace reports - too much scrolling– Post discharge documentation issuesPost discharge documentation issues• UTMB does not yet have a formal policy for nursing UTMB does not yet have a formal policy for nursing

post discharge documentation in Epicpost discharge documentation in Epic– No access to ED Chart at this timeNo access to ED Chart at this time– No access to ED Census Snapshot report at this timeNo access to ED Census Snapshot report at this time

– ADT issues especially during downtimeADT issues especially during downtime

Challenges con’tClarity ReportingClarity Reporting– Not enough report writer involvement in build processNot enough report writer involvement in build process– Not speaking same language about where data lived, Not speaking same language about where data lived,

what data meant, how ADT Events were impactedwhat data meant, how ADT Events were impacted– Not enough report writers Not enough report writers

• Clarity reports bottlenecked Clarity reports bottlenecked

The NEW WorkflowThe NEW Workflow– Not enough team playersNot enough team players– Shifting the paradigm from a push flow to a pull flowShifting the paradigm from a push flow to a pull flow

EPIC ASAP training

• Diane MitchellDiane Mitchell

• UTMB Lead IT Training SpecialistUTMB Lead IT Training Specialist

Instructor Led Training5 roles trained in 3 week period

• 87 Nurses in 8 classes 87 Nurses in 8 classes – 8 hour class with lunch provided8 hour class with lunch provided

• 36 Patient Care Technicians/HUCS 36 Patient Care Technicians/HUCS (clerks) in 5 classes (clerks) in 5 classes – 2 hour class2 hour class

• 7 Care Managers in 2 classes 7 Care Managers in 2 classes – 1 ½ hour class1 ½ hour class

• 5 Patient Service Representatives in 3 5 Patient Service Representatives in 3 classes classes (1 ½ hour class)(1 ½ hour class)

Training

• Presentation at ED Faculty meeting- Presentation at ED Faculty meeting- attended by 15 physicians, attended by 15 physicians, physicians assistants and Nurse physicians assistants and Nurse practionerspractioners– Handouts for those unable to attendHandouts for those unable to attend

• Total of 150 ED Staff Members in 16 Total of 150 ED Staff Members in 16 sessionssessions

SuccessesTrainingTraining– Teamed with Subject Matter Experts on:Teamed with Subject Matter Experts on:• Class contentClass content• Building training patientsBuilding training patients• Questions during training sessionsQuestions during training sessions

– Positive Feedback from staffPositive Feedback from staff– 100% attendance by full time staff100% attendance by full time staff• Only 1 make up class addedOnly 1 make up class added• Access dependant on class attendanceAccess dependant on class attendance• Lunch Provided – Nursing ClassLunch Provided – Nursing Class

Next Challenges

• Optimization TrainingOptimization Training

• Upgrade to Spring 07 releaseUpgrade to Spring 07 release

• Physician DocumentationPhysician Documentation

Conclusions and Recommendations

• Closer involvement of report writers and Closer involvement of report writers and build teambuild team

• Workflow change with Epic is good, but Workflow change with Epic is good, but some of our changes haven’t worked as some of our changes haven’t worked as intendedintended

• Training went really wellTraining went really well

Questions?