Best Practice Series: EDM to Inpatient Admissions with CPOE

Overview

This document will cover the admission and CPOE process for registered emergency room patients who will be admitted to the hospital as either observation or an inpatient, where the facility is using CPOE for ordering in the Emergency Department, as well as, the inpatient floors. This recommendation is based on the premise that continuity of care for the patient is the main concern. The recommended work flow is broken into two scenarios. The first scenario is a straightforward situation where a bed and nursing staff are available and the patient is admitted. The second scenario outlines the recommended process for those times that a bed is not available and the patient is going to be held for some significant or indeterminate amount of time in the ED.

MEDITECH Applications and Routines

Emergency Department Management (EDM)*

Physician Care Manager (PCM)*

Provider Order Management (POM)*

Provider Desktop (PWM)*

Admissions (ADM)*

Nursing (NUR)*

MIS

(*indicates required)

Outside Vendor Requirements

Not Applicable

1

MEDITECH Output Formats

Any existing ED throughput reports may need to be reevaluated if changes are made to the current process for capturing admission/departure information. The ARRA quality measure report for ED throughput should also be evaluated to make sure that any changes in the collection of this data do not adversely affect the report.

MEDITECH Outline of Design Process

MIS Location dictionary: Create inpatient type "ED Hold" location

PHA Location dictionary: Add dispensing machine/stock inventory at the inventory prompt if appropriate

MIS Room dictionary: Create inpatient rooms/beds for the ED Hold location to mirror the ED rooms

EDM Status Event dictionary: Create an Admit Request status event

EDM Tracker dictionary: Include location, status event

OE Order Set dictionary: Include admission order in all admitting sets

MEDITECH's Recommended Workflow

Scenario 1: Bed is available when admit request is filed.

1. Patient is registered and being treated by the Emergency Department staff.

2. Decision is made to admit the patient.

3. ED physician places an admit request via the tracker to notify patient access that a bed is needed. This does not constitute the actual "Admit" order.

4. Patient is admitted to an inpatient room and bed.

Note: Any orders entered after the patient is admitted will flow to the NUR Status Board for acknowledgment.

5. The admitting physician enters the admitting orders utilizing the transfer functionality. This allows the physician to review the existing ED orders and to perform med reconciliation since the patient is transitioning between levels of care.

6. Final documentation is done and the patient departed from the Emergency Department using the Departure routine.

Note: Since the patient has already been admitted, departing the patient using the departure routine will not automatically discontinue all of their active orders.

7. Remove patient from tracker by updating status event to Departed.

2

Scenario 2: No bed is available when admit request is filed.

1. The patient is registered and being treated by the Emergency Department Staff. In this example the patient, Todd Collins, highlighted on the tracker below, will be admitted to the ICU for further care.

Emergency Department Tracker

3

2. The decision is made to admit the patient and the ED Physician places an admit request via the tracker to notify patient registration that a bed is needed. This does not constitute the actual "Admit Order". If your organization is not using the Admit Request and Bed Board functionality, then this part of the process may be manual without affecting the overall work flow outlined in this document.

Emergency Department Tracker

4

3. Clicking the Admit Request button launches the Enter/Edit Bed Request routine. The Admit Request screen is filled out, including the requested service.

Bed Request

5

4. Registration sees the admission request on the Bed Request work list, however there is no bed available, nursing does not have the capacity, or for some other reason the patient can not currently be admitted. If your organization is not using Bed Management, then this part of the process may be manual.

ADM Bed Board

6

5. Patient is registered to an "ED Hold" room and bed. The beds should be set up to mirror the physical ED beds so that everyone knows exactly where the patient is physically located. The patient remains on the tracker, and the Emergency Department staff continue to care for the patient. Medication orders for this patient can be set up to come from the same Dispensing machine(s) as the ED.

Note: For REG ER patients, the ordering physician will see the Emergency Department CDS whether they access POM from the Tracker or from a different access point. Once the patient is admitted to the ED Hold location, the ED Physician will continue to see the ED CDS when accessing POM from the tracker, however, the inpatient physician will see the inpatient CDS when accessing the patient from their desktop or PCI.

Inpatient Admission

7

6. Patient will show up on the admitting physician's rounding list and physician desktop. The patient could also be accessed from PCI.

Rounding List

8

7. Admitting physician places admission orders, orders go to tracker and nurses in the ED will provide any treatments that are required until a bed becomes available. Most hospitals have reported that for reimbursement for any inpatient care, an "Admit Order" must be placed on the patient. The "Admit Order" should be included on all the admitting order sets.

Note: The priority of procedures can be set by location in the OE Procedure dictionary. Using the work flow outlined here, hospitals can set up procedures to default to a routine status instead of STAT, which is commonly associated to ED orders. This will reduce confusion and concern for the ancillary departments receiving the admitting orders for a patient being held in the ED.

Review Patient Orders

9

8. As noted above the patient continues to show on the tracker, and the indicators will be updated so that uninterrupted care may continue on the patient until the room and nursing staff are available. In some cases, patients are not able to make it up to the floors for several hours and most hospitals reviewing this work flow noted that it was important that if the patient is still in the ED then the orders must be active and must update the tracker.

Emergency Department Tracker

10

9. The patient is transferred to a floor by admissions once a bed is available. Any orders that were entered after the patient was put into the ED Hold room and bed will flow to the NUR status board on the patient's new location for acknowledgment. Nurses will only have to acknowledge the orders that were placed while the patient was in an ADM IN status.

Transfer Inpatient

11

10. The patient is departed from Emergency Department and any final documentation is done using the departure routine.

Depart

12

11. Remove patient from tracker by updating status event to Departed. The patient is then removed from the EDM tracker, as seen below:

Emergency Department Tracker

13

12. The admitting orders (and any other order placed after the patient was placed in the ED Hold location) will flow to the inpatient nurses status board for acknowledgment. However, the orders placed prior to this have been suppressed. This allows nursing to acknowledge the admission orders, without having to acknowledge all of the ED orders.

Acknowledge/Verify Orders via NUR Status Board

14

MEDITECH Design Process

MIS Location Dictionary:

The MIS Location dictionary contains all information about areas of the healthcare organization that provide patient care and other ancillary services. A new location for the ED hold patients is created as an inpatient type location as shown below.

MIS Location Dictionary

15

MIS Room Dictionary:

The MIS Room dictionary is used to define information for rooms that accommodate patients admitted to inpatient or outpatient locations. A new room or set of rooms is created that reflects the physical rooms that and beds available in the Emergency Department. Patients will be admitted to these rooms when a bed is not available on the floor, and the patient will be held in the ED for an extended period of time.

MIS Room Dictionary

16

Pharmacy Location Dictionary:

The Pharmacy Location dictionary is used to define pharmacy specific information for MIS locations in pharmacy. The first inventory entered within this dictionary will be used to dispense medications, as long as, the medication is stocked. If the medication is not stocked for this inventory, the second inventory would be used. In the example below, when a new medication order is being placed for patient in the ED Hold location, the system will first try to assign the ED dispensing machine inventory to the order if the drug is stocked in that inventory, otherwise it will use the Main inventory.

PHA Location Dictionary

17

EDM Status Event Dictionary:

Build a "Decision to Admit" status event in the Emergency Department Enter/Edit Status Event Dictionary. This entry should auto file with the function set to ARQ -Admission Request, as seen below in the Enter/Edit Status Event Dictionary:

EDM Status Event Dictionary

18

Build an "Admitted" status event in the Emergency Department Enter/Edit Status Event dictionary. This entry should have the auto file with function prompt set to ADM - Admit Patient, as seen below in the Enter/Edit Status Event dictionary, In order to support the work flow in scenario 2 above, the "Final Status Event" and "Automatically remove patient from room" prompts should be set to N. This allows the patient to remain on the tracker after being placed in the ED Hold location so that ED staff and registration know where the patient is and that the bed is occupied.

EDM Status Event Dictionary

19

Build a "Departed" status event in the Emergency Department Enter/Edit Status Event dictionary. This entry should have the auto file with function prompt set to DIS - Departed, as seen below in the Enter/Edit Status Event dictionary. REG ER patients will automatically be removed from the tracker because this status has been set up as the final status. Once the Final Status Event is set to yes in this dictionary, Y defaults into the Automatically remove patient from room? prompt. In the scenarios above where the patient is being admitted, the status would be manually updated to departed to remove the patient from the tracker.

EDM Status Event Dictionary

20

EDM Tracker Dictionary:

The EDM Tracker dictionary is used to define the patients and information that appear on the Emergency Department trackers. For the purposes of this work flow it is important that the tracker include the patient's room (pt room) as well as the status event (pt status event) as shown below. This will allow ED staff to know where the patient is located at a glance, while filing the Admit request will update the status event to Pend Adm, letting the staff know that a request has been submitted and the patient will be admitted once a bed is available.

EDM Tracker Dictionary

21

EDM Integrated Desktop Dictionary:

The EDM integrated Desktop dictionary is used to define what functions will be available to users when they access the tracker. Physicians will need access to the Admit Request routine and the Departure routine. ED admissions staff would need access to the Admit routine.

EDM Integrated Desktop Dictionary

22

OE Order Set Dictionary:

In the OE Order Set dictionary, for all admission sets an admission order should be included. This is not specific to this work flow, but in most cases it is important for reimbursement that an actual admission order is placed on any patient that is admitted to the hospital.

Supporting Documentation

For further information about EDM and PCM, please access the Emergency Department or Physician Care Manager Product and Resources page off of meditech.com. These pages offer many on-line tutorials and supporting documents.

Emergency Department

http://www.meditech.com/predm/homepage.asp

Physician Care Manager

http://www.meditech.com/prpcm/homepage.asp

23