How do I chart … The Basic and Essential Anesthesia Data?

How do I chart …How do I chart …

The Basic and EssentialThe Basic and Essential

Anesthesia Data?Anesthesia Data?

The Basic and Essential Anesthesia DataThe Basic and Essential Anesthesia Data

The College of Physicians & Surgeons of Ontario uses The College of Physicians & Surgeons of Ontario uses the Anesthesia Peer Assessment Form to set the the Anesthesia Peer Assessment Form to set the minimum standard for Anesthesia record-keeping.minimum standard for Anesthesia record-keeping.

(Click to view the various sections of the form)(Click to view the various sections of the form)

Whether using paper or electronic records, we need to Whether using paper or electronic records, we need to be sure we meet and exceed this minimum standard.be sure we meet and exceed this minimum standard.

Over the years the paper record has evolved to include Over the years the paper record has evolved to include many “prompts” to remind us about data entry. We are many “prompts” to remind us about data entry. We are comfortable with the paper record and have developed comfortable with the paper record and have developed efficient ways of completing it.efficient ways of completing it.

The electronic record has strengths and weaknesses.The electronic record has strengths and weaknesses.No more mind-numbing vital sign data entry!No more mind-numbing vital sign data entry!

The challenge is to develop new workflow patterns forThe challenge is to develop new workflow patterns fordata entry to make the e-record more complete than data entry to make the e-record more complete than the paper record ever was or could be.the paper record ever was or could be.

Here

The Basic and Essential Anesthesia DataThe Basic and Essential Anesthesia DataThe MacroBar – WorkFlow SignpostsThe MacroBar – WorkFlow Signposts

Marker: Anesthesia Case Marker: Anesthesia Case StartStart (OHIP billing) (OHIP billing)

Marker: Equipment CheckMarker: Equipment Check

Marker / Reminder: Patient AssessmentMarker / Reminder: Patient Assessment

Reminder: Assign ASA Level / Medical Team / Pt Wt-HeightReminder: Assign ASA Level / Medical Team / Pt Wt-Height

Marker: Regional Anesthesia StartMarker: Regional Anesthesia Start

Marker: General Anesthesia StartMarker: General Anesthesia Start

Marker: Monitored Anesthesia Care StartMarker: Monitored Anesthesia Care Start

Marker: Antibiotics–First Dose / Start TimerMarker: Antibiotics–First Dose / Start Timer

Marker: End of Surgery / Confirm ProcedureMarker: End of Surgery / Confirm Procedure

Reminder: Fluid Balance / Final IV Bag LevelsReminder: Fluid Balance / Final IV Bag Levels

Marker: End of GA / Emergence EventsMarker: End of GA / Emergence Events

Action: Transfer to PACU /SDCU / ICUAction: Transfer to PACU /SDCU / ICU

Action: Discharge to non-SIMS unit – nurses do NOT use SIMS (e.g. ICU/Endo Suite/Brachy Unit)

Reminder: Transfer of Care NoteReminder: Transfer of Care Note

Marker: Anesthesia Case Marker: Anesthesia Case FinishFinish

Marker: places Marker: places a symbol on a symbol on the timelinethe timeline

Reminder: you Reminder: you need to chart need to chart somethingsomething


When the Anesthetist turns on the anesthesia machine, When the Anesthetist turns on the anesthesia machine, the SIMS computer turns on automatically. the SIMS computer turns on automatically.

The SIMS computer will Auto-Logon – you do The SIMS computer will Auto-Logon – you do notnot log log into Windows with your TOH password.into Windows with your TOH password.

Double-click the icon for SIMS-Perioperative Manager Double-click the icon for SIMS-Perioperative Manager and when prompted, logon with your SIMS password.and when prompted, logon with your SIMS password.

You will now see the Census List with the patients You will now see the Census List with the patients listed: Surgery-Todaylisted: Surgery-Today

The ORs are listed The ORs are listed in numerical order – in numerical order –Your patients are listed in Your patients are listed in your OR your OR alphabeticallyalphabetically,, not by time!not by time!

Step 1: Get Anesthesia Manager OPENStep 1: Get Anesthesia Manager OPEN

Click Here for more Help on opening Anesthesia Mgr


Find and highlight with a Left-Click of the mouse, yourFind and highlight with a Left-Click of the mouse, yourfirst or next patient’s namefirst or next patient’s name

Click on the “Click on the “START SESSIONSTART SESSION” button” button

Some important concepts:Some important concepts:

- the whole patient record for the surgery – from SDA - the whole patient record for the surgery – from SDA or SDCU to the OR to PACU – is an or SDCU to the OR to PACU – is an ENCOUNTERENCOUNTER

- the patient’s admission in SDA/SDCU is a - the patient’s admission in SDA/SDCU is a SESSIONSESSION

- to move from SDA/SDCU to the OR, the patient - to move from SDA/SDCU to the OR, the patient must go through the must go through the TRANSFERTRANSFER zone zone

- to move the patient into the OR (and start charting)- to move the patient into the OR (and start charting)you must pick up the patient from Transferyou must pick up the patient from Transferand and START A NEW SESSIONSTART A NEW SESSION

- patient leaves the OR for PACU => into - patient leaves the OR for PACU => into TRANSFERTRANSFER

Step 2: Start the Anesthesia Manager SESSIONStep 2: Start the Anesthesia Manager SESSION


Click Here for Help on Navigating

Anesthesia Mgr

For more detailed information, For more detailed information, take the Grand Tour….take the Grand Tour….

Click Here for Help on Real-Time

Variables


Step 3: Insert the Anesthesia Case START event (flag = S)Step 3: Insert the Anesthesia Case START event (flag = S)

Macro Barfor workflow

Chevrons show when AM started running this

session

Yellow columnis current time

Left-Click the mouse on the START Macro button

Click Button to enter Start Case

time

The Basic and Essential Anesthesia DataThe Basic and Essential Anesthesia DataEdit Event dialog appears –either accept the current timeshown or edit the time.

We will change it to 20:50 and click OK

After clicking on the START button:

The Button is depressed

TimeBox 20:50 shows the flag

symbol “S”

From the moment Anesthesia Manager is open, it is fully From the moment Anesthesia Manager is open, it is fully operational and will capture any Vital Signs which appear on the operational and will capture any Vital Signs which appear on the monitor or any action by the ventilator.monitor or any action by the ventilator.

By clicking the Anesthesia Start macro button, you have set the By clicking the Anesthesia Start macro button, you have set the time for when you started the case. (for tracking purposes)time for when you started the case. (for tracking purposes)

Note: You Note: You cancan set the Start Flag to before AM started – it is set the Start Flag to before AM started – it isvery important to remember this when it comes to printvery important to remember this when it comes to print


Step 4: Chart the Equipment Check (flag = C)Step 4: Chart the Equipment Check (flag = C)

Click on theEquip Check

button

All these Equip Eventsare entered with

one Click!

Time is edited to

20:55

Note: GasMachine #left blank

After clicking on the EQUIPMENT CHECK button:

Equip Check button is depressed

TimeBox 20:55shows symbol “C”


To enter the Gas Machine # you need to displayTo enter the Gas Machine # you need to displaythe Events Log – click its icon on the ToolBar the Events Log – click its icon on the ToolBar

Below is shown the Events Log with all the Below is shown the Events Log with all the Events so far.Events so far.

To add a Comment you need to EDIT the Event:To add a Comment you need to EDIT the Event:Highlight by a mouse click and click EditHighlight by a mouse click and click Editor – Double-click the Eventor – Double-click the Event


[TAB] from the Time field [TAB] from the Time field or mouse click to the or mouse click to the Comment box; Comment box; Enter the Gas Machine #Enter the Gas Machine #Then [TAB] again to the Then [TAB] again to the the [OK] button and the [OK] button and hit [ENTER]hit [ENTER]

The updated Events LogThe updated Events Lognow shows the Gasnow shows the GasMachine # in the CommentMachine # in the Commentcolumncolumn


At this point you have everything ready to proceed with At this point you have everything ready to proceed with your anesthetic case.your anesthetic case.

When you choose to document will be determined by your When you choose to document will be determined by your personal choice and workhabits.personal choice and workhabits.

The WorkFlow buttons on the MacroBar are designed to The WorkFlow buttons on the MacroBar are designed to drop Bookmarks (Flags) on the TimeLine at the various drop Bookmarks (Flags) on the TimeLine at the various stages of your case. When it is convenient, you return to stages of your case. When it is convenient, you return to these TimeBoxes with the Flags and complete the chart.these TimeBoxes with the Flags and complete the chart.


Step 5: Documenting your Assessment of the PatientStep 5: Documenting your Assessment of the Patient

1.1. More than likely, your patient has had a recent visit More than likely, your patient has had a recent visit to the PAU and an MD Assessment is available in to the PAU and an MD Assessment is available in Preop Manager, but done by someone else.Preop Manager, but done by someone else.

2.2. The Patient may have been assessed in the PAU or The Patient may have been assessed in the PAU or SDCU by the Nurse only and the MD Assessment SDCU by the Nurse only and the MD Assessment needs to be doneneeds to be done

3.3. The Patient has not been seen in the PAU or SDCU; The Patient has not been seen in the PAU or SDCU; no RN or MD Assessment has been doneno RN or MD Assessment has been donee.g. inpatient from warde.g. inpatient from ward

The following scenarios are possible:The following scenarios are possible:

What needs to be done?What needs to be done?1.1. Check vOacis: Review the PAU visit MD Assessment Check vOacis: Review the PAU visit MD Assessment

– OR- – OR-

2.2. Complete a new MD Assessment in Preop ManagerComplete a new MD Assessment in Preop Manager

The person giving the anesthetic must document The person giving the anesthetic must document his/her own medical assessment of the patient. his/her own medical assessment of the patient.

The Basic and Essential Anesthesia DataThe Basic and Essential Anesthesia DataStep 5: Documenting your Assessment of the PatientStep 5: Documenting your Assessment of the Patient

If vOacis has a recent Preop Manager Assessment If vOacis has a recent Preop Manager Assessment complete with an MD Assessment done by someone else:complete with an MD Assessment done by someone else:(either a PAU visit or a ward/ER Consultation)(either a PAU visit or a ward/ER Consultation)

- You need to document your - You need to document your ownown preop assessment in preop assessment in Anesthesia Mgr – using the Preop Evaluation eventsetAnesthesia Mgr – using the Preop Evaluation eventset

If vOacis has a recent Preop Manager Assessment If vOacis has a recent Preop Manager Assessment withoutwithout an MD Assessment (i.e Nurse Assess only):an MD Assessment (i.e Nurse Assess only):

-You need to document your own preop assessment as an You need to document your own preop assessment as an MD Assessment in Preop Mgr – select the patient from MD Assessment in Preop Mgr – select the patient from the “Surgery Today” census listthe “Surgery Today” census list

-Preop Mgr may have the MD Assess section “locked” - Preop Mgr may have the MD Assess section “locked” - use the Addendum section in this caseuse the Addendum section in this case

If vOacis has no recent Preop Manager Assessment:If vOacis has no recent Preop Manager Assessment:

-You need to document your own preop assessment as an You need to document your own preop assessment as an MD Assessment in Preop Mgr – select the patient from MD Assessment in Preop Mgr – select the patient from the “Surgery Today” census listthe “Surgery Today” census list

The Basic and Essential Anesthesia DataThe Basic and Essential Anesthesia DataStep 5: Documenting your Assessment of the Patient Step 5: Documenting your Assessment of the Patient

in Anesthesia Managerin Anesthesia Manager

Click on the “Pt Assess” button on the MacroBar Click on the “Pt Assess” button on the MacroBar and edit the dialog and edit the dialog TimeTime field if needed field if needed

The symbol “P” appears as a Flag on the TimeLine The symbol “P” appears as a Flag on the TimeLine at the selected timeat the selected time

The “Add Events” window pops up:The “Add Events” window pops up: 1. Select EventSet “A010_Preop Evaluation” 1. Select EventSet “A010_Preop Evaluation” 2. Check the Time field - edit if needed 2. Check the Time field - edit if needed

Pt Assessbutton

Click Here to Select


Step 5: Documenting your Assessment of the PatientStep 5: Documenting your Assessment of the Patient

Click on each Event as

appropriate

Using the Event Set Using the Event Set A010_Preop Evaluation, A010_Preop Evaluation, select events to select events to document what you document what you assessedassessed

Bring the selected Bring the selected Events over to the right-Events over to the right-hand panel, enter any hand panel, enter any Comments required and Comments required and then click [OK]then click [OK]

We recommend that a We recommend that a brief medical problem brief medical problem list be entered as an list be entered as an Anesth History comment Anesth History comment


Step 6: Chart the ASA Level and the Medical TeamStep 6: Chart the ASA Level and the Medical Team

Strictly speaking, the ASA levelStrictly speaking, the ASA levelgoes with Preop Assessment.goes with Preop Assessment.

Anesthesia Manager has placedAnesthesia Manager has placedit in a grouping called:it in a grouping called:DEMOGRAPHICSDEMOGRAPHICS

We have a single Macro buttonWe have a single Macro buttoncalled ASA/Team which willcalled ASA/Team which willremind you to open up the remind you to open up the Demographics window.Demographics window.

It’s up to you to remember to It’s up to you to remember to enter both items!enter both items!



Clicking on ASA Level brings up the selection boxClicking on ASA Level brings up the selection boxUse the drop-down box or hit the keyboard [DOWN ARROW] Use the drop-down box or hit the keyboard [DOWN ARROW] repeatedly until the desired ASA Level is highlightedrepeatedly until the desired ASA Level is highlighted

Click this smallarrow to revealthe drop-down



This window pops up when Medical Team is clickedThis window pops up when Medical Team is clicked

When you click in the empty Anesthesiologist boxWhen you click in the empty Anesthesiologist boxa drop-down of names appears.a drop-down of names appears.

Although you can select with the mouse by scrollingAlthough you can select with the mouse by scrollingdown the list, using the keyboard is faster.down the list, using the keyboard is faster.Tip: Remember the keystrokes for the next timeTip: Remember the keystrokes for the next time

To select Elliott:-Jump to the start of

the “E” names by typing the letter “E”

-Either use the [DOWN] arrow keyor the [PgDn] keyto reach the name

and hit [ENTER]Use mouse to moveto a different box

Don’t forget toenter the rest of the Team!



Once the ASA/Team button has been used, it will Once the ASA/Team button has been used, it will appear depressed in the MacroBar.appear depressed in the MacroBar.If you need to see Demographics again, use the If you need to see Demographics again, use the Demographics button at the bottom of the ToolBar Demographics button at the bottom of the ToolBar


Click Here(may be along way

down)

An alternate way to access the sections in DemographicsAn alternate way to access the sections in Demographics

Click Hereto return toFlowsheets


This is also a good time to enter the patient’s weight.This is also a good time to enter the patient’s weight.Unfortunately, you will need to remember the weightUnfortunately, you will need to remember the weightfrom the Preop Assessment to then enter it.from the Preop Assessment to then enter it.

Entering the Weight here will be useful later when you use Entering the Weight here will be useful later when you use drug infusions based on weight. The weight will show up drug infusions based on weight. The weight will show up automatically when the drug infusion window opens.automatically when the drug infusion window opens.


Step 7: Bookmark on the TimeLine when AnestheticStep 7: Bookmark on the TimeLine when AnestheticTechnique beginsTechnique begins

TechniqueTechnique TimeLine Flag SymbolTimeLine Flag Symbol

RegionalRegional RR

GeneralGeneral GG

Monitored CareMonitored Care MM

Macro

Bar

Macro

Bar

Work

flow

Work

flow

This case is a combined Spinal and General –

both RA and GA buttons have been pressed

Flag Symbol “R”

for RegionalTechnique

Flag Symbol “G”

for GeneralTechnique


Step 7: Bookmark on the TimeLine when AnestheticStep 7: Bookmark on the TimeLine when AnestheticTechnique beginsTechnique begins

Hovering the mouse over the Anesthetic Technique buttons Hovering the mouse over the Anesthetic Technique buttons shows Events which will be entered automatically for youshows Events which will be entered automatically for you

The Regional, General and MAC Start buttons registerThe Regional, General and MAC Start buttons registera a Reminder Event only Reminder Event only - you need to specify the- you need to specify theAnesthesia Type when you document the eventsAnesthesia Type when you document the events

In most cases, once your patient’s surgery is under way,In most cases, once your patient’s surgery is under way,then you will return to the Bookmark to document.then you will return to the Bookmark to document.


Step 8: Return to the “R”, “G” or “M” Technique Step 8: Return to the “R”, “G” or “M” Technique SymbolSymbol

=> Document Events=> Document EventsClick in the TimeBox with Click in the TimeBox with the Symbol “G” tothe Symbol “G” tobring up the Add Eventsbring up the Add Eventswindowwindow

In most GA casesyou can usethe Basic GA

event set

Correct timealreadyentered

The Basic and Essential Anesthesia DataThe Basic and Essential Anesthesia DataStep 8: “R”, “G” or “M” Symbol => Document EventsStep 8: “R”, “G” or “M” Symbol => Document Events

Note the “Must Do” –Note the “Must Do” –You need to select the You need to select the Anesthesia Type.Anesthesia Type.

The Basic GA Set has The Basic GA Set has (G)_General Anesthesia(G)_General Anesthesiabuilt-in, ready to select.built-in, ready to select.

A complete list of the A complete list of the Anesthesia Types is Anesthesia Types is in Event Set A001in Event Set A001

These are Reminders –Don’t select!

Organized into Sections with a note for full list

The Basic and Essential Anesthesia DataThe Basic and Essential Anesthesia DataStep 8: “R”, “G” or “M” Symbol => Document EventsStep 8: “R”, “G” or “M” Symbol => Document Events

The Sections provided are:The Sections provided are:

- - IV LinesIV Lines- - Airway ManagementAirway Management- - VentilationVentilation- - Patient PositionPatient Position- - EyesEyes- - Add EquipmentAdd Equipment- - Transport/End ActivityTransport/End Activity

This Basic GA event set givesThis Basic GA event set givesyou the most commonly usedyou the most commonly useditems/events that you will need.items/events that you will need.

With everything in one list, you With everything in one list, you will be less likely to forget to will be less likely to forget to document something.document something.

Each Section has its own, more Each Section has its own, more detailed, list of choices for detailed, list of choices for thosethosemore specialized cases.more specialized cases.


Step 9: Document Anesthetic Technique EventsStep 9: Document Anesthetic Technique Events

General AnesthesiaGeneral Anesthesia

In many cases the In many cases the “Basic GA” Event Set“Basic GA” Event Setcontains all the eventscontains all the eventsneeded.needed.

More detailed Event Sets More detailed Event Sets are available:are available:

A050 – ETT (oral)A050 – ETT (oral)A052 – ETT (nasal)A052 – ETT (nasal)A054 – LMAA054 – LMAA056 – FOB IntubationA056 – FOB IntubationA058 – AW Complic’nsA058 – AW Complic’ns

and…and…A150 – Thoracic SL ETTA150 – Thoracic SL ETTA152 – Lung Isol’n DL ETTA152 – Lung Isol’n DL ETT



Regional AnesthesiaRegional Anesthesia

The“Basic Spinal” Event The“Basic Spinal” Event Set contains the events Set contains the events commonly needed for commonly needed for Spinal Anesthesia.Spinal Anesthesia.

Other Event Sets include:Other Event Sets include:A060 – Reg’l Block TypesA060 – Reg’l Block TypesA062 – Epidural BlockA062 – Epidural BlockA064 – Spinal BlockA064 – Spinal BlockA066 – Upper Limb BlocksA066 – Upper Limb BlocksA068 – Lower Limb BlocksA068 – Lower Limb BlocksA070 – IV Reg’l (Bier) BlkA070 – IV Reg’l (Bier) BlkA072 – Head&Neck, TrunkA072 – Head&Neck, Trunk



Monitored Anesthesia CareMonitored Anesthesia Care

The“Basic MAC” Event Set The“Basic MAC” Event Set contains the events contains the events commonly needed. commonly needed.

Other Event Sets include:Other Event Sets include:A014 – Basic EyeA014 – Basic EyeA080 – Anes-MACA080 – Anes-MACA190 – Eye Care CentreA190 – Eye Care CentreA192 – Eye InstituteA192 – Eye Institute



More detailed descriptions More detailed descriptions about Technique-specific about Technique-specific Events are available:Events are available:

GA – Oral ETT

Spinal Anesthesia

Epidural Anesthesia

A detailed tutorial about A detailed tutorial about documenting Events is documenting Events is available:available:

Documenting Events


Step 10: Document Fluids IN / OUTStep 10: Document Fluids IN / OUT

The Flowsheet “Med Infusions & Fluids” has it all…The Flowsheet “Med Infusions & Fluids” has it all…

(The Anesthesia Summary Flowsheet can also be used)(The Anesthesia Summary Flowsheet can also be used)

“Fluids IN” refers to not only typical IV Fluids and Blood “Fluids IN” refers to not only typical IV Fluids and Blood Products but also IV Med Infusions (see Propofol above).Products but also IV Med Infusions (see Propofol above).



There are many tasks to be done related to There are many tasks to be done related to Fluid Management:Fluid Management:

- starting an IV solution bag using gravity feed- starting an IV solution bag using gravity feed- running an IV on an infusion pump- running an IV on an infusion pump- documenting a “bag level”- documenting a “bag level”- finishing and starting a new bag- finishing and starting a new bag- interrupting one solution to run another- interrupting one solution to run another- discontinuing (stopping) an IV solution- discontinuing (stopping) an IV solution- tracking urine output / blood loss- tracking urine output / blood loss

Tutorials regarding Fluids are Tutorials regarding Fluids are available:available:

Intro to IV Fluids

Detailed Fluids IN/OUT



It is helpful to keep the tally of Fluids IN / OUT up-to-dateIt is helpful to keep the tally of Fluids IN / OUT up-to-dateat regular intervals.at regular intervals.

Near the end of the case, you will want to do the final Near the end of the case, you will want to do the final “Bag Levels” so that the calculated Fluid Balance will be “Bag Levels” so that the calculated Fluid Balance will be accurate.accurate.

Bag LevelButton is a Reminder

Pops upFluid Balance

window

OpensFluid Balance

window

Click on this Button to get a detailed breakdown of the

Fluids given


Step 11: Document MedicationsStep 11: Document Medications

A detailed tutorial about A detailed tutorial about documenting Medications documenting Medications is available:is available:

Documenting Meds

Documenting Medications is one of the central activities in Documenting Medications is one of the central activities in recording an anesthetic.recording an anesthetic.

- AM opens with a “default” list of drugs- AM opens with a “default” list of drugs- drugs are either given by “bolus” or “infusion”- drugs are either given by “bolus” or “infusion”- drugs not found in the default list need to be Added - drugs not found in the default list need to be Added - doses can be Entered, Modified or Deleted- doses can be Entered, Modified or Deleted- drugs can be Discontinued- drugs can be Discontinued- a running tally of drug dosages given- a running tally of drug dosages given is shown in a Summary is shown in a Summary



The way Anesth Mgr handles Medications is a bit odd.The way Anesth Mgr handles Medications is a bit odd.

Older versions supported Meds in two ways:Older versions supported Meds in two ways:- bolus doses = Medication Flowsheet- bolus doses = Medication Flowsheet- infusions (called “drips”) = Fluids Flowsheet- infusions (called “drips”) = Fluids Flowsheet

Later versions added Combination Meds:Later versions added Combination Meds:- both bolus & infusions = Medication Flowsheet- both bolus & infusions = Medication Flowsheet

It would be better if ALL infusions were together on the It would be better if ALL infusions were together on the Medication Flowsheet.Medication Flowsheet.



The Default drug list in the The Default drug list in the Medications Flowsheet is a Medications Flowsheet is a mix of single drugs and mix of single drugs and combos.combos.

Medications can be Medications can be Bolus or Bolus or InfusionsInfusions(look for /min or /h)(look for /min or /h)

Medications can be Medications can be Single Drug orSingle Drug orCombinationsCombinations(look for multi-line (look for multi-line white box when 2 or more white box when 2 or more drugs)drugs)

Combo Bolus with preset doses

Single Drug Bolus- row highlighted

Combo Infusion- rates to be entered



As an example, let’s use Propofol without any Lido mixed in.As an example, let’s use Propofol without any Lido mixed in.

The default list of drugs has plain Propofol as a bolus but The default list of drugs has plain Propofol as a bolus but the infusion is a combo of Propofol + Lido.the infusion is a combo of Propofol + Lido.

We need to add a plain Propofol infusion.We need to add a plain Propofol infusion.

If we go to the Fluids Flowsheet, Propofol is listed underIf we go to the Fluids Flowsheet, Propofol is listed underOther IVF. But if you hover the mouse over the PropofolOther IVF. But if you hover the mouse over the Propofollisted, you see it is actually the P+L combo.listed, you see it is actually the P+L combo.

AM displays the drug masses of combos in Medications but AM displays the drug masses of combos in Medications but shows the drug volumes in Fluids.shows the drug volumes in Fluids.



To add the “old-style” drip Propofol,To add the “old-style” drip Propofol,move the mouse pointer over the headingmove the mouse pointer over the headingFluids IN and when the finger appears,Fluids IN and when the finger appears,left-click.left-click.

A windows pops up for you to add a “Fluid” - in this case,A windows pops up for you to add a “Fluid” - in this case,chose the Family called “General Anesthetic” and then seechose the Family called “General Anesthetic” and then seewhat “Treatments” are available.what “Treatments” are available.

We want Propofol inmcg/kg/min

Click on Click on [Add][Add]and thenand then[Cancel][Cancel]

Update: We have standardized Propofol infusions to mg/kg/min



A Med Infusion (“drip”) shows up A Med Infusion (“drip”) shows up in Green under a new heading forin Green under a new heading forGeneral AnestheticGeneral Anesthetic

By default the drug is displayedBy default the drug is displayedby “Dose only”by “Dose only”By right-clicking, you can choose By right-clicking, you can choose to see both Volume and Doseto see both Volume and Dose

Now you can see the pump rate on one line

and the dose on a 2nd line

This looks good but the Propofol bolus and infusion are on This looks good but the Propofol bolus and infusion are on different Flowsheets!different Flowsheets!



An easy way to select Medications not listed whenAn easy way to select Medications not listed whenAnesthesia opens is to use the Protocol Button.Anesthesia opens is to use the Protocol Button.

A major advantage to Protocols is that we can listA major advantage to Protocols is that we can listbolus and infusions, both single drug and combos, bolus and infusions, both single drug and combos, all in the same placeall in the same place..

This isBolus Propofol

+ Lido

These areInfusions

(/min)

The Combo iconshows a “+”

with a pill bottle

Update: To avoid confusion on the Summary PrintOuts, most 1-druginfusions (e.g. Vasopressors) will use the older “Fluid Drip” technique until Picis can correct how the combo infusions are represented



When we Add Propofol as a 1-drug combo infusion,When we Add Propofol as a 1-drug combo infusion,this is what shows up in AM under Medications:this is what shows up in AM under Medications:

Now Propofol (plain) bolus and infusion

are together

This is what we see when we add some This is what we see when we add some doses on the Medication Flowsheet:doses on the Medication Flowsheet:

When we switch to the Fluids Flowsheet,When we switch to the Fluids Flowsheet,the pump rate is entered automatically:the pump rate is entered automatically:

This looks perfect on screen within AM

but on a printout the rate is NOT shown; instead you see the mass of drug given per time column.We hope Picis can correct this soon.


Step 11: Document Medications - Step 11: Document Medications - AntibioticsAntibiotics

The Antibiotic First The Antibiotic First Dose button pops up Dose button pops up a time window, then a time window, then puts an “A” on the puts an “A” on the timeline and startstimeline and startsa Timer (counts up)a Timer (counts up)

When you have the time later, enter the antibiotic in the time When you have the time later, enter the antibiotic in the time column with the symbol “A”column with the symbol “A”

If it’s Cefazolin, it’s easy – it’s a default drug.If it’s Cefazolin, it’s easy – it’s a default drug.

Otherwise you will need to Add the antibiotic first.Otherwise you will need to Add the antibiotic first.Two choices:Two choices:1. Use the Protocols – Anes-Antibiotics list 12 common ones1. Use the Protocols – Anes-Antibiotics list 12 common ones2. Click on Anti-Infectives on the Med Flowsheet2. Click on Anti-Infectives on the Med Flowsheet (this will list every antibiotic on TOH formulary! (this will list every antibiotic on TOH formulary! Shortcut – type a few letters e.g. “v” pops up vancomycin) Shortcut – type a few letters e.g. “v” pops up vancomycin)


Step 12: End of Surgery / Update ProcedureStep 12: End of Surgery / Update Procedure

With the last few stitches, markWith the last few stitches, markthe End of Surgery with the the End of Surgery with the “End S” button“End S” button

The Demographics window popsThe Demographics window popsup and you need to check the up and you need to check the listed Procedure and update iflisted Procedure and update ifnecessary. (This is important in necessary. (This is important in Remote Locations – procedure Remote Locations – procedure will NOT be there automatically)will NOT be there automatically)


Step 12: End of Surgery / Update ProcedureStep 12: End of Surgery / Update Procedure

Take a look at the Required Events box belowTake a look at the Required Events box below

The only events left are:

1.Finish Time2. QA Indicator

All the others have at least

one entry


Step 13: Fluid Balance – Enter IV Bag LevelsStep 13: Fluid Balance – Enter IV Bag Levels

Enter IV Bag / Blood Bag levelsEnter IV Bag / Blood Bag levels

Also Update Urine Output andAlso Update Urine Output andEstimated Blood LossEstimated Blood Loss

Check in Fluid Balance window –Check in Fluid Balance window –updates dynamically as you enterupdates dynamically as you enterdata.data.

Step 14: Mark End of General Anesthesia (g)Step 14: Mark End of General Anesthesia (g)

The End GA button places the letter The End GA button places the letter (g) on the TimeLine for you and (g) on the TimeLine for you and automatically enters a group of automatically enters a group of events appropriate for the end of a events appropriate for the end of a typical GA.typical GA.

If there are discrepancies with what If there are discrepancies with what you want to record, you will need to you want to record, you will need to edit these events in PACUedit these events in PACU


Step 15: Transfer to PACU / SDCUStep 15: Transfer to PACU / SDCU

The green PACU-SDCU-ICU buttonThe green PACU-SDCU-ICU buttonbegins a Transfer of the patient into the begins a Transfer of the patient into the

“Transfer Zone”.“Transfer Zone”.

It is It is essentialessential that your patient be that your patient be “transferred” or else the PACU/SDCU“transferred” or else the PACU/SDCUwill not be able to retrieve your will not be able to retrieve your patient’s record!patient’s record!

You will be shown the Demographics screenYou will be shown the Demographics screenone more time, in case something missing one more time, in case something missing had slipped your notice.had slipped your notice.


Step 15: Transfer to PACU / SDCUStep 15: Transfer to PACU / SDCU

Click [Transfer]Click [Transfer]to proceed.to proceed.

If you realize If you realize you forgot to you forgot to chart somethingchart somethingclick [Cancel]click [Cancel]


Step 16: Documentation in PACU / SDCUStep 16: Documentation in PACU / SDCU

Open the Patient in Remote View:Open the Patient in Remote View:

Important tip: The patient must have been admitted intoImportant tip: The patient must have been admitted intoPACU or SDCU if you want to document in Remote View.PACU or SDCU if you want to document in Remote View.


Step 16: Documentation in PACU / SDCUStep 16: Documentation in PACU / SDCU

Patient in Remote View – note White ID band:Patient in Remote View – note White ID band:

Use the Report button to open Add Events Use the Report button to open Add Events and use A005_PACU-SDCU-ICU Reportand use A005_PACU-SDCU-ICU Reportto document to document QA IndicatorQA Indicator & & Transfer of CareTransfer of Care

The Click on the Finish button to enter theThe Click on the Finish button to enter theAnesthesia Case Finish timeAnesthesia Case Finish time


Step 17: Print the Anesthesia Record to vOACISStep 17: Print the Anesthesia Record to vOACIS

While in Remote View, after the Finish button, the While in Remote View, after the Finish button, the Print Anesthesia Record pops up:Print Anesthesia Record pops up:

Make sure to choose the Anesthesia record

You need to enter the Anesthesia Start time which probably is not the same as the time

you opened the session.

You need to look up the Anesthesia Start time before you click on the

Finish button!

The Start & EndThe Start & Endtimes for datatimes for datato print shownto print shownhere are for the here are for the

PACU sessionPACU session


Step 17: Print the Anesthesia Record to vOACISStep 17: Print the Anesthesia Record to vOACIS

The Anesthesia Session times are now shown. The Anesthesia Session times are now shown.

We need to add the We need to add the time in PACU until time in PACU until Case Finish TimeCase Finish Timeif we want to if we want to include the include the Transfer of Care Transfer of Care events and the first events and the first few vital signs few vital signs captured in PACU.captured in PACU.21:10 was the End of the

Anesthesia Session.The Case Finish time in

PACU needs to be entered here: 21:16


Alternate Steps 16 & 17: Alternate Steps 16 & 17: Patients who Patients who DO NOT GODO NOT GO to PACU / SDCU to PACU / SDCU

If your Patient is in a Remote Location and will not be going If your Patient is in a Remote Location and will not be going to PACU – you need to change the end sequence a little.to PACU – you need to change the end sequence a little.

You need to complete the Report and Finish Time You need to complete the Report and Finish Time BEFORE: BEFORE:

1.1.Clicking on the X-SIMS (Discharge) ButtonClicking on the X-SIMS (Discharge) Button

2.2.Leaving your ORLeaving your OR

You will need to Enter an estimatedYou will need to Enter an estimatedFinish Time and use that time whenFinish Time and use that time whenprinting the Anesthesia Recordprinting the Anesthesia Record


Alternate Steps 16 & 17: Alternate Steps 16 & 17: Patients who DO NOT GO to PACU / SDCUPatients who DO NOT GO to PACU / SDCU

This is the This is the DISCHARGE window.DISCHARGE window.Be Be veryvery careful… careful…

You cannot UNDOYou cannot UNDOa Discharge!a Discharge!

Remember:Remember:Discharge is for Discharge is for Patients who will notPatients who will notbe going to the main be going to the main PACU or SDCU PACU or SDCU

For ICU Patients, you For ICU Patients, you will Transfer first, then will Transfer first, then start a sessionstart a session on the on the ICU computer, enter ICU computer, enter reports – then reports – then DischargeDischarge


YourYourElectronic Anesthesia RecordElectronic Anesthesia Record

is nowis now

How do I chart … The Basic and Essential Anesthesia Data?

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