Implementation of clinical nursing module report

• 1. By Deepti Taiwade IIHMR, New Delhi Health IT

2. Table of content : Organization Profile Introduction Review of Literature Objectives Methodology Implementation Process Discussion Recommendation Summary References 3. ORGANIZATION Profile: 1. History First conceived in 1984 by Delhi Government Finally India's first full-fledged trauma centre to treat victims of road accident- 2006 2. Area & Infrastructure : 20,600 sq meters seven storey's consist of five operation theatres 152 inpatient 30 casualty beds, 26 ICU beds to provide both pre-hospital and emergency care. 4. Company Noida, UP 5. Infrastructure of OT Preoperative Room (Reception) Intra - operative (OT) Postoperative (Recovery Room) OT-1 Surger y OT-2 Orthopedic s OT-3 Emergen cy OT-4 Emergen cy OT-5 Neurolog y OT-6 Common (2-2- 2days) 6. Frame Relay Network SD Cisco 1720 BRI S/T CONSOLE AUX WIC 0 OK OK B2 B1 WIC 1 OK DSU CPU LNK100FDX S3 LOOP LP Remote 512K SD Cisco 1720 BRI S/T CONSOLE AUX WIC 0 OK OK B2 B1 WIC 1 OK DSU CPU LNK100FDX S3 LOOP LP Remote 256K SD OK Service Reset 100-240V 2 1 10Base-T AUI EthernetWan Production Plant T1 SD Centilion 1200 PC CAPOPOWER RS - 232C Bay Networks READY ALARM RESET Production Plant T1 SD OK Service Reset 100-240V 2 1 10Base-T AUI EthernetWan Corporate T1 Page 1 JPNATC - WAN & LAN network Thin clients WAN Frame Relay Network Switches Frame Relay Network Scanner for VOE ServerPrinters Wireless access Users Security cameras Biometric Diagnostic devices PC terminals Tablets 7. Clinical Transformation Implementation of Nursing Module of VistA EHR independently. 8. ELECTRONIC HEALTH RECORD (EHR) VETERANS HEALTH INFORMATION SYSTEMS & TECHNOLOGY ARCHITECTURE (VISTA) 9. COMPUTERIZED PATIENT RECORD SYSTEM (CPRS) 10. DATABASE: VistA was developed using the M or Mumps language/ database An open source Mumps database engine, called GTM for Linux & Unix computers has also been developed GTM is an implementation of the Standard M programming system (M = MUMPS) PUTTY PuTTy is a free and open-source terminal emulator, serial console and network file transfer application. It supports several network protocols, including SCP, SSH, Telnet and rlogin. The name "PuTTy" has no definitive meaning,[1] though "tty" is the name for a terminal in the Unix tradition, usually held to be short for Teletype. 11. v/s 12. MGWSI The M/Gateway Services Integrator (MGWSI) is a software module for integrating disparate environments. Its primary purpose is to provide the connection between the Enterprise Web Developer (EWD) runtime environment and PHP and Java Server Pages, but it can be used as a standalone product and deployed for your own purposes if required EWD Enterprise Web Developer (EWD) is the advanced web application development technology EWD's unique approach makes it one of the world's most productive platforms for web application development, allowing building sophisticated, modern Ajax database-driven applications as simply and as quickly as building static web pages. 13. MIRTH: Mirth is an open source Java-based integration engine sponsored & primarily developed by Web Reach, Inc. Mirth was designed based on the client- server style & the enterprise service bus architecture. Mirth delivers the industry's first free, open source HL-7 messaging middleware. The standards-based mirth software is designed to dramatically reduce the time & cost required to achieve health information system interoperability & data exchange, & to speed secure information sharing across communities of healthcare professionals. "Mirth's ability to support multi-channel messaging modes, multi-protocol connectors, multiple languages for transformer scripting, & a full complement of end-point technologies make it an attractive interface engine for VistA- based solutions" 14. Read : VistA NURSING USER MANUAL; Implementation of VistA Nursing Module at JPNATC Computerized Patient Record System (CPRS) Read-Only User Guide: Learnt how to use CPRS VistA-Healthe Vet Monograph; EHR Clinical Nursing Module Site referred was : VISTA NURSING MODULE http://www.va.gov/ Got technical manual to get technical assistance in implementing VistA Nursing Module 15. General: The objective of this project is to implement VistA Nursing EHR in JPNATC, AIIMS, New Delhi & ensure smooth & uninterrupted running of the same Specific: To understand the Clinical workflow of the nursing in OT & wards. To perform gap analysis of existing clinical nursing workflow, with respect to i) WHO Checklist & VistA Nursing Module in OT ii) VistA Nursing Module only in Wards To map & customize the existing manual nursing procedures to the VistA Nursing EHR form. To liaise & update with various stakeholders in the implementation project To train the Nursing Informatics In charge & Technical Staff (JPNATC) 16. Review of Existing VistA EHR Modules Process Mapping of OT & Wards Gap & Need Analysis Designing, Customizing & Updating Templates User Testing Training: hands on , onsite imparted to NIS and technical team Tools: observation using WHO checklist, feedback from staff. 17. Process Mapping Need & Gap Analysis Designing/Creating/Updating Templates User Testing Training Operation & Maintenance 18. NURSING WORKFLOW: IN 19. Postoperative (monitoring) (Assists in surgery) 20. Preoperative Workflow: 21. Intra operative Workflow: 22. Postoperative Workflow: 23. DISCHARGE/TRANSFER PATIENT PERFORM PROCEDURES NEEDED NURSE: 1.MONITOR VITAL SIGNS 2.MEASURE INTAKE OUTPUT 3.ADMINISTER MEDICATION NURSE ADMITS PATIENT IN NURSING LOCATION PATIENT ARRIVES AT RECEPTION Workflow In Wards: 24. Gap Analysis In OT : Done through WHO checklist Lacunae: It was supposed to be a group activity, but in practice checklist was filled randomly by anyone who is free. 25. SURGERY MODULE AT JPNATC : (OPERATION THEATRE) v/s NURSING MODULE OF VISTA (TO BE IMPLEMENTED AT JPNATC) PATIENT CLASSIFICATION PATIENT ASSESMENT PATIENT CARE ASSIGNMENT NURSING CARE PLAN WHICH ARE SYSTEM FOCUSED & CONTAIN BOTH NURSING PROBLEM & MEDICAL DIAGNOSIS CLINICAL PROTOCOLS/GUIDELINES FOR CARE, PATIENT EDUCATION MATERIAL DISCHARGE PLANNING & OTHER PATIENT RELATED MEDICAL RECORD DATA NURSING CLINICAL MODULE CONSISTS 26. Gap Analysis in Wards through VistA Nursing Module Following recommendations were made based on the analysis, which are enlisted in table of list of register made. 27. S.No. Name of Registers/Fields Contents/Remarks Related Formats 1. SURGERY OT LIST: Similar list can be found in Surgery Template of JPNATC's Software a.TC No. Filled by User b. Date Filled by User c. Consultant Filled by User d. Diagnosis Filled by User e. Surgery Filled by User f. Blood Request Filled by User g. Special Request Filled by User h. Department VISTA CPRS will show I. Case No VISTA CPRS will show j. Case Type VISTA CPRS will show k. Name-Age Sex VISTA CPRS will show l. Ward Bed VISTA CPRS will show 1. Preoperative Registers JPNATC Manual ProcessList of Registers made during Gap Analysis in OT & Wards: 28. S.No. Name of Registers/Fields Contents/Remarks Related Formats 2. PATIENT ID SLIP Patient ID Slip can be made through Patient Data Objects in Shared Templates of VISTA CPRS Demo a) TC No. Filled by User a) Diagnosis Filled by User a) Posted for Filled by User a) On Date Filled by User a) Name VISTA CPRS will show a) Age/Sex VISTA CPRS will show 3. TRANSFER IN BOOK Can be made through (Section 1:-Chapter 4 Special Functions; Admit/Transfer Pt. (Nursing Pkg. Only);pg no 155) a. Patient Details VISTA CPRS will show a. Things Received with Patient Filled by User a. Received time/by Filled by User a. Sent To OT (Time/By) Filled by User a. Remark Filled by User Recommendation :- We can Create New Template 4 REPORTING BOOK (Morning/Evening Shift) 4 & 5 are Non Clinical Registers 5 Gate pass for Class IV 29. S. N o. Name of Registers Contents/ Remarks Related Formats 6 RECORD KEEPING A. Patient's Detail VISTA CPRS will show A. Staff on Duty Filled by User Similar to VA*SU Brief Operative Visit , (Surgery Template) in VISTA CPRS DEMO, additional fields needed can be edited. A. Date Filled by User A. Diagnosis & Operation Filled by User A. In/Out Time Filled by User A. Circulatory/Scrub Nurse Filled by User A. Anesthesia Filled by User A. Sets Used Filled by User A. Sets Packed By Filled by User A. Sponges Filled by User A. Specimen Filled by User A. Extra Items Filled by User A. Remark Filled by User 7 NURSES RECORD BOOK I. Date & Time Filled by User I. Medication & Treatment Filled by User Recording can be done through Brief Assignment Worksheet (Nursing User Manual; pg. no. 473) I. Diet Filled by User Intra-operative Registers List: 30. S. No. Name of Registers Contents/Remarks Related Formats 8 VITALS CHARTING VITALS & I/O MODULE ALREADY BEING IMPLEMENTED IN JPNATC 9 I/O MONITORING 10 NURSES RECORD BOOK Similar to Register 7 11 Transfer Out Book To Staff on Duty, Already Printed Similar to Transfer Out Book of JPNATC, changes required can be done by editing Template Kindly receive the patient; Already Printed Date/Time Filled by User Name of Ward Filled by User Can also be made through (Section 1:-Chapter 4 Special Functions; Admit/ Transfer Pt. (Nursing Pkg. Only);pg no 155) Name VISTA CPRS will show Age/Sex VISTA CPRS will show TC No. VISTA CPRS will show With complete file + nurses notes Already Printed Other Material Received Filled by User Post-operative Registers List: 31. S. No. Name of Registers Contents/Remarks Related Formats 1. ADMISSION REGISTER Somewhat similar to JPNATC Admission Assessment Note, changes required, need to be configured. CR No. Filled by User Can also be made through (Section 1:-Chapter 4 Special Functions; Admit/Transfer Pt. (Nursing Pkg. Only);pg no 155) DOA/TOA (Date/Time of Admission) Filled by User MLC Filled by User NLC Filled by User Ward Admitted Filled by User Time of Shifting Filled by User Name VISTA CPRS will show Sex/Age VISTA CPRS will show Fathers/Husband Name:- VISTA CPRS will show Local Address:- VISTA CPRS will show 2 VITALS CHARTING Register 3D.2 & 3D.3 are similar to register 3C.1 & 3C.2 resp. 3 I/O MONITORING 4 Treatment/Assignment Book Similar to Complete Assignment Worksheet (Nursing Manual Section 3 :-Clinical; Chapter 2 Patient Assignments; pg no 475) Name VISTA CPRS will show Bed No. VISTA CPRS will show NANDA Nursing Care Plan can be made through (Section 3 :- Clinical; Chapter 3 Patient Plan of Care) Diagnosis Filled by User Medicine Filled by User Time Filled by User Treatment Filled by User Recommendation :- Interdisciplinary Plan Care Management in VISTA CPRS TEMPLATES can be used. 5 NURSES RECORD BOOK Same as Register 3C.3 Clinical Registers List: 32. 2 VITALS CHARTING Register 3D.2 & 3D.3 are similar to register 3C.1 & 3C.2 resp. 3 I/O MONITORING 4 Treatment/Assignment Book Similar to Complete Assignment Worksheet (Nursing Manual Section 3 :-Clinical; Chapter 2 Patient Assignments; pg no 475) Name VISTA CPRS will show Bed No. VISTA CPRS will show NANDA Nursing Care Plan can be made through (Section 3 :- Clinical; Chapter 3 Patient Plan of Care) Diagnosis Filled by User Medicine Filled by User Time Filled by User Treatment Filled by User Recommendation :- Interdisciplinary Plan Care Management in VISTA CPRS TEMPLATES can be used. 5 NURSES RECORD BOOK Same as Register 3C.3 33. S. No. Name of Registers 17 Specimen Book 18 Daily Maintenance & Repair Record Book 19 Inventory Record 20 Laundry Receiving Book Non Clinical Registers List: S. No. Name of Checklist Related Format 1 PREOPERATIVE CHECKLIST Somewhat similar preoperative checklist was found in VA SU PRE- OP VISIT in VISTA CPRS DEMO, since both the checklists are not exactly same ,to meet the need of JPNATC, an entire new template need to be created Recommendation :- 2 WHO SURGERY SAFETY CHECKLIST Need to create entire checklist via Template Checklist: 34. OT: Designed Templates for entire clinical nursing process WARDS: For existing templates : Modified & customized templates as per users feedback For Manual Recordings: Created/ Designed entirely new templates 35. Manual Process of Nurses Record Book: 36. CREATED TEMPLATE: Continued 37. Complexities Faced 38. Whether PUTTY or Templates 39. Self Care Deficit 40. USER TESTING: Nurse used the Template for live patient in Orthopedics Ward & gave following feedback for modification:- 1.Nurses Daily Record: Wants entire list of medication used in JPNATC 2.Nursing Care Plan: Wants whole customized care plan for various intervention which they were actually carrying out for patient. 41. TO NIS & Technical Staff at JPNATC 42. LIASED WITH STAKEHOLDERS STAKEHOLDERS HEAD IT, JPNATC CEO, GTI INFOTEL IIHMR TRAINEES NURSE INFORMATIC S ,JPNATC IT TEAM , JPNATC TECHNICAL STAFF AT GTI PROJECT MANAGER, VISTA EWD 43. Implementation of Nursing Module of VistA EHR, in JPNATC, AIIMS enable the client to meet its said objective to a larger extent & be self sufficient in carrying out operations It provides following benefit: Time- Real time flow of information Place-Remote dissemination of information Standardization-Processes & Workflows Coordination- Among care providers Decision support-Clinical knowledgebase, Clinical pathways & protocols Retrospective analysis- Trends, audits, outcomes 44. JPNATC, AIIMS should make all the clinical process recording paperless HIS ,being an open source application, does not increase the expense for the organization but at the same time enhance the quality by improving the processes such as making all clinical documentation electronic thus decreasing duplicity to a great extent, save time & cost to patient since the patient record can be accessed from any of JPNATC's locations rather than one patient consulted in the previous visit, it will help the Management to keep a strict control over functioning of the organization & thus help spread a good word of mouth for JPNATC, AIIMS. 45. With the implementation of VistA EHR, JPNATC AIIMS would gain in the following arenas Better management control Standardization of operations & functioning Decrease in cost Better quality of services Development of a good brand image Higher growth prospects 46. 1. JPNATC PROFILE http://www.jpnatc.com/ 2. GTI INFOTEL PROFILE http://www.gtiinfotel.com/ 3.U.S. Department of Veteran Affairs (VA);1985;VistA; http://en.wikipedia.org/wiki/VistA 4. James. M. Walker, Eric J Bieber, Frank Richards, & Sandra Buckley; Implementing an Electronic Health Record System (Health Informatics); Paperback- June 28, 2006 5.Jerome Carter; Electronic Health Records, Second Edition; Paperback- March 15,2008