• JULY 2007 FEATURE ARTICLES •
EDIS
EDIS
Overhaul
Implementation of an EDIS in a pediatric emergency department translates to more efficient and timely care.
By Dwight Doerhoff, MSN, RN
With nearly 60,000 visits per year, treatments
at the tertiary pediatric emergency
department (ED) at St. Louis Children’s
Hospital involve the ordering, prescribing
and administration of medications as a routine part of
caring for our patients. Previous studies have shown that
the process of giving medications in an emergency department
is a complex one, and our emergency department
was no different.
The 2,000 employees and medical staff of 700 at
St. Louis Children’s Hospital provide a full range of pediatric
services to the St. Louis metropolitan area and our
primary service region covering six states. As a Level 1
pediatric trauma center and the pediatric teaching hospital
for Washington University School of Medicine, we
offer nationally recognized programs for physician training
and research.
Like many hospital emergency departments operating
in the world of paper documentation, we were faced with
the challenges of paper charts that could only be in one
place at a time and could only be used by one clinician at
a time. Medication orders and prescriptions were handwritten
and were often difficult to read. Additionally, our
physicians lacked an efficient communication method to
let nurses know that there were new medication orders
to be carried out.
Some medication orders required additional staff members
such as a unit secretary and pharmacy technician to
handle the orders before the medication could be delivered
to the emergency department. Finally, acetaminophen, antibiotics
and medications used for the treatment of asthma
are commonly used in pediatrics. Typically, the dosage for
these medications are based on the weight of the child, so having access to the patient’s weight at the time of ordering
or prescribing is essential.
Early on, Dr. David Jaffe, our emergency department
medical director, had recognized the need for an emergency
department information system (EDIS). According to Dr.
Jaffe, the department’s physical layout was designed with
an EDIS in mind. He, and all concerned, felt that such a
system would be essential to improving patient flow and
patient care from presentation at triage, to disposition.
Possible Solution Assessment
With project funding secured in 2003, the search for
an EDIS could begin in earnest. An evaluation team was
formed that consisted of ED leadership and front-line
ED staff, as well as a project manager and systems analyst
from the information systems department. Although we
had been using an electronic patient tracking system since
1998, it was not capable of meeting our requirements
of having a complete electronic patient record, a robust
patient tracking system and an easy to use order management
system.
Based on this assessment, our evaluation team chose
a solution from Wellsoft Corporation and an additional
vendor. Wellsoft was selected for evaluation because their
system was being used in the emergency department at
Children’s Hospital of Philadelphia—a facility very similar
to our own. The other vendor was selected for evaluation
because their system had recently been installed in the
adult emergency department at our sister hospital across
the street.
The exhaustive process of evaluation and selection of
the new EDIS included prioritizing system requirements
with ED leadership, front–line ED staff and information systems staff; vendor demonstrations both onsite and over
the Web; and, customer site visits to see the two systems in
action. The team ultimately chose Wellsoft due to its ease
of use, proven track record at a similar children’s hospital
and feedback from other Wellsoft clients.
Implementation
Implementation began with the vendor spending several
days onsite getting to know our staff and understanding our
current processes. The support of the vendor was critical
in gaining the support of the staff that would have to rely
on the system once it was in place. “Their experiences
installing Wellsoft in other emergency departments was
invaluable in helping us improve our current processes
and develop new processes,” says Emergency Department
Manager Linda Robert.
In an effort to cause as little disruption as possible while
ensuring buy–in from staff, we chose to implement the system
in three phases. The first phase encompassed patient
tracking, triage nurse documentation, results reporting
from the hospital’s lab system, automated discharge instructions
(based on diagnosis) and electronic prescription
writing. “The transition went so smoothly that by the end
of the first week of using Wellsoft, the nurses were asking
when we were going to enter the rest of the nursing notes
into the system,” says Shannon Miller, clinical educator for
the emergency department.
Primary nurse documentation followed in phase two,
and finally, order entry along with physician and nurse
practitioner documentation followed in phase three. At
the time we went live with our first phase, Wellsoft did not
have a weight–based medication–dosing calculator. To their
credit, the company agreed to
begin work on developing a
tool within the application to
meet this need. In the meantime,
the system’s flexibility and ease of customization
allowed us to work closely with the hospital’s pharmacy
team to develop prescriptions based on weight ranges for
many of the commonly prescribed medications.
Benefits and Results
Several immediate benefits related to the medication
process were seen with the first phase of implementation.
Physicians and nurse practitioners could review the
child’s home medications, allergies and weight on the
screen as they wrote their discharge medications using
the prebuilt weight–based prescriptions. Prescriptions
were printed on safety paper, which eliminated calls from
pharmacies that couldn’t read the prescription or the name
of the person who wrote the prescription. In addition,
the weight of the patient is printed on the prescription
so the pharmacist can confirm that the correct dose is
being dispensed.
With the implementation of complete nursing documentation
during phase two, physicians, nurse practitioners,
and other nurses had instant computer access to the
documentation of care provided to the patient while in the
ED, including medication administrations. In preparation
of phase three, we again worked closely with the pharmacy
team to develop weight–based medication orders for the
most commonly ordered medications.
The third phase of implementation allowed a physician
or nurse practitioner to enter a medication order and have
it immediately flagged and made accessible from any computer
in the department. If the medication being ordered is
weight based, the order entry system presents the physician
or nurse practitioner with typical dosing guidelines for the
medication and the weight range chosen.
Multiple hand–offs of medication orders is a thing of
the past, especially for medications not stocked in the
ED that need to be filled by pharmacy. When the order
is entered, the pharmacy receives a notification that there
is a medication order for them to fill. The pharmacist has
instant access to all of the patient’s clinical information in
the system such as weight, allergies and home medications,
as well as the nursing and physician notes from the current
visit or any prior visits to the ED. Should the pharmacist
have a question about a medication order, the EDIS clearly
identifies who placed the order, so when they call, they can
ask to speak directly to the physician or nurse practitioner
that placed the order.
Since the implementation of Wellsoft’s order entry
system, we have been able to provide reports back to
the pharmacy on the amount of time it takes to process,
fill and dispense medications for emergency department
patients—something that was previously difficult to track
with a paper–based system. In addition, we are beginning to
use the data on medications ordered to improve the quality
of care being provided to specific populations of children
such as those with asthma and sickle–cell anemia.
Even though we have already realized some benefits
of using Wellsoft at St. Louis Children’s hospital, we are
moving forward with implementation of the new weight–based
dosing calculator that was recently announced as
part of the company’s Integrated Medication System. We
fully expect this to enhance the medication ordering and
prescribing process in our pediatric emergency department,
so that we can provide the best and most expedient care
to our young charges.
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Dwight Doerhoff is a patient care information
systems specialist at St. Louis Children’s
Hospital. Contact him at ded7609@bjc.org. |