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QSEN: Informatics

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Jenny Schneider

on 10 December 2013

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Transcript of QSEN: Informatics

QSEN: Informatics
PROS:
Improved patient care and safety, entire multidisciplinary team has access to information, easier referrals and follow up consultation, improved communication and continuity of care, improved organization and documentation, consolidation
Electronic Medical Records
Contains ALL information
(if used properly),
used for
diagnosis and treatment
What is Informatics?
The study of the structure and behavior of natural and artificial systems that generate, process, store, and communicate information.
How do
nurses
use informatics?
Nursing informatics is a science and practice that integrates nursing, it's information and knowledge, with management of information and communication technologies to promote the health of people, families, and communities worldwide.
A:
Allow Questions
A FEW CONS...
Electronic malfunctions,
patient care is overshadowed by technology, amount of time to learn computer systems.

That being said...
patient care and safety is improved
.
Which is most important!

Methods of relaying information
electronic medical records,
vital sign machines,
white boards,
bedside reporting,
computers,
cell phones,
video conference
RexAnn Pfister, Mai Vang, Elisa Hernandez-Tavener, Jessica Burnworth, Chris Watson, Fina Gardea, Jenny Schneider
December 10, 2013
Examples in everyday life:
Google, Wikipedia, Facebook, Twitter, text messaging, cell phones, face time, video chat
PROS CONTINUED...
Potential allergies,
drug interactions,
identification,
advanced directives,
family/contact information
President Bush: goal to have all records computerized in 10 years.
Goals:
avoid medical mistakes, reduce costs, improve care.
PROS of E.M.R.'s for NURSES
improved communication, legibility of HCP orders, improved test scheduling, results and reporting,
reduction of medication orders, identification of allergies and drug interactions, automated reminders and alerts, continuity and consistency of care, one central location, saves time and allows more time with patient
COMPLICATIONS:
PAPER CHARTING &
VERBAL ORDERS
sound alike/look alike drugs
(amlodipine/amiloride)

abbreviations
(IU/IV)

LEGIBILITY!

www.jointcommission.org/assets/1/18/Do_Not_Use_List.pdf
Important Documentation
Assessment

(fall, IV condition, risks, vitals, pain),
Delegation
of tasks,
Condition
of environment
(call bell, alarms on),
Interventions
and challenges,
Teaching
performed
EMR Goal for
NURSES
Patient Safety, Teamwork,
Continuity of Care
COMMUNICATION
Possibly the most VITAL part of Informatics
Nurse- Nurse
Nurse-Doctor/HCP
Nurse-Patient
An estimated 80% of serious medical errors involve patient hand-off/end of shift report
S.H.A.R.E
acronym used to ensure complete patient handoff/report...
S:
Standardize Critical Content
provide history, emphasize key information, synthesize key information from separate sources before passing to the receiver
H:
Hardwire Within Your System
develop standardized forms, tools and methods (checklists), identify new and existing technologies to assist in successful hand-offs, state expectations about uniform hand-off/report on the unit.
Use critical thinking when discussing patient, utilize the interdisciplinary team, receivers should scrutinize and question data, senders and receivers of info should share contact information in event that there are any additional questions
R:
Reinforce Quality & Measurement
demonstrate leadership and commitment to successful hand-offs, hold staff accountable, use data and available technology, use systematic approach
E:

Educate & Coach
Management and individual units need to teach staff what constitutes as a successful hand-off/report. Standardize hand-off, provide adequate time for proper report, provide feedback to fellow staff, make hand-offs an organizational priority
Call Lights
Call lights increase patient safety, allow patient to contact nurse without ambulating.
Decreased number of falls, increase quick response of health care team, especially in emergencies.
Call Light: Proper Use
Don't use as an excuse to not check on patients!
Certain generations don't want to draw attention or complain.
Check on patients even when they DON'T hit call light
Cell Phones
Nurses able to contact each other, HCP's, and other members of healthcare team.

Improves communication,
Don't have to search or wait.
Results and referrals are much quicker.
White Boards
Contain patient's name, nurse's name, phone numbers, date, time, orientations, vitals, and much more.
Not the
ONLY
source of information for the client.
Great tool for orientation.
Vital Sign Machine
Stores and automatically transfers vitals into the computer (EMR) in most hospitals.
Current vitals and compares to past.
Quick, visual.
Can still communicate with patient while taking vitals.
Vitals, continued...
Many different types of machines. Be familiar with the ones on your unit so the results are correct.
Don't rely on machines. Know how to manually obtain vital signs.
Get vitals in a timely fashion and
chart
them!
Glucometer
The glucometer, like vitals machine, is able to transfer results to the patients chart automatically when docked (in most hospitals)
Entire health care team has access.
Benefits
of Computers
Databases
-- drug information, disease pathophysiology, patient education
Patient information
-- able to monitor results, vitals, telemetry
Bedside computer monitors
-- able to converse with patient and spend time with them
Medications:
Using Informatics
Before the
1960's:
Floorstock and Prescription System
Floorstock:
bulk from pharmacy, nonspecific
to patient and not labeled.
Prescription System
: enough for 2-5 days, not patient labeled, Pharmacist reviewed med, but not the pt. history, allergies, diagnosis, or previous medications.
Problems:
Nurses-- too much responsibility, administering, inventory, interpreting orders, transcribing to MAR, preparing medication, and keeping track of unlabeled medications.
Medication errors were as high as 25%
Medications 1960's-1980's
24 Hour Unit Dose Cart-Fill System:
labeled, based on unit's specific patient's
Benefits:
Patient Safety-- multiple checks before administration. Locked system, must have authorization.
Pharmacists role was more active, very intense-- refill every 24 hours!
1980's-1990's
PCU-based automated dispensing cabinets, contain patient profiles, controlled by pharmacy, specific meds in specific compartments, access when med is due.
Cartless-- safer and more beneficial. Not bulk of meds, only allowed to get patient specific medications.
Medication Carts:
Convenience for nurse, dispense an assortment of meds.
Not as safe.
Different types:
Box Cart, Bin Cart Punchcard Cart
Continuity of Care
Comprehensive, coordinated, and integrated provision of health services.
Focus:
needs of client. Informal caregivers (family) and formal caregivers (healthcare team) acknowledge need for interdisciplinary approach.
Importance of Continuity of Care
Adequate communication between healthcare professionals
decreases risk of complications.
Makes adequate follow-up and testing results a easier to obtain.
Between Health Care Professionals
Document
EVERYTHING
so error doesn't occur. Don't ever assume, document.
Communication is vital
.
Avoid missed doses, overdoses, lack of communication, lack of assessment.
Steps of Continuity of Care
Shift change reports, universal guidelines, meetings on the unit.
Use available technology.
Discharge Planning
A process used to decide what a patient needs for a smooth move from one level of care to another.
Evaluation
Discussion
Planning
Support
Referrals
Discharge Team
Preparation
, all available information on patient, where the patient is going after hospital, support systems available in family and community, financial assistance, case management
Education
on disease/condition!
Ways NURSES educate themselves on informatics
Find a mentor!
Don't be afraid to ask questions.
Learn from peers and take time to figure out the computers, monitors, documentation and technology on the floor.
Ways to Improve:
Don't get frustrated.
There will always be new technology. Learn how to use it, attend classes and meetings. Be open to change.
The safety of the patient is the most important.
Ways to Improve:
Help peers in need.
Some of us are more technologically sound, explain computers and new systems to peers so errors don't occur and proper info is passed along.
RESOURCES:
Listed in NOTES
Full transcript