Tasks in Epic
1) To populate your patient list with your assigned patients, please utilize the “sign in” button in the toolbar near the top of the screen. Patients should be assigned to “BJH 44_SICU” followed by the color and number. This assists the nursing staff to know who they should contact and put verbal orders under.
Powerpoint on how to manage team lists – Epic – Manage Provider Team Lists
2) Print Handoff: Using the print menu located in the top right corner of the screen, the handoff should be printed. Under service, please ensure that “Critical Care” is selected, and as always ensure you are selecting the correct printer to minimize HIPAA violations.
3) Patient Preview: The patient preview area that appears at the bottom of the Patient Lists screen when a specific patient is selected can facilitate rapid acquisition of information in the morning or when admitting a new patient. It allows for evaluation of vital signs and trends, I/O data, ordered medications, and labs (although the labs tab on the preview lists labs by order instead of allowing for trends- labs are better evaluated through the results review tab inside individual charts).
4) Summary: The General Adult Overview can be a useful tab to utilize to quickly see problem list, vital signs, and medications, but tends to be overly thorough. Tab selection and organization tends to be based on personal preferences, but URO Overview tends to be a more concise version of the General Adult Overview. Other suggested tabs include VS (vital signs), Radiology Results, Micro, Fever (which displays useful temperature, WBC, and creatinine trends, anti-infective administration), Med History (showing when specific medications were administered), and Anti-Coagulation (showing anticoagulant administration and labs in a more legible format). The flowheet section of the summary tab will be essential to evaluate vital sign trends, infusion trends, and changes to ventilator settings.
“5) Review Current Patient Orders: Inside a patient’s chart,select the “Orders” tab and review all of your current patient orders. Pay close attention to specific order details. Does your patient have duplicate orders or orders that do not apply to them any longer? If so, discuss it during rounds and discontinue all unnecessary orders/medications. An easy way to clean up the “Orders” tab is to utilize the “Discontinue/Cancel…” button at the bottom right hand side. Also in the same area is the “Release” button. This is how you will release orders or orders entered as a “Professional Recommendation” from a surgical or consulting service and allow those orders to become active.
6) Placing Patient Orders: To place an order, select the desired patient, enter their chart, and select the orders tab. An order entry screen should pop up on the sidebar, next to the summary and handoff sections. From here, you will be able to place orders for everything your patient requires. The most common orders in the SICU order set, the CC SUR Critical Care Surgery Daily Rounding order set. To open an order set, double-click the order and make your adjustments.If you need to write an order that is not contained within the SICU rder set, the search bar can be utilized. If one does not find the desired order initially, ensure you are searching the “Facility List”, not a “Preference List”.Once all orders are written, click the “Submit” button and sign your orders. At that time, any flagged duplicate orders or contraindications will require reconciliation. Please do not ignore this safety check. A notification flag will be visible to the RN and the appropriate departments such as the pharmacy alerting them of new orders. Take time to familiarize yourself with the various order sets that are available- one can order cultures and labs individually or utilize an order set like the Adult Sepsis Focused order set that might serve to save time.
7) Restraints: When renewing expiring restraints, the relevant order will appear near the top of the order list indicating that they will expire shortly. On the right hand side there will be an option to reorder. Always ensure that the type and location of restraint to be used is completed on the order set.
8) Modifying orders:
- To change IVF rates: Use the “Modify” button located on the right hand side. Note that if you do not sign these modified orders, they will not be signed.
- To titrate sedation/pressor drips: If medications are to be titrated by the bedside RN, the titration parameters should be specified in the order itself. If the medication is to be titrated based by the ICU team, the rate should be specified in the order and the “Do Not Titrate” button should be selected. If the patient is on more than one titratable medication for the same indication, be clear about which one to titrate first, by how much, and to what goal. For example, if a patient is on multiple sedative agents, the bedside RN must know which to wean first and to what goal rate for RASS goal. If the medications have separate goals (e.g. Fentanyl for pain goal, Propofol for RASS goal) it allows for separate titration.
- To change frequency/dosage of existing drug: Use the modify button.
9) Sending a Communication to the RN: It is important to communicate with the nurse primarily via verbal communication.When a written communication is necessary, the correct way is to send a “Nursing Communication Order”.
10) Ordering Blood Products: Orders for transfusing blood and related products are placed in the order sets: RBCs → Adult Red Blood Cells Administration; FFP → Adult Plasma Administration; Platelet → Adult Platelet Administration. When an order set is used, a communication will automatically be sent to the RN and if applicable, the NS carrier IVF will be ordered as well. Two orders are needed: order the blood product and order that the bedside nurse transfuse the specific product.
11) Documenting procedures- enter a new note, and specify “Procedure” as the type of note. This will allow you to select from a list of common SICU procedures that will allow you to quickly fill out the note using buttons and short free text areas. Please remember to specify the supervising fellow and the co-signing attending.
12) For other events, such as family discussions, use the “Event” note and just document what happened. Remember to assign the fellow and/or attending as cosigners as applicable. It is important to review the notes tab at the beginning of your shift to catch up on any events or new notes from overnight/off shift.
13) Transferring a patient to another unit: An order needs to be placed for a patient to transfer to another unit from SICU. When the Orders section is first accessed, the “Session Type” needs to be changed to “Pre-Transfer.”. This will place the orders in a HOLD status, which will be released upon transferring to a new unit. Before any order is placed, look over the current order and determine if their current order will apply for the patient on the new unit. Discontinue all unnecessary orders, specifically the electrolyte repletion orders and SICU-specific order sets. If the patient current orders are okay for the transfer then simply fill out the “Transfer Patient (Transfer of Care of Service to)” order which is found bymanually typing the title in. The “Transfer Progress” would be “Transfer initiated.” If a patient need telemetry on the floor, the “Telemetry Centralized Monitoring-Initial” order set should be used. Consider changing the heart rate parameters. The order will have to be activated with the patient’s room number placed in the comments so that the telemetry box can be sent to the ICU. Think about different needs upon transfer: fall risk, need for sitter, continuous pulse oximetry, etc.