Harbor:ORCHID Downtime

• • Assigned Staff: Any tech savvy staff member.
  • There are two levels of 724 backup computer:

Level 2: There are nine computers designated as level 2 724 backups. These computers are always available, and can print the state of the ED at the time of the downtime as well as limited information for visits going back 10 days. At downtime, a login and password will be distributed throughout the hospital.

• • Locations of the level 2 backup computers:
    • Peds Nursing Station HARSE1H2972401
    • Trauma Nursing Station HARSE1H1072401
    • RME Nursing Station HARSE1E2472401
    • ED Registration Office
    • Acute Adult Front Nursing Station HARSE1J2572401
    • ED Pediatric Nursing Office SE141 HARSE1E4172401
      • Charge nurses have a key to this office
    • Gold Unit HARSE1F2572401
    • Psych ED Station #1
    • Psych ED Station #2
    • Urgent Care

Level 1:

• If a downtime is planned or prolonged, a level 1 viewer will be activated on ALL computers. This will require at least 30 minutes after the beginning of the downtime. This is a read-only version of FirstNet and includes full information about previous visits. For a planned downtime, the level 1 will available at the start of the downtime and will reflect the state of ORCHID 15 minutes prior to downtime.
  • Go to the Harbor Home Page --> Open ORCHID Here --> 724 Read Only folder. The login will be publicized just before the downtime.
• Open the “724AccessViewer” from the desktop.
• Login using the ID and Password that will be distributed at the downtime.
• Click on the “Firstnet Search” tab
• Choose the Tracking Group “HAR ED”
• Click the “Tracking Location” column to sort by that. You could also sort by DOB to bring the pediatric patients to the top.
• Click “Print List”
• Choose “Landscape” orientation and only the essential columns. If you choose them all, they will not fit on the page.
• Print a copy for each pod and distribute them.
• To read a patient’s chart, double click on it. There is a button at the top left to print the chart.
• Assign someone to staple them, sort by pod, and distribute to each pod and triage.

• Assigned staff: Attending MD
• The extent of the closure should be determined by the attending, charge nurse, and administrator on duty. For example, a crash of FirstNet only may allow us to remain open to trauma, while failure of all network systems might require diversion of all ambulance traffic.
  • “ED Saturation” is a closure to Advanced Life Support ambulances, remaining open to trauma, STEMI, and BLS ambulances.
  • “Internal Disaster” closes to ALL ambulances, including trauma and STEMI. Consider involving the trauma and cardiology attending in the decision to go on internal disaster.
• Notify the nursing supervisor, who will call the administrator on duty. Discuss whether to open the hospital emergency operations center to provide additional planning resources.
• Notify the MICN to place us on the appropriate level of diversion to ambulance traffic.
  • If access to Redinet is down, the MICN should call the MAC, who can update Redinet
  • If needed, the nursing supervisor can call MLK and ask them to stop sending patients.
  • Email (and call during daytime hours hours) Ross F.

• There is a cabinet in each of the five nursing stations and the triage hallway labeled “Downtime Forms” stocked with forms for about 200 patients.
• [Prior to a planned downtime, forms will be set out in each area. Packets will be prepared in advance for newly arriving patients containing a physician documentation form (253), nursing note/MAR (or PEDS version), MSE form, and order sheet].
• Originals for photocopying are located in the ORCHID Downtime folder in the AED doctor’s box
• Other important forms (eg, commonly used order sets, restraints) for the ED are in the Harbor ORCHID Wiki Harbor Home Page -> Scroll down to ORCHID Wiki -> Downtime -> Emergency Medicine
• Less commonly used order sets are found at: Harbor Home Page -> ORCHID -> Downtime Resources -> Orders -> DHS Order Sets
• Pharmacy forms (eg heparin infusion, prior authorization) are found at: Intranet -> Click Clinical tab -> Select References Micromedex -> Click on “Other Tools” -> Formulary -> In the formulary window click “Go to the Formulary tool”
• Type in medication name and click go

• Internet Downtime Forms
  • Pharmacy
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  • Order Sets

• Print the 724 charts of patients in the waiting room.
• Registration will enter patients who arrive during downtime on a log with name, mode of arrival, DOB, arrival time, and chief complaint at the router desk.
• Registration will perform quick registration into the downtime registration program (ADR). They will print patient stickers and place a blue armband on the patient. The patient will be given an MRN (use the patient's old MRN if it can be found in the 724 or patient’s documents) and new FIN, assigned by the downtime registration system (ADR).
• Registration will give each patient’s chart a preassembled packet including: MD note (253), nursing note/MAR, MSE note, and order sheet.
• The Router will start the nursing triage note on each patient with name, sex, chief complaint, arrival time and triage priority. These forms will be taken to the triage nurse.
• A senior triage nurse will be assigned the sole job of managing waiting flow of waiting room patients from router to triage to MSE to final room. She will use stacks of sorted patient charts and/or a list.
• Patients who are “bring back now” or have chest pain of cardiac origin will be taking directly to a treatment area and will be quick registered by the registration staff in those areas.
• Stable patients will wait in the waiting room and will be called to the registration windows for full registration.
• The triage nurse will sort the triage forms by acuity and arrival time and call patients in order.
• If the patient is sent to a room for RME or treatment, their forms will accompany them.
• If the patient is sent back to the waiting room, the triage form will be sorted by ESI score and arrival time and kept on the triage counter.
• Sort the 724 printouts on patients that were in the ED prior to downtime in with the forms of newly triaged patients.
• A nurse will visit each patient in the waiting room to create a list of all patients. This list will be compared to the piles of charts in the "waiting for room" and "waiting for triage" stacks to ensure that nobody has been missed. [This will not be necessary for a planned downtime, as the time of the switch from regular registration to downtime registration should be clear].
• Consider calling the sheriff for assistance with crowd control if needed to separate patients from family members if needed to determine who has been accounted for.

• MSE/RME providers will come to the waiting room flow coordinator to be told who the next patient is for MSE.
• Providers doing a screening MSE will use the MSE form.

• Assigned staff member: Area charge RNs
• Write patients on the white boards. In the AED, color code green and purple team patients.
• The charts of new patients waiting to be seen will be placed in a basket in the physician workroom.
• The ED clerk will make a log of patient departure times and dispositions.
• Providers will write the team color, attending and resident spectra numbers on the room glass. For planned downtimes, pre-printed forms with this information will be available to be clipped outside the room.

• Move each pod's chart rack to the front counter.
• Providers will write all orders on the generic order sheet.
• After the clerk has transcribed orders from the order sheet to the lab and radiology requisition forms, he will place them standing up in the chart rack, signifying there are orders to be done.
• When the orders have been completed, the nurse will place the chart down on its side in the folder.
• Order sets are online at the path in the "Gather Your Forms" section above. The trauma order set will be pre-printed. Put a patient sticker on each page, sign and date the last page with your name, eNumber, time, and date.

• Call the laboratory supervisor to notify him or her of the problem.
• Providers will write all orders on generic order sheets.
• Clerk will transcribe to a one-page lab requisition form. Clerk will notify nurse that there are new orders.
• Nurse will draw (or call phlebotomy), label with timed patient stickers, and place in tube with requisitions and tube to lab.

• The lab will print lab results and fax them to the AED radio room. There are backup fax machines in Gold and Registration. If the phone system is down, have the labs tubed to the AED at 212 for side A, 211 for side B, 111 for PED
• Designate a runner to distribute the results to providers around the ED. They will attempt to find the appropriate workroom based on age and the white boards in RME and the AED.

• Provider will write the order on a generic sheet.
• Clerk will transcribe to a radiology requisition form.
• Clerk will notify nurse that there is a new order
• Nurse will be responsible for communicating with technician and getting them the requisition form and getting the patient to the study or the portable tech to the patient.

• If Synapse is down, you will need to view images on the machine on which they were shot (eg, CT scanner, X-ray machine, or portable x-ray machine). For CT reads, call the reading room x7295 (daytime). At night page the radiology resident at 5814 to come down and make preliminary reads on the scanner. Ask if radiology can dedicate a staff member to the ED. If Synapse remains operational, residents may continue to place preliminary reads in Synapse. If the downtime occurs during a contract service reading time, you may need to call them to get emergent reads and discuss whether they can fax their reads.

• Tech will print two copies of the EKG. One will go the patient chart. The tech will call the patient’s attending (number posted on room) and bring the other copy to them.

• Providers will write orders on an order sheet and give it to the area clerk. For urgent orders, the provider will notify the nurse.
• The clerk will copy the order form and place a copy in the bin at each nursing station for collection by the pharmacist.
• The pharmacist will review antibiotics, anticoagulants, and drips prior to administration. The collected order sheets will be needed for use by pharmacy at recovery.

Medication Administration

• Nurses will be notified by the provider (urgent meds), clerk, or pharmacists that there are medication orders and will review the order sheet.
• For patients who were not in the Pyxis prior to downtime, the nurse will add the patient to the Pyxis. If patients move from Acute ED to boarding, they will need to be moved from the acute Pyxis to the boarding Pyxis.

• Nurses will document on the nursing note/MAR form. There is an addendum page that can be added if necessary.
• The nurse will keep her documentation in the chart rack that will be placed on the counter.

• If you begin seeing the patient during the downtime, document on the 253. If you started seeing the patient before the downtime, you can either finish their documentation on a 253, or wait for ORCHID to come back up and finish in ORCHID.

• Interqual: Provider calls UR to request Interqual.
• If patient had Full Registration prior to downtime, insurance information will be in Level 1 724. If this is not there, UR will call ED registration.
• UR calls provider back with updates
• Insurance information entered prior to the downtime can be seen in the level 1 724. For patients who have full registration during the downtime, UR will call ED registration.
• Provider will call report to the admitting service
• Provider will write the Request for Admit order on an order sheet, including service, attending, diagnosis, and level of care.
• Clerk calls bed control so they can search for a bed.
• Bed control calls clerk when a bed is ready.
• Clerk notifies nurse.
• Nurse calls report.

• Interqual: Provider calls UR to request Interqual
• UR calls provider back with updates
• Provider will give report to accepting MD
• Provider will print blank EMTALA form ORCHID downtime website

• The nurse will check with registration that they have completed full registration prior to discharging patients.
• The 253 form has a section for your handwritten discharge instructions. Give the carbon copy to the patient.
• Write prescriptions on paper with the patient’s MRN and note them on the 253
• Discharge instructions can be printed from the 724. Go to the FirstNet Search Tab. Choose any patient and click the "Patient ED" button on the left. You can search through any standard discharge instruction and modify as you wish. Print it. There are no custom DHS instructions. There is no record kept of what was written or printed.
• Nurses will depart discharged patients from the board when they have departed from the ED. Lab and radiology will ensure that the necessary orders are in on the back end as part of their recovery process.

• If patient was in ORCHID, provider will complete Post-Visit Follow Up form enter after recovery. Note there is an extra step at the bottom of the form that most be completed if the patient is already departed from the ED.
• If patient was arrived and departed during downtime (never was in ORCHID), provider will need to e-mail the appropriate follow up coordinator (AED follow up person, PED Medical Director), or just complete the lab follow up yourself.

• Providers will be responsible for arranging follow up after go live, having appropriate appointments made, and communicating this to the patient after recovery.

• Write on paper. Fax medications to pharmacy.

• [For a long, planned downtime, a team may be allowed back into the system prior to the system being release for everyone. Their priorities will be: 1. Entering patients into ORCHID that arrived during downtime. 2. Moving patients to their correct rooms in ORCHID. 3. Removing patients who were discharged during the downtime and entering: arrival time, diagnosis [Best ICD10 guess], disposition, providers, last room (or just AOF or POF for adult vs peds), and time left ED entered in ORCHID].
• For a short or unplanned downtime, registration will enter patients who arrived during downtime into ORCHID. There is a “downtime registration” box on the quick registration page that allows using the MRN that was assigned during downtime. Registration will register the patients who are on boarding status or already admitted. Bed control will change the encounter status to inpatient for the admitted patients.
• When the system comes back up, clinicians should stop documenting on paper and continue documentation in ORCHID.
• Providers will enter all ongoing orders except medications for patients still in the ED at recovery. This will include entering the Request for Admit and diagnoses.
• For patients who were admitted during downtime but are still physically in the ED, the ED provider will enter the Request for Admit and diagnoses into ORCHID. Other orders will be responsibility of the inpatient teams caring for the patients.
• For patients that were admitted and have departed the ED at recovery, back-entry of information into ORCHID will be the responsibility of the personnel on the units caring for them at that time.

Medication documentation after recovery

• For all patients who are still in the ED or were admitted at the end of downtime, pharmacy will back-enter all medications orders placed during downtime. For patients who were discharged during the downtime, pharmacy will enter only narcotic medications. Bedside nurses will chart the administration of these medications on their patients based on the written record.