1. SIMS FILE PUSH-OCT 2013 File push to occur weekend of October 20 – New template to address high volume/rapid turnover (RAPID TEMPLATE) – “GA-Anesthesia Standard” template changes – Refresh my memory

2. Rapid Template Rapid Template designed to accommodate high volume rooms at the Riverside Campus (cysto, D&C, Litho) ONLY Features include: – No need to complete formal Preop Assessment using Preop Manager – Default template includes most commonly administered drugs – Customized Event Sets – Customized Icons

3. Using the RAPID Template Launch Anesthesia Manager Select Patient as per usual fashion Use pull down menu on ADT screen to select the RAPID Template Should you accidentally launch the incorrect template, simply TRANSFER your patient back to the network and start from the beginning

4. RAPID Template-HOME Screen

5. SYSTEM Icons-NO CHANGES* *addition of anesthesia WIKI to all templates discussed later in ppt

6. CUSTOM ICONS-Modified

7. CUSTOM ICON-PIT This ICON will place an “O” on the timeline and add the following text to the Events: “Oxytocin 20u/L added to IV Fluid (O)”

8. CUSTOM ICON-END GA This ICON will place an “g” on the timeline and add the following text to the Events: Oropharynx suctioned as required Adequate spontaneous ventilation resumed Opens eyes to verbal stimulation OR exhibiting purposeful movement Airway device, (ETT/LMA), if present, *removed, ventilating well End General (g) Italics denote changes from “Anesthesia Standard”

9. CUSTOM ICON-ZZZ This ICON will place an “g” on the timeline and add the following text to the Events: Oropharynx suctioned as required Adequate spontaneous ventilation resumed Airway device (ETT/LMA), if present, *left in situ Italics denote changes from “Anesthesia Standard” this icon can be used when taking a patient to the PACU who has not emerged from GA

10. MEDICATIONS-Default New Medications: Ketamine mg Ketorolac mg Lidocaine PF (Pain) mg/kg Remifentanil mcg

11. FLUIDS-Default New infusions: Lidocaine 1% PF (PAIN) mg/h Remifentanil 0-1 mcg/kg/min Ketamine (GA) mg/h Propofol mcg/kg/min

12. EVENT SETS-Modified 3 new Event Sets added: A!01_Rapid Preop Eval A!05_Rapid GA A!10_Rapid MAC Remainder of Event Sets stripped down

13. EVENT SET A!01_RAPID Preoperative Evaluation takes the place of Preop Manager – Review of Systems (Events) relating to procedures specific to the RAPID template – Review of Systems (Events) relating to CVS and Resp system

14. EVENT SET A!01_RAPID Preoperative Evaluation takes the place of Preop Manager – Review of Systems (Events) relating to GI/End/Haem system – Physical Exam (Events) related to the Airway

15. EVENT SET A!01_RAPID Preoperative Evaluation takes the place of Preop Manager – Physical Exam (Events) related to the CVS/Resp systems – Relevant lab, Meds, Allergies, NPO status – Anesthetic Plan

16. A!05_RAPID GA Highlighted events are new

17. A!05_RAPID GA Highlighted events are new

18. A!10_RAPID MAC Highlighted events are new

19. Anesthesia Standard Template Changes The push of the RAPID TEMPLATE has given us the opportunity to incorporate changes to the “Anesthesia Standard” template I am happy to report that we have recently established a SIMS Committee. This Committee will: – meet on a quarterly basis – Is multidisciplinary in representation (IT/Nursing/Anesthesia) Anesthesia Reps: Zunder, Jee, Bryson, Pysyk – will facilitate improvements and upgrades in a timely fashion

20. “GA-Anesthesia Standard” Template Changes Eliminating subheadings General fixes to various event sets Anesthesia WIKI WRONG PATIENT protocol and documentation Preop Manager pull down for Meds/Allergies Preop Manager-addition of “HER” pathway to Alerts Artifact Rejection Surgeon NOT requesting antibiotics Addition of Albumin 5% to database/protocols Documenting on the INCORRECT patient

21. Subheadings Originally programmed as ON by default, we realize they take up precious screen real estate New Default Setting is OFF All meds and fluids to be listed alphabetically

22. General Fixes-Event Sets A001_Anesthesia Type (M)_Monitored Anesthesia Care-Deep Sedation – added in at request of Business Groups to reflect changes to the MOHLTC Schedule of Benefits

23. General Fixes-Event Sets A005_PACU-SDCU-ICU Report Reminder by QPS Committee to submit a PSLS Report should you answer YES to: “Periop Adverse Event/Near Miss:

24. General Fixes-Event Sets A011_Basic GA Steep Trendelenberg (Position Checks q1h) – Added at request of QPS Committee Trend/Rev Trend Angle – Added in at request of QPS Committee Upper arm Krauss armrest – Position in Event Set changed

25. General Fixes-Event Sets A012_Basic Spinal Please REMEMBER to chart SPINAL Drug Dosage in Medications – Added in as a reminder to document as audit committees have noted absence of spinal med doses

26. General Fixes-Event Sets A013_Basic MAC Same options added to this event set similar to – Basic GA – Basic MAC

27. General Fixes-Event Sets A066_Regional Upper Limb Local anesthetic thru needle – Typo corrected (used to say “catheter”

28. General Fixes-Event Sets A150_Thoracic GA-DLETT Eschmann Stylet (Bougie) – Position in Event Set changed

29. Anesthesia WIKI Displays all Educational/Update Material Relevant to SIMS http://wiki.med.uottawa.ca/display/WIKITHESIA/SIMS+Reference

30. Preop Manager New Med/Med Allergies “pull down” list Will contain ~80 of the most commonly prescribed medications. The generic name is in brackets and follows the common trade name of the drug The list is organized alphabetically by generic name Please forward any suggestions for further additions to the list A similar “pull down” will be created for the most common Allergies. Hopefully, this will facilitate creation of a more comprehensive consult rather than having to look at Med Rec sheets (paper or electronic). We have no control over Nursing who will continue to use the “Med Rec” solution. However, residents should be encouraged to use the “drop down” menu for their “in patient” consultations. Staff/Residents/Fellows should be encouraged to use the “drop down” menu for Preop Assessments completed on the day of surgery.

31. Acetaminophen Tylenol with Codeine (Acetamnophen Combo) Tylenol #3 Cordarone (Amiodarone) Amitryptiline (Amitryptiline) Norvasc (Amlodipine) Atenolol (Atenolol) Lipitor (Atorvastatin) Monocor (Bisoprolol) Pulmicort Turbohaler (Budesonide) Atacand (Candesartan) Captopril (Captopril) Tegretol (Carbamazepine) Celebrex (Celecoxib) Celexa (Citalopram) Plavix (Clopidogrel) Pradaxa (Dabigatran Etexilate) Dexamethasone (Dexamethasone) Valium (Diazepam) Diclofenac (Diclofenac) Digoxin (Digoxin) Diltiazem (Diltiazem) Vasotec (Enalapril) Nexium (Esomeprazole) Pepsid (Famotidine) Fentanyl Citrate (Fentanyl) Proscar (Finasteride) Symbicort (Formorterol) Flovent Diskus (Fluticasone) Monopril (Fosinopril) Lasix (Furosemide) Glyburide (Glibenclamide) Nitro Dur (Glyceryl Trinitrate) Hydrochlorothiazide (Hydrochlorothiazide) Hydromorphone IR (Hydromorphone) Hydromorphone Contin CR CAP (Hydromorphone) Ibuprofen (Ibuprofen) Indemathacin (Indamethacin) Atrovent HFA (Ipatropium Bromide) Avapro (Irbesartan) Trandate (Labetalol) Prevacid (Lansoprazole) Synthroid (Levothyroxine Sodium) Prinivil (Lisinopril) Ativan (Lorazepam) Mevacor (Lovastatin) Metformin (Metformin) Metoprolol (Metoprolol) Morphine Sulphate (Morphine) MS Contin (Morphine) M Eslon (Morphine) Singulair (Montelukast) Naproxen (Naproxen) Trasderm Nitro (Glyceryl Trinitrate) Nortriptyline (Nortriptyline) Zyprexa (Olanzapine) PMS Oxycodone Oxycontin (Oxycodone) Dilantin (Phenytoin) Potassium Chloride Predisone (Prednisone) Seroquel (Quetiapine) Altace (Ramipril) Zantac (Ranitidine) Xarelto (Rivaroxaban) Crestor (Rosuvastatin) Ventolin (Salbutamol) Advair (Salmeterol) Serevent (Salmeterol) Zoloft (Sertraline) Zocor (Simvastatin) Flomax (Tamsulosin) Bricanyl Turbohaler……(Terbutaline) Spiriva (Tiotropium Bromide) Tridural (Tramadol) Verapamil Hydrochloride (Verapamil) Coumadin tab (Warfarin) Preop Manager New Medication pull down list

32. Preop Manager Addition of HER Pathway Added at request of PAU to reflect patients that may be eligible for “HER”

33. Artifact Rejection In order to prevent spurious results from being imported into SIMS, artifact rejection as described will be incorporated for – Invasive Blood Pressure – Heart Rate – Temperature

34. Surgeon NOT requesting antibiotics The absence of an antibiotic dose in the SIMS database may be interpreted as failure to administer when in fact, the drug is specifically NOT requested by the surgeon during the Preop pause. In order to capture the request NOT to administer, please place a 0 for dose under Cefazolin

35. 5% Albumin As a result of concerns related to HES, a request has been made to add 5% albumin to the database “*Anes_Fluids In” protocol has been updated

36. Documenting on WRONG PATIENT protocol In order to prevent confusion, we’ve come up with ONLY two options. The appropriate choice will be determined by two main factors: – How long have you been documenting on the INCORRECT patient? – Is there ample time to document on the CORRECT patient? We have created a new event set titled, “A235_Incorrect Patient”. Please follow the steps and complete the required fields for the option that has been chosen. – Please refer to the Anesthesia WIKI for more detailed informationAnesthesia WIKI

37. Documenting on WRONG PATIENT protocol

38. No more paper PAU Pre-assessments accompanying chart use hallway PC’s and launch either – vOACIS – Preop Manager NO MORE PAPER

39. Refresher Points How can I minimize EKG artifact? How can I eliminate white space on the monitor Documentation of Demographics in Satellite areas Printout Start/Stop times Remote View IV tips OR Corridor computers to access Preop Manager/vOACIS

40. EKG artifact SIMS obtains HR information from the EKG. Interference creates multiple artifacts that are recorded

41. EKG artifact To eliminate artifact, change the HR source from AUTO to Pleth

42. EKG artifact Atrial Fib-HR Source AUTOPDF in vOACIS

43. EKG artifact Atrial Fib-HR Source PLETH PDF in vOACIS

44. Eliminating blank spaces

45. Right click anywhere in the “Real Time Variables”

46. Eliminating blank spaces Highlight the variables (Ctrl-Click) that you do not wish to display and hit <<Remove

47. Eliminating blank spaces Blanks spaces have now disappeared. NB. All MEASURED variables are CAPTURED, PRINTED and ARCHIVED. What you see on the screen is ONLY what you choose to VIEW.

48. Documenting DEMOGRAPHICS in satellite areas In Satellite areas, it is OUR responsibility to add in the Medical Team (surgeon is not populated as in the Main OR) and the Procedure (not populated as in the Main OR). There should be a cheat sheet in these various areas which lists the most popular procedures and the keywords used to find them.

49. Documenting DEMOGRAPHICS in satellite areas Cheat Sheet-Labor and DeliveryCheat Sheet-Diagnostic Imaging

50. Documenting DEMOGRAPHICS in satellite areas Cheat Sheet-UltrasoundCheat Sheet-Endoscopy Suite

51. Documenting DEMOGRAPHICS in satellite areas Cheat Sheet-Dental Clinic

52. Printout Start/Stop times In the above list of “Events”, notice how the “Anesthesia Case Start (S) is at 07:30 and the next documented anesthesia event-”GE Health Care Aestiva machine #:” is at 07:39

53. Printout Start/Stop times 1 1. Start time in print spool changed to 08:00

54. Printout Start/Stop times ? All descriptors entered before 08:00- preoperative events and machine check are not printed to the pdf

55. Printout Start/Stop times Anesthesia Start Time at 07:30 is time stamped on the record regardless of the start time in the print spool First event other than anesthesia start is recorded at 07:39

56. Printout Start/Stop times 1 3 2 1.Hitting the printer icon will bring up the print spool so you can adjust time 2.Enter in the first anesthesia event 3.Enter in the last anesthesia event 4.Upload to vOACIS 4

57. Printout Start/Stop times Notice how 07:30 anesthesia stamp is included even though the print spool was set to 07:39 Notice how the all events relative to the Preoperative Evaluation and Equipment check are now included

58. Remote View Check in on ANY patient in the SIMS system last patient on your list now in the PACU electronic record from a previous surgical procedure(s)

59. 1.Pull down Census Type to pick “Surgery patients-Today” 2.Find your patient from the OR list or Enter MRN of patient if procedure on different date 3.Hit Remote View 1 2 3

60. 1.You are now looking at a patient in “Remote View” (notice white banner at top) 2.Timeline shows patient in the GA (PACU) Postop and GA (Surgical Post-op) sessions 1 2 2

61. Remote View-Nursing assessments Scan to see how your patient is doing with regard to pain, nausea/vomiting, etc.

62. IV tips Multiple IV’s-same fluid Click on “fluid order”Notice default is IV

63. IV tips Multiple IV’s-same fluid Use slider to choose IV Site Roll mouse over order- location of IV is now identified

64. IV tips Patient arrives with IV (less than full bag) Patient arrives to Operating room with an IV running-only 350 ml. left in bag Bag is completed and you go to hang a new bag. The system assumes the NEW bag is similar in volume to the previous bag-350 ml.

65. IV tips Patient arrives with IV (less than full bag) You need to change the volume to reflect what is in the new bag, typically 1000 ml.

66. IV tips-”Undoing” an IV Fluid You recognize that you intended to start a 1L bag rather than a 350 ml bag. You click on the “350”  dialogue box appears Hit “Undo” and you get the following message

67. IV tips-”Undoing” an IV Fluid Reason for “error” message is because there has been activity on the 350 NS (in this case, a bag level) In order to eliminate the fluid order, you will need to “Undo” all changes made to the order from current time back to start time.

68. IV tips-”Undoing” an IV Fluid Notice how the “bag level” is now gone. Now, click on the start of the order and UNDO

69. IV tips-”Undoing” an IV Fluid The fluid order has now been deleted