1. How do I chart … The Basic and Essential Anesthesia Data?

2. The Basic and Essential Anesthesia Data The College of Physicians & Surgeons of Ontario uses the Anesthesia Peer Assessment Form to set the minimum standard for Anesthesia record-keeping. (Click to view the various sections of the form) Whether using paper or electronic records, we need to be sure we meet and exceed this minimum standard. Over the years the paper record has evolved to include many “prompts” to remind us about data entry. We are comfortable with the paper record and have developed efficient ways of completing it. The electronic record has strengths and weaknesses. No more mind-numbing vital sign data entry! The challenge is to develop new workflow patterns for data entry to make the e-record more complete than the paper record ever was or could be. Here

3. The Basic and Essential Anesthesia Data The MacroBar – WorkFlow Signposts Marker: Anesthesia Case Start (OHIP billing) Marker: Equipment Check Marker / Reminder: Patient Assessment Reminder: Assign ASA Level / Medical Team / Pt Wt-Height Marker: Regional Anesthesia Start Marker: General Anesthesia Start Marker: Monitored Anesthesia Care Start Marker: Antibiotics–First Dose / Start Timer Marker: End of Surgery / Confirm Procedure Reminder: Fluid Balance / Final IV Bag Levels Marker: End of GA / Emergence Events Action: Transfer to PACU /SDCU / ICU Action: Discharge to non-SIMS unit – nurses do NOT use SIMS (e.g. ICU/Endo Suite/Brachy Unit) Reminder: Transfer of Care Note Marker: Anesthesia Case Finish Marker: places a symbol on the timeline Reminder: you need to chart something

4. The Basic and Essential Anesthesia Data When the Anesthetist turns on the anesthesia machine, the SIMS computer turns on automatically. The SIMS computer will Auto-Logon – you do not log into Windows with your TOH password. Double-click the icon for SIMS-Perioperative Manager and when prompted, logon with your SIMS password. You will now see the Census List with the patients listed: Surgery-Today The ORs are listed in numerical order – Your patients are listed in your OR alphabetically, not by time! Step 1: Get Anesthesia Manager OPEN Click Here for more Help on opening Anesthesia Mgr

5. The Basic and Essential Anesthesia Data Find and highlight with a Left-Click of the mouse, your first or next patient’s name Click on the “START SESSION” button Some important concepts: - the whole patient record for the surgery – from SDA or SDCU to the OR to PACU – is an ENCOUNTER - the patient’s admission in SDA/SDCU is a SESSION - to move from SDA/SDCU to the OR, the patient must go through the TRANSFER zone - to move the patient into the OR (and start charting) you must pick up the patient from Transfer and START A NEW SESSION - patient leaves the OR for PACU => into TRANSFER Step 2: Start the Anesthesia Manager SESSION

6. The Basic and Essential Anesthesia Data Click Here for Help on Navigating Anesthesia Mgr For more detailed information, take the Grand Tour…. Click Here for Help on Real-Time Variables

7. The Basic and Essential Anesthesia Data Step 3: Insert the Anesthesia Case START event (flag = S) Macro Bar for workflow Chevrons show when AM started running this session Yellow column is current time Left-Click the mouse on the START Macro button Click Button to enter Start Case time

8. The Basic and Essential Anesthesia Data Edit Event dialog appears – either accept the current time shown or edit the time. We will change it to 20:50 and click OK After clicking on the START button: The Button is depressed TimeBox 20:50 shows the flag symbol “S” From the moment Anesthesia Manager is open, it is fully operational and will capture any Vital Signs which appear on the monitor or any action by the ventilator. By clicking the Anesthesia Start macro button, you have set the time for when you started the case. (for tracking purposes) Note: You can set the Start Flag to before AM started – it is very important to remember this when it comes to print

9. The Basic and Essential Anesthesia Data Step 4: Chart the Equipment Check (flag = C) Click on the Equip Check button All these Equip Events are entered with one Click! Time is edited to 20:55 Note: Gas Machine # left blank After clicking on the EQUIPMENT CHECK button: Equip Check button is depressed TimeBox 20:55 shows symbol “C”

10. The Basic and Essential Anesthesia Data To enter the Gas Machine # you need to display the Events Log – click its icon on the ToolBar Below is shown the Events Log with all the Events so far. To add a Comment you need to EDIT the Event: Highlight by a mouse click and click Edit or – Double-click the Event

11. The Basic and Essential Anesthesia Data [TAB] from the Time field or mouse click to the Comment box; Enter the Gas Machine # Then [TAB] again to the the [OK] button and hit [ENTER] The updated Events Log now shows the Gas Machine # in the Comment column

12. The Basic and Essential Anesthesia Data At this point you have everything ready to proceed with your anesthetic case. When you choose to document will be determined by your personal choice and workhabits. The WorkFlow buttons on the MacroBar are designed to drop Bookmarks (Flags) on the TimeLine at the various stages of your case. When it is convenient, you return to these TimeBoxes with the Flags and complete the chart.

13. The Basic and Essential Anesthesia Data Step 5: Documenting your Assessment of the Patient 1.More than likely, your patient has had a recent visit to the PAU and an MD Assessment is available in Preop Manager, but done by someone else. 2.The Patient may have been assessed in the PAU or SDCU by the Nurse only and the MD Assessment needs to be done 3.The Patient has not been seen in the PAU or SDCU; no RN or MD Assessment has been done e.g. inpatient from ward The following scenarios are possible: What needs to be done? 1.Check vOacis: Review the PAU visit MD Assessment – OR- 2.Complete a new MD Assessment in Preop Manager The person giving the anesthetic must document his/her own medical assessment of the patient.

14. The Basic and Essential Anesthesia Data Step 5: Documenting your Assessment of the Patient If vOacis has a recent Preop Manager Assessment complete with an MD Assessment done by someone else: (either a PAU visit or a ward/ER Consultation) - You need to document your own preop assessment in Anesthesia Mgr – using the Preop Evaluation eventset If vOacis has a recent Preop Manager Assessment without an MD Assessment (i.e Nurse Assess only): -You need to document your own preop assessment as an MD Assessment in Preop Mgr – select the patient from the “Surgery Today” census list -Preop Mgr may have the MD Assess section “locked” - use the Addendum section in this case If vOacis has no recent Preop Manager Assessment: -You need to document your own preop assessment as an MD Assessment in Preop Mgr – select the patient from the “Surgery Today” census list

15. The Basic and Essential Anesthesia Data Step 5: Documenting your Assessment of the Patient in Anesthesia Manager Click on the “Pt Assess” button on the MacroBar and edit the dialog Time field if needed The symbol “P” appears as a Flag on the TimeLine at the selected time The “Add Events” window pops up: 1. Select EventSet “A010_Preop Evaluation” 2. Check the Time field - edit if needed Pt Assess button Click Here to Select

16. The Basic and Essential Anesthesia Data Step 5: Documenting your Assessment of the Patient Click on each Event as appropriate Using the Event Set A010_Preop Evaluation, select events to document what you assessed Bring the selected Events over to the right- hand panel, enter any Comments required and then click [OK] We recommend that a brief medical problem list be entered as an Anesth History comment

17. The Basic and Essential Anesthesia Data Step 6: Chart the ASA Level and the Medical Team Strictly speaking, the ASA level goes with Preop Assessment. Anesthesia Manager has placed it in a grouping called: DEMOGRAPHICS We have a single Macro button called ASA/Team which will remind you to open up the Demographics window. It’s up to you to remember to enter both items!

18. The Basic and Essential Anesthesia Data Step 6: Chart the ASA Level and the Medical Team Clicking on ASA Level brings up the selection box Use the drop-down box or hit the keyboard [DOWN ARROW] repeatedly until the desired ASA Level is highlighted Click this small arrow to reveal the drop-down

19. The Basic and Essential Anesthesia Data Step 6: Chart the ASA Level and the Medical Team This window pops up when Medical Team is clicked When you click in the empty Anesthesiologist box a drop-down of names appears. Although you can select with the mouse by scrolling down the list, using the keyboard is faster. Tip: Remember the keystrokes for the next time To select Elliott: -Jump to the start of the “E” names by typing the letter “E” -Either use the [DOWN] arrow key or the [PgDn] key to reach the name and hit [ENTER] Use mouse to move to a different box Don’t forget to enter the rest of the Team!

20. The Basic and Essential Anesthesia Data Step 6: Chart the ASA Level and the Medical Team Once the ASA/Team button has been used, it will appear depressed in the MacroBar. If you need to see Demographics again, use the Demographics button at the bottom of the ToolBar

21. The Basic and Essential Anesthesia Data Click Here (may be a long way down) An alternate way to access the sections in Demographics Click Here to return to Flowsheets

22. The Basic and Essential Anesthesia Data This is also a good time to enter the patient’s weight. Unfortunately, you will need to remember the weight from the Preop Assessment to then enter it. Entering the Weight here will be useful later when you use drug infusions based on weight. The weight will show up automatically when the drug infusion window opens.

23. The Basic and Essential Anesthesia Data Step 7: Bookmark on the TimeLine when Anesthetic Technique begins TechniqueTimeLine Flag Symbol RegionalR GeneralG Monitored CareM MacroBar Workflow This case is a combined Spinal and General – both RA and GA buttons have been pressed Flag Symbol “R” for Regional Technique Flag Symbol “G” for General Technique

24. The Basic and Essential Anesthesia Data Step 7: Bookmark on the TimeLine when Anesthetic Technique begins Hovering the mouse over the Anesthetic Technique buttons shows Events which will be entered automatically for you The Regional, General and MAC Start buttons register a Reminder Event only - you need to specify the Anesthesia Type when you document the events In most cases, once your patient’s surgery is under way, then you will return to the Bookmark to document.

25. The Basic and Essential Anesthesia Data Step 8: Return to the “R”, “G” or “M” Technique Symbol => Document Events Click in the TimeBox with the Symbol “G” to bring up the Add Events window In most GA cases you can use the Basic GA event set Correct time already entered

26. The Basic and Essential Anesthesia Data Step 8: “R”, “G” or “M” Symbol => Document Events Note the “Must Do” – You need to select the Anesthesia Type. The Basic GA Set has (G)_General Anesthesia built-in, ready to select. A complete list of the Anesthesia Types is in Event Set A001 These are Reminders – Don’t select! Organized into Sections with a note for full list

27. The Basic and Essential Anesthesia Data Step 8: “R”, “G” or “M” Symbol => Document Events The Sections provided are: - IV Lines - Airway Management - Ventilation - Patient Position - Eyes - Add Equipment - Transport/End Activity This Basic GA event set gives you the most commonly used items/events that you will need. With everything in one list, you will be less likely to forget to document something. Each Section has its own, more detailed, list of choices for those more specialized cases.

28. The Basic and Essential Anesthesia Data Step 9: Document Anesthetic Technique Events General Anesthesia In many cases the “Basic GA” Event Set contains all the events needed. More detailed Event Sets are available: A050 – ETT (oral) A052 – ETT (nasal) A054 – LMA A056 – FOB Intubation A058 – AW Complic’ns and… A150 – Thoracic SL ETT A152 – Lung Isol’n DL ETT

29. The Basic and Essential Anesthesia Data Step 9: Document Anesthetic Technique Events Regional Anesthesia The“Basic Spinal” Event Set contains the events commonly needed for Spinal Anesthesia. Other Event Sets include: A060 – Reg’l Block Types A062 – Epidural Block A064 – Spinal Block A066 – Upper Limb Blocks A068 – Lower Limb Blocks A070 – IV Reg’l (Bier) Blk A072 – Head&Neck, Trunk

30. The Basic and Essential Anesthesia Data Step 9: Document Anesthetic Technique Events Monitored Anesthesia Care The“Basic MAC” Event Set contains the events commonly needed. Other Event Sets include: A014 – Basic Eye A080 – Anes-MAC A190 – Eye Care Centre A192 – Eye Institute

31. The Basic and Essential Anesthesia Data Step 9: Document Anesthetic Technique Events More detailed descriptions about Technique-specific Events are available: GA – Oral ETTSpinal AnesthesiaEpidural Anesthesia A detailed tutorial about documenting Events is available: Documenting Events

32. The Basic and Essential Anesthesia Data Step 10: Document Fluids IN / OUT The Flowsheet “Med Infusions & Fluids” has it all… (The Anesthesia Summary Flowsheet can also be used) “Fluids IN” refers to not only typical IV Fluids and Blood Products but also IV Med Infusions (see Propofol above).

33. The Basic and Essential Anesthesia Data Step 10: Document Fluids IN / OUT There are many tasks to be done related to Fluid Management: - starting an IV solution bag using gravity feed - running an IV on an infusion pump - documenting a “bag level” - finishing and starting a new bag - interrupting one solution to run another - discontinuing (stopping) an IV solution - tracking urine output / blood loss Tutorials regarding Fluids are available: Intro to IV FluidsDetailed Fluids IN/OUT

34. The Basic and Essential Anesthesia Data Step 10: Document Fluids IN / OUT It is helpful to keep the tally of Fluids IN / OUT up-to-date at regular intervals. Near the end of the case, you will want to do the final “Bag Levels” so that the calculated Fluid Balance will be accurate. Bag Level Button is a Reminder Pops up Fluid Balance window Opens Fluid Balance window Click on this Button to get a detailed breakdown of the Fluids given

35. The Basic and Essential Anesthesia Data Step 11: Document Medications A detailed tutorial about documenting Medications is available: Documenting Meds Documenting Medications is one of the central activities in recording an anesthetic. - AM opens with a “default” list of drugs - drugs are either given by “bolus” or “infusion” - drugs not found in the default list need to be Added - doses can be Entered, Modified or Deleted - drugs can be Discontinued - a running tally of drug dosages given is shown in a Summary

36. The Basic and Essential Anesthesia Data Step 11: Document Medications The way Anesth Mgr handles Medications is a bit odd. Older versions supported Meds in two ways: - bolus doses = Medication Flowsheet - infusions (called “drips”) = Fluids Flowsheet Later versions added Combination Meds: - both bolus & infusions = Medication Flowsheet It would be better if ALL infusions were together on the Medication Flowsheet.

37. The Basic and Essential Anesthesia Data Step 11: Document Medications The Default drug list in the Medications Flowsheet is a mix of single drugs and combos. Medications can be Bolus or Infusions (look for /min or /h) Medications can be Single Drug or Combinations (look for multi-line white box when 2 or more drugs) Combo Bolus with preset doses Single Drug Bolus - row highlighted Combo Infusion - rates to be entered

38. The Basic and Essential Anesthesia Data Step 11: Document Medications As an example, let’s use Propofol without any Lido mixed in. The default list of drugs has plain Propofol as a bolus but the infusion is a combo of Propofol + Lido. We need to add a plain Propofol infusion. If we go to the Fluids Flowsheet, Propofol is listed under Other IVF. But if you hover the mouse over the Propofol listed, you see it is actually the P+L combo. AM displays the drug masses of combos in Medications but shows the drug volumes in Fluids.

39. The Basic and Essential Anesthesia Data Step 11: Document Medications To add the “old-style” drip Propofol, move the mouse pointer over the heading Fluids IN and when the finger appears, left-click. A windows pops up for you to add a “Fluid” - in this case, chose the Family called “General Anesthetic” and then see what “Treatments” are available. We want Propofol in mcg/kg/min Click on [Add] and then [Cancel] Update: We have standardized Propofol infusions to mg/kg/min

40. The Basic and Essential Anesthesia Data Step 11: Document Medications A Med Infusion (“drip”) shows up in Green under a new heading for General Anesthetic By default the drug is displayed by “Dose only” By right-clicking, you can choose to see both Volume and Dose Now you can see the pump rate on one line and the dose on a 2 nd line This looks good but the Propofol bolus and infusion are on different Flowsheets!

41. The Basic and Essential Anesthesia Data Step 11: Document Medications An easy way to select Medications not listed when Anesthesia opens is to use the Protocol Button. A major advantage to Protocols is that we can list bolus and infusions, both single drug and combos, all in the same place. This is Bolus Propofol + Lido These are Infusions (/min) The Combo icon shows a “+” with a pill bottle Update: To avoid confusion on the Summary PrintOuts, most 1-drug infusions (e.g. Vasopressors) will use the older “Fluid Drip” technique until Picis can correct how the combo infusions are represented

42. The Basic and Essential Anesthesia Data Step 11: Document Medications When we Add Propofol as a 1-drug combo infusion, this is what shows up in AM under Medications: Now Propofol (plain) bolus and infusion are together This is what we see when we add some doses on the Medication Flowsheet: When we switch to the Fluids Flowsheet, the pump rate is entered automatically: This looks perfect on screen within AM but on a printout the rate is NOT shown; instead you see the mass of drug given per time column. We hope Picis can correct this soon.

43. The Basic and Essential Anesthesia Data Step 11: Document Medications - Antibiotics The Antibiotic First Dose button pops up a time window, then puts an “A” on the timeline and starts a Timer (counts up) When you have the time later, enter the antibiotic in the time column with the symbol “A” If it’s Cefazolin, it’s easy – it’s a default drug. Otherwise you will need to Add the antibiotic first. Two choices: 1. Use the Protocols – Anes-Antibiotics list 12 common ones 2. Click on Anti-Infectives on the Med Flowsheet (this will list every antibiotic on TOH formulary! Shortcut – type a few letters e.g. “v” pops up vancomycin)

44. The Basic and Essential Anesthesia Data Step 12: End of Surgery / Update Procedure With the last few stitches, mark the End of Surgery with the “End S” button The Demographics window pops up and you need to check the listed Procedure and update if necessary. (This is important in Remote Locations – procedure will NOT be there automatically)

45. The Basic and Essential Anesthesia Data Step 12: End of Surgery / Update Procedure Take a look at the Required Events box below The only events left are: 1.Finish Time 2. QA Indicator All the others have at least one entry

46. The Basic and Essential Anesthesia Data Step 13: Fluid Balance – Enter IV Bag Levels Enter IV Bag / Blood Bag levels Also Update Urine Output and Estimated Blood Loss Check in Fluid Balance window – updates dynamically as you enter data. Step 14: Mark End of General Anesthesia (g) The End GA button places the letter (g) on the TimeLine for you and automatically enters a group of events appropriate for the end of a typical GA. If there are discrepancies with what you want to record, you will need to edit these events in PACU

47. The Basic and Essential Anesthesia Data Step 15: Transfer to PACU / SDCU The green PACU-SDCU-ICU button begins a Transfer of the patient into the “Transfer Zone”. It is essential that your patient be “transferred” or else the PACU/SDCU will not be able to retrieve your patient’s record! You will be shown the Demographics screen one more time, in case something missing had slipped your notice.

48. The Basic and Essential Anesthesia Data Step 15: Transfer to PACU / SDCU Click [Transfer] to proceed. If you realize you forgot to chart something click [Cancel]

49. The Basic and Essential Anesthesia Data Step 16: Documentation in PACU / SDCU Open the Patient in Remote View: Important tip: The patient must have been admitted into PACU or SDCU if you want to document in Remote View.

50. The Basic and Essential Anesthesia Data Step 16: Documentation in PACU / SDCU Patient in Remote View – note White ID band: Use the Report button to open Add Events and use A005_PACU-SDCU-ICU Report to document QA Indicator & Transfer of Care The Click on the Finish button to enter the Anesthesia Case Finish time

51. The Basic and Essential Anesthesia Data Step 17: Print the Anesthesia Record to vOACIS While in Remote View, after the Finish button, the Print Anesthesia Record pops up: Make sure to choose the Anesthesia record You need to enter the Anesthesia Start time which probably is not the same as the time you opened the session. You need to look up the Anesthesia Start time before you click on the Finish button! The Start & End times for data to print shown here are for the PACU session

52. The Basic and Essential Anesthesia Data Step 17: Print the Anesthesia Record to vOACIS The Anesthesia Session times are now shown. We need to add the time in PACU until Case Finish Time if we want to include the Transfer of Care events and the first few vital signs captured in PACU. 21:10 was the End of the Anesthesia Session. The Case Finish time in PACU needs to be entered here: 21:16

53. The Basic and Essential Anesthesia Data Alternate Steps 16 & 17: Patients who DO NOT GO to PACU / SDCU If your Patient is in a Remote Location and will not be going to PACU – you need to change the end sequence a little. You need to complete the Report and Finish Time BEFORE: 1.Clicking on the X-SIMS (Discharge) Button 2.Leaving your OR You will need to Enter an estimated Finish Time and use that time when printing the Anesthesia Record

54. The Basic and Essential Anesthesia Data Alternate Steps 16 & 17: Patients who DO NOT GO to PACU / SDCU This is the DISCHARGE window. Be very careful… You cannot UNDO a Discharge! Remember: Discharge is for Patients who will not be going to the main PACU or SDCU For ICU Patients, you will Transfer first, then start a session on the ICU computer, enter reports – then Discharge

55. The Basic and Essential Anesthesia Data Your Electronic Anesthesia Record is now