# Presentation: 392818

## #226 – Consults:  Kill or Be Killed

**Harold D. Bonds, MT (ASCP) SC**
- G. V. Montgomery VAMC
- Jackson, Mississippi
**Sheri Kreuz, RD, MBA**
- SDS, Clin2 Team
- Salt Lake City OIFO
- Additional Information provided by:
**	****       ****Pamela Johnson****	****      Mary Montufar****	****     Ann Narciso**
- 	Clinical Applications Coordinator	Clinical Applications Coordinator	Clinical Applications Coordinator
- 	Richmond VAMC		Palo Alto VAMC		Palo Alto VAMC

## #226 – Consults:  Kill or Be Killed

**Goals:**
- Identify uses of the Consult Tracking Package
- Administrative Use for Lodger/Hoptel Services
- Disease Management for improving patient outcomes.
- Scheduling-Consult Package linkage issues
- Go over current Remedy Tickets
- Provide feedback from sites using the linkage
- Survival:  Don’t be Killed by Consults
- Consult Monitoring Strategies

## #226 – Consults:  Kill or Be Killed

- LEARNING OBJECTIVES:
**1. Distinguish unique innovations within consult package**
**2. Evaluate for application at any site**
**3. Discuss lessons learned related to Consult/Scheduling interface**
**4. Discuss Consult Monitoring Strategies**

## #226 – Consults:  Kill or Be Killed

**Utilizing the Consult Tracking Package for Tracking Hoptel Resources**
**Harold D. Bonds, MT (ASCP) SC**

## #226 – Consults:  Kill or Be Killed

**Goals: **
- Provide control over the Hoptel bed program availability, budget, and staffing.
- Provide a mechanism for tracking Hoptel services availability, budget and staffing by data management.
- Create a process for approval of Hoptel service utilization electronically within the patient record using a team approach.

## #226 – Consults:  Kill or Be Killed

**Objective:** Better utilization of the Hoptel bed resources for availability, tracking, and cost containment using the Quality Management process for performance improvement of Plan, Study (Do), Check Act.

## #226 – Consults:  Kill or Be Killed

- Plan:
- Formulate a process to achieve the goals of Hoptel bed program availability, budget, and staffing by utilizing the Consult Package along with the Text Integration Utilities and Scheduling Packages.

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

- Create a consult request in CPRS for the Hoptel program with required information in a template format for requesting a patient be considered for the Hoptel program.

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

- Create a progress note for answering the Hoptel consult that is blank in the Text Integration Package.  (accomplished on 12/26/02)

## #226 – Consults:  Kill or Be Killed

- Create templates located in the shared templates section of CPRS for the services involved to use in answering the consult. Each service attaches an addendum to the original note for completion of the process.

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

- Create a clinic called “HOPTEL” for scheduling the patients into the Hoptel program.

**Notes:**
This will allow control over the availability of the Hoptel beds.  There are a total of eight (8) beds available within the hospital itself and ten (10) additional beds available at local motels for the Hoptel program.  The clinic will have eight (8) slots for scheduling with an overbook limit of ten (10) overbooks allowed.  This will allow for a tracking mechanism for data management, funding approval, and staffing requirements to meet the needs of the Hoptel program.  If additional beds are needed over the limit of eighteen (18), approval will be made by the Executive Leadership (Chief of Staff, Chief Executive Nurse) before assigning a bed to the patient.

## #226 – Consults:  Kill or Be Killed

- Consult template created and checked to ensure it is working properly.
- Template approved by the Chief Executive Nurse and attached to the consult.
- Quick order created for the consult.
- All components working properly.
- Teams were created for the each service.

## #226 – Consults:  Kill or Be Killed

- Progress note title created under the Consult Document Class.  Templates created for the Nursing Intravenous Access Team, Patient Information Management Service (formerly Medical Administration Service), and Social Work.  Templates and progress note checked to ensure working properly to answer the consult.

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

- Request for creation of a new clinic called “HOPTEL” submitted to MAS for creation. [Sometimes the patient is scheduled for treatment for 6-12 weeks. Appointments  to be entered each day separately.

## #226 – Consults:  Kill or Be Killed

- Set a target date for completion of the process.
- Train personnel in utilization of process.
- Memo from Chief of Staff to Medical Staff regarding how and when to request the consult.

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

- Management of Home Oxygen Patients

## #226 – Consults:  Kill or Be Killed

- Goal:
- 	Provide insight into how G. V. Montgomery VAMC manages patients on Home Oxygen through CPRS electronic documentation from the initial request through the different disciplines to the outcome of the patients.

**Notes:**
As Clinical Applications Coordinators, we are called on to be the driving force behind implementing new policies and meeting regulatory guidelines for processes within the VHA medical centers.  

## #226 – Consults:  Kill or Be Killed

- Flow Map the current process
- Initial Request (Consult) to Pulmonary Services
- Pulmonologist answers consult identifying Respiratory Therapist in Home Oxygen Service as additional signer
- Respiratory Therapists carry Home Oxygen equipment to Patient home and sets up.
- All documentation is recorded on paper (Locally created forms; not filed in Medical Record)
- Missed follow up in Pulmonary
- Prescription tracking process manually kept in MS Excel Spreadsheet
- Lack of patient compliance with policies/prescription
- Lack of Equipment tracking/usage/cost (Prosthetics Package usage)
- Patient Safety Issues

## #226 – Consults:  Kill or Be Killed

- National Leadership Board (NLB) Home Oxygen Program recommendations
- NLB Recommendation #1 - Clinical Provider Involvement
- Explain the process for requesting Home Oxygen for a patient utilizing the Consult package and the approval process by the Pulmonary Physicians
- Home Oxygen Request (Pulmonary) consult.
- Consult note duplicating the Home Oxygen consult entered by the Pulmonologist.

## #226 – Consults:  Kill or Be Killed

- National Leadership Board (NLB) Home Oxygen Program recommendations
- NLB Recommendation #1 - Clinical Provider Involvement
- Respiratory Therapist Setup and Monitoring of Home Oxygen Usage

## #226 – Consults:  Kill or Be Killed

- National Leadership Board (NLB) Home Oxygen Program recommendations
- NLB Recommendation #2 – Standardized Annual Renewal Process
- Ensure Home Oxygen Prescription is entered into the Prosthetics Package
- Run Monthly Reports for Prescription expirations
- Ensure follow up appointments for Home Oxygen patients

## #226 – Consults:  Kill or Be Killed

- National Leadership Board (NLB) Home Oxygen Program recommendations
- NLB Recommendation #3 – Monitoring Home Oxygen Patients
- CPRS documentation
- Inpatient Education for Home Oxygen use and safety

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

- National Leadership Board (NLB) Home Oxygen Program recommendations
- NLB Recommendation #3 – Monitoring Home Oxygen Patients
- CPRS documentation
- Inpatient Education for Home Oxygen use and safety
- Initial Home Oxygen Set up

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

- Create a Home Oxygen Request to be entered into the Prosthetic Package for equipment set up on patient.
- Select CONSULT MANAGEMENT OPTION
- Select COPY PROSTHETIC REQUEST
- Select HOME OXYGEN REQUEST
- Enter EQUIPMENT (RESPIRATORY) as the name to add.

## #226 – Consults:  Kill or Be Killed

- Create a dialog template to attach to the request in CPRS and attach to the request.

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

- National Leadership Board (NLB) Home Oxygen Program recommendations
- NLB Recommendation #3 – Monitoring Home Oxygen Patients
- CPRS documentation
- Inpatient Education for Home Oxygen use and safety
- Initial Home Oxygen Set up
- Follow Up Home Oxygen visits

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

- National Leadership Board (NLB) Home Oxygen Program recommendations
- NLB Recommendation #3 – Monitoring Home Oxygen Patients
- CPRS documentation
- Inpatient Education for Home Oxygen use and safety
- Initial Home Oxygen Set up
- Follow Up Home Oxygen visits
- Home Oxygen Ventilator Patients

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

- National Leadership Board (NLB) Home Oxygen Program recommendations
- NLB Recommendation #3 – Monitoring Home Oxygen Patients
- CPRS documentation
- Inpatient Education for Home Oxygen use and safety
- Initial Home Oxygen Set up
- Follow Up Home Oxygen visits
- Home Oxygen Ventilator Patients
- Home Safety Inspections

## #226 – Consults:  Kill or Be Killed

- National Leadership Board (NLB) Home Oxygen Program recommendations
- NLB Recommendation #3 – Monitoring Home Oxygen Patients
- CPRS documentation
- Inpatient Education for Home Oxygen use and safety
- Initial Home Oxygen Set up
- Follow Up Home Oxygen visits
- Home Oxygen Ventilator Patients
- Home Safety Inspections
- Home Visit Patient Safety Education

## #226 – Consults:  Kill or Be Killed

- National Leadership Board (NLB) Home Oxygen Program recommendations
- NLB Recommendations #2, 4, and 7 – Patient Compliance and Safety
- JCAHO Patient Safety Goals
- Verify all JCAHO Patient Safety Goals are met
- Document in CPRS the verification of JCAHO Patient Safety Goals

## #226 – Consults:  Kill or Be Killed

- National Leadership Board (NLB) Home Oxygen Program recommendations
- NLB Recommendations #2, 4, and 7 – Patient Compliance and Safety
- Patient declines re-evaluation
- Patient non-compliant with prescription
- Patient non-compliant with safety guidelines
- Compliance with VHA Directive 2006-021 – Reducing Fire Risks in patients with Home Oxygen
- CPRS Clinical Warning Note posting for all patients using Home Oxygen

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

- National Leadership Board (NLB) Home Oxygen Program recommendations
- NLB Recommendations #2, 4, and 7 – Patient Compliance and Safety
- Patient declines re-evaluation
- Patient non-compliant with prescription
- Patient non-compliant with safety guidelines
- Compliance with VHA Directive 2006-021 – Reducing Fire Risks in patients with Home Oxygen
- CPRS Clinical Warning Note posting for all patients using Home Oxygen
- CPRS Patient Record Flag for non-compliant patients with directive and signed agreement

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

- National Leadership Board (NLB) Home Oxygen Program recommendations
- NLB Recommendations #5 and 6
- Develop Home Oxygen Advisory Board
- Define Home Oxygen Advisory Board Membership responsibilities

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

- Policy regarding reducing/eliminating smoking with use of Home Oxygen

## #226 – Consults:  Kill or Be Killed

-  REDUCING SMOKING FIRE HAZARD WITH OXYGEN TREATMENT
- 1.   PURPOSE:  The purpose of this memorandum is to establish policy and procedure, and to provide a process for reducing the fire hazard of smoking when oxygen treatment is expected at the G. V. (Sonny) Montgomery VA Medical Center.  This guideline provides the minimum requirements for reducing the fire hazard of smoking when oxygen treatment is expected, and reinforces the VHA policy of smoking cessation and control.
- 2.   POLICY:  It is the policy of this medical center that, whenever oxygen treatment is being delivered, access to smoking materials must be restricted; patients who smoke must be offered nicotine replacement therapy or other alternatives; and all smoking must be prohibited in the vicinity of oxygen delivery equipment.
- 3.   DEFINITIONS:  High-risk Patients:  High-risk patients are patients who exhibit unsafe clinical or behavioral traits involving oxygen and smoking, such as:
-  	 - Attempting to hide their smoking materials or activities from staff;
-  	 - Having a history of non-compliance with smoking rules; or
-  	- Smoking in a patient sleeping room or other areas designed as non-smoking areas.
- 4.   RESPONSIBILITY:
-  	A.  Center Director:  Overall direction to ensure implementation and compliance with this policy, in accordance with VHA Directive 2006-021, Reducing the Fire Hazard of Smoking When Oxygen Treatment Is Expected.
-      	B.  Chief of Staff: General supervision of the clinics and wards and oversight of policy implementation as it relates to clinical staff.
-      	C.  Chief, Nursing Service, or Designee:  General supervision of the clinics and wards and oversight of policy implementation as it relates to nursing staff and the Home Oxygen Program staff.

## #226 – Consults:  Kill or Be Killed

- 	D.  Office of Quality Management:
-          	(1) Ensures appropriate tracking of reported incidents involving patients who have a close call or confirmed adverse event related to smoking.
-         	 (2) Ensures that each incident is reported to the prescribing clinician and to the appropriate committee: Home Care Advisory Board for Home Oxygen Therapy; Environment of Care Committee for any incidents occurring at the medical center.
- 	E.  Chair, Environment of Care Committee:  Ensures that appropriate tracking and action is taken as appropriate in compliance with this policy.
- 	F.  Chair, Home Care Advisory Board:  Ensures that appropriate tracking and action is taken as appropriate in compliance with this policy.
- 	G.  Respiratory Therapists:  Ensures that the patient and/or the patient's surrogate have been informed of the terms regarding safe administration of oxygen therapy when therapy is initiated and agree to comply with terms stated.
- 	H.  Facility Management Service: Ensures that signs are posted in smoking areas that oxygen is not allowed.
- 	I.  Front-Line Staff:  Reporting as appropriate all close calls and adverse events related to patients smoking while oxygen is in use.

## #226 – Consults:  Kill or Be Killed

- 5.   PROCEDURE:
-      A.  Inpatient
-          (1) In all patient care settings on the facility grounds, smoking is prohibited in patient sleeping rooms and all areas designated as non-smoking areas.
-          (2) Oxygen cylinders and other oxygen delivery equipment are not permitted within smoking shelters.
-          (3) Patients who smoke must be offered nicotine replacement therapy (e.g., patch, gum, lozenges) to treat nicotine withdrawal, or other smoking cessation intervention alternatives must be offered.  A clinical reminder will be added to the patient record to verify whether they accepted or refused. NOTE:  Guidance on nicotine replacement therapy (NRT) is available from the VHA Office of Public Health Care Group (13B) through their "Medications for Management of Tobacco Dependence." (See Attachment A)
-          (4) A fire-assessment is conducted for all new oxygen therapy inpatients who smoke, and a reassessment is conducted when renewing an oxygen prescription or at any time there is a significant change in the patient's oxygen therapy set-up (e.g., transfer to a different ward or unit).
-          (5) For those patients who are determined to be high-risk patients, a clinical interdisciplinary team reviews each case involving a high-risk patient who is prescribed oxygen in order to determine appropriate restricted environmental or clinical requirements.  The high-risk patient is assigned a sleeping room that is:
-         a. Fully equipped with Quick Response (QR) fire sprinklers;
-         b. Provided with standard response fire sprinklers and smoke detection (e. g., system or battery powered); or
-         c. Located as close to the nursing station as practical to increase the level of monitoring and supervision.

## #226 – Consults:  Kill or Be Killed

-  	(6) Patients, family members, and visitors of these high-risk patients must be instructed by staff that smoking materials may not be brought into the facility.  Family members and visitors are to be requested to acknowledge that they understand this requirement by signing a locally developed fire and oxygen hazard awareness form.  (See Attachment B)
- 	(7) All patients who fail to comply with oxygen therapy and smoking safety guidelines are referred to their clinical interdisciplinary team or the facility Ethics Consultation Service for review, as appropriate, to determine continued oxygen therapy, and how such therapy will be provided in ongoing care.  NOTE: A flag will be placed in CPRS to identify those patients who are considered high-risk patients.
-      B.  Outpatient
- 	(1) In all patient care settings on the facility grounds, smoking is prohibited in all areas designated as non-smoking areas.
- 	(2) Oxygen cylinders and other oxygen delivery equipment are not permitted within smoking shelters and signs will be posted.
- 	(3) Patients who need portable oxygen tank exchange while in the hospital must have an order placed in CPRS, requesting the tank.  (See Attachment C)

## #226 – Consults:  Kill or Be Killed

- 	(4) Patients who smoke must be offered nicotine replacement therapy (e.g., patch, gum, lozenges) to treat nicotine withdrawal, or other smoking cessation intervention alternatives must be offered.  A clinical reminder will be added to the patient record to verify rather they accepted or refused.  NOTE: Guidance on nicotine replacement therapy (NRT) is available from the VHA Office of Public Health Care Group (13B) through their "Medications for Management of Tobacco Dependence."  (See Attachment A)
- 	(5) All patients who fail to comply with oxygen therapy and smoking safety guidelines are referred to the Home Care Advisory Board for review to determine appropriateness of continued oxygen therapy, and how such therapy will be provided in ongoing care.  NOTE: A flag will be placed in our system to identify those patients who are considered high-risk patients.
-  C.  Home Care
- 	(1) A consult for Home Oxygen must be placed in CPRS by the ordering provider.
- 	(2) Upon approval of home oxygen through the Home Oxygen Consult, the Home Oxygen Respiratory Therapist will assess the patient's smoking status. If the patient smokes, the patient and/or family member must sign the No Smoking with Oxygen Contract.   (See Attachment B).
- 	(3) Patients requesting multiple oxygen exchange must have an order for multiple exchange and these must be exchanged through the Home Oxygen Program.  Patients who smoke will receive additional education prior to the exchange.
-  	(4) A fire-assessment is conducted for all new oxygen therapy patients who smoke, and a reassessment is conducted when renewing an oxygen prescription or at any time there is a significant change in the patient's oxygen therapy set-up.

## #226 – Consults:  Kill or Be Killed

- 	(5) The educational materials will be provided upon initial delivery and every six months thereafter at a minimum.
- 	(6) The patient's home environments will be assessed for smoke alarms. If no smoke alarms, the patient and/or family will be instructed to obtain a smoke alarm and place the working alarm in the home. However, if a patient or family member smokes and does not have a smoke alarm, one will be issued with instructions for utilization in the home.  Patients and family will be advised to test smoke alarm monthly.
- 	(7) Education and orientation will be provided to each patient and other family members who smoke in the dwelling regarding the hazards of smoking while oxygen is being administered.
- 	(8) High-risk home oxygen patients and/or family members must sign the No Smoking with Oxygen Contract.  (See Attachment B)
- 	(9) Any home oxygen orders sent to private vendors will include high-risk for smoking while oxygen is in use.
- 	(10) Home Care Respiratory Therapists will complete initial assessment and do a 30-day follow-up phone call to assess compliance with smoking and home oxygen use.  Patient will be seen in Home Oxygen Clinic within 3 months for follow-up of compliance and annually thereafter at minimum.
- 	(11) Incidents, where patients are reported as non-compliant with the guidelines set forth in the education and orientation material and/or whose behavior poses a risk of self harm or harm to others, are documented and reported to the Home Oxygen Coordinator, or designee. Home Oxygen Coordinator, or designee, must report non-compliant behavior to the patient's provider, or appropriate designee, who must counsel the patient and/or patient's surrogate of the potential risks associated with such activity and potential consequences of continued activity.  NOTE: A flag will be placed in CPRS to identify those patients who are considered high-risk patients.

## #226 – Consults:  Kill or Be Killed

- 	(12) When there is potential of identified conflict between the patient's right to smoke and/or the patient's continued smoking while using oxygen and the risk of harm to self or others, the provider(s) or others are to utilize an interdisciplinary review process, or request an Ethics Consultation, to address and resolve the situation.
- 	(13) All patients who fail to comply with oxygen therapy  and smoking safety guidelines are referred to an interdisciplinary  clinical committee or the facility Ethics Consultation Service, as  appropriate, for review to determine continued oxygen therapy and how such therapy will be provided in ongoing care.
- 6.   REPORTING REQUIREMENTS:
-      A.  VA Form 10-71 (586), Patient Incident/Adverse Event Report (PIR) will be completed involving patients receiving oxygen therapy who have  close calls or confirmed adverse events related to smoking, in accordance  with Center Policy Memorandum A-11Q-31, Patient Safety Improvement  Program.
-      B.  Each PIR will be forwarded to the Office of Quality Management.  The Office of Quality Management will report on significant events or ongoing trends related to Smoking and Oxygen Use to the Environment of Care Committee.
-      C.  A flag will be placed in the medical record of all patients determined to be High-Risk.  The note attached to the flag will document any close calls or confirmed adverse events related to smoking and oxygen use.
- ATTACHMENTS:	(A)  Medications for Management of Tobacco Dependence
- 			(B)  No Smoking with Oxygen Contract
- 			(C)  Home Oxygen Tank Exchange Order

## #226 – Consults:  Kill or Be Killed

- REFERENCES:
-         Veterans Health Administration (VHA) Patient Safety Alert dated January 6, 2005, Fire Response and Planning at: http://vaww.ncps.med.va.gov/Guidelines/alerts/FireResponseAlert.pdf
-         Joint Commission on Accreditation of Healthcare Organizations,  Environment of Care Standards, EC. 1.30
-         VHA National Ethics Teleconference Call, October 23, 2001, Home Oxygen for Patients Who Smoke:  Prescription versus Proscription at: http://vaww1.va.gov/vhaethics/download/Transcripts/EthicsHotlineCall10.23.01.doc
-         VHA Prosthetic Clinical Management Program (PCMP); Clinical Practice Recommendations
-         Home Use of Supplemental Oxygen, Draft and dated January 11, 2005; Department of Veterans Health Administration.
-         JCAHO Standards; Understanding Clinical Respiratory Services for 2004.
-         VHA Directive 2003-035, Smoke Free Policy for VA Health Care Facilities, dated July 1, 2003;
-         VHA Directive 2003-042, National Smoking and Tobacco Use Cessation Program, dated August 6, 2003;
-         VHA Directive 2006-021, Reducing the Fire Hazard of Smoking when Oxygen Treatment is Expected, dated May 1, 2006.

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

-                                                          Attachment C
-                                   GUIDELINES FOR OXYGEN TANK EXCHANGE
- - For patients needing a portable oxygen exchange tank while in the Medical Center, the primary provider will enter an order for Single Tank Exchange.
- - The Single Tank Exchange (Respiratory) order will be listed under text orders.  The provider must enter justification for the exchange, verification of the patient's current oxygen order and if this is a VA or non-VA home oxygen patient.
- - The Single Tank Exchange order will be sent to the Respiratory Department and the provider will be directed to page Respiratory for the oxygen exchange.
- - Respiratory Therapists will issue the oxygen tank and document the issued tank's serial number and the returned tank's serial number.
- - If the patient requested or has need for multiple oxygen tanks, the order for the multiple tanks will be entered under orders (Multiple Oxygen Tanks, Home Oxygen) and the Home Oxygen Respiratory Therapists will be paged (altered to the request) and the tanks will be issued from the warehouse.
- - Patients enrolled in the VA Home Oxygen Program will have a posting in CPRS to identity these patients.
- - Patients who smoke will be re-educated regarding risk associated with smoking and oxygen use during each tank exchange by Respiratory.
- - Patients who are at risk for home oxygen due to smoking non-compliance will have their records flagged in CPRS as a warning not to issue home oxygen.

## #226 – Consults:  Kill or Be Killed

-                                                          Attachment C (continued)
-  HOME OXYGEN SINGLE TANK EXCHANGE ORDER
- (Completed by ordering provider)
- VA Home Oxygen:___
- Non-VA Home Oxygen:___
-         Who is providing oxygen:_____________________
- Patient's current home oxygen order:
-                         ___Liter flow
-                         ___Duration
-                         ___Route
- Justification:          ___Tank is empty
-                               ___Requires additional tank volume due to travel
-                               ___Tank is mal-functioning
-  Smoking Status:
-         Current Smoker:
-         Education regarding not smoking with oxygen reinforced.
-         Non-Smoker:
- (Completed by Respiratory Therapy)
- Tank Issued, Serial Number:_____________
- Tank Retuned, Serial Number:__________

## #226 – Consults:  Kill or Be Killed

-                                                          Attachment C (continued)
-  HOME OXYGEN MULTIPLE TANK EXCHANGE ORDER
- (Must be enrolled in VA Home Oxygen Program with Current Home Oxygen Orders)
- (Completed by ordering provider)
- Request ____ portable tank exchange
- Justification:          ___Travel Time exceeds number of portable tanks issued
-                         ___Patient missed home visit via Home Oxygen RT
-                         ___Tanks mal-functioning
- ___Patient and/or family members verbalized understanding of risks
- associated with transporting and storing portable oxygen tanks.
- ___Patient and/or family member have safe identified storage area for
- portable tanks.
-  ___Smoking Status:
-         Current Smoker:
-         Education regarding not smoking with oxygen reinforced.
-         Non-Smoker:
- (Completed by Home Oxygen Respiratory Therapist)
- Tank Issued, Serial Number:_____________
- Tank Returned
-             Not Applicable:_________
-             Serial Number:__________

## #226 – Consults:  Kill or Be Killed

- Statistics for Home Oxygen patients with improvements in patient outcomes.
- Provide statistical data to show improved compliance, decreased cost and improved outcome for Home Oxygen Patients.

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

## #226 – Consults:  Kill or Be Killed

- 67 of 101 Chronic Obstructive Pulmonary Disease patients on Home Oxygen were hospitalized less than 2 times during a 6 year period.
- 83 of 101 have been hospitalized less than 4 times in 6 years.

## CONSULT/SCHEDULING LINK – update since Summer 2006 Release

- Sheri Kreuz, RD, MBA
- SDS, Clin2 Team
- Salt Lake City OIFO

## Objectives

- Discuss issues with Service Consults Schedule-Management Report
- Discuss a few process issues
- Discuss Remedy Tickets
- Mention E3R(s)
- Discuss CPRS v27 Enhancements/Initiatives related to Consults

## Service Consults Schedule-Management Report [GMRC RPT SD SCH-MGT CONSULTS]

- STATUSES Prior to New Report
- PENDING
- ACTIVE
- SCHEDULED
- INCOMPLETE
- DISCONTINUED
- CANCELLED
- COMPLETED

## Service Consults Schedule-Management Report [GMRC RPT SD SCH-MGT CONSULTS]

- AFTER

** **
**             ****2  Active, By Admin**
**       ****202  Active, Can By Clinic**
**       ****239  Active, Can By Patient**
**       ****160  Active, No-Show**
**       ****297  Active, Edit Resubmit**
**         ****4  Active, IFC**
**       ****277  Active, Manually**
**       ****263  Incomplete**
**      ****5593  Pending**
**        ****10  Pending, EWL**
**       ****665  Sch, Linked, Ck'd Out**
**      ****3171  Scheduled, Linked**
**        ****60  Sch, Not Linked now**
**         ****5  Schedule, IFC**
**       ****970  Sch, Never Linked**
**----------**
**     ****11918  Total OPEN consults**
** **
**      ****2129  Cancelled**
**     ****27208  Completed**
**      ****1261  Discontinued**
**----------**
**     ****30598  Total CLOSED consults**
** **
**==========**
**     ****42516  GRAND TOTAL**

## Service Consults Schedule-Management Report [GMRC RPT SD SCH-MGT CONSULTS]

- Sch. Not Linked now – History of consult being linked to an appointment; consult later marked SCHEDULED manually
- Scheduled, Linked – Consult currently linked to an appointment
- Sch. Never Linked – Consult marked SCHEDULED manually with no history of being linked to an appointment

## REPORT STATUS ISSUES (con’t)

- Sch, Linked, Ck’d Out – consult complete but no note for either of these reasons
- Incorrect note title completed
- Incomplete note – awaiting provider signature

## NO SHOW ISSUE

- Consults linked to an appointment where patient is a NO SHOW
- Consult status changes from SCHEDULED to ACTIVE
- Reprint Consult to prevent being lost
- Auto-Rebook – currently allows a dc’d consult to be changed back to Scheduled

## CANCELLATION ISSUE

- CANCELLED consult can be attached to an appointment when:
- Service allowed appointment to be made for the consult
- Patient was a NO SHOW for the appointment
- Service CANCELLED the consult less than 6 months ago

## CANCELLATION ISSUE (con’t)

- Consult Status History
- PENDING
- SCHEDULED (LINKED using interface)
- NO-SHOWED
- CANCELLED
- All other consults in a CANCELLED status are NOT allowed to be linked to an appointment.
- Any consult that was cancelled initially (never SCHEDULED) by the service will NOT be displayed to link to an appointment.

## REMEDY TICKETs 159382 (174399,184547)Procedure Name = Service Name

- Will this appointment be for a CONSULT/PROCEDURE? YES//
- Please select from the list of consult(s), press 0 for none.
- TWENTY,PATIENT
- #  Service                 Sending Provider    Request Date   Cons #  Reqst Type
- ------------------------------------------------------------------------------------------------------
- 1.                              VEHU,ZERO         06/27/07@06:57 1070    Procedure

**Notes:**
Service is blank when the PROCEDURE NAME matches exactly the SERVICE NAME of the related service(s).  No patch yet assigned/no timeframe for fixing.  (VMP team responsible for consults – new developer being transitioned to GMRC; still no timeframe for these tickets – priority 6).

## REMEDY TICKET – 168769 Report Not Consistent 

- GMRC RPT SD SCH-MGT CONSULTS
- If service is a GROUPER and contains other GROUPER service(s), the sub-grouper service(s) do not print.
- User would need to know to run the report on the sub-GROUPER service(s).
- Fix will be made to compile all services related to user’s selection
- No patch designated yet/no timeframe

**Notes:**
The SERVICE CONSULTS SCHEDULE-MANAGEMENT REPORT does not behave the same as other GMRC-related reports where Grouper Services include sub-grouper service(s) in the report totals. (VMP team responsible for consults – new developer being transitioned to GMRC; still no timeframe for these tickets – priority 6).

## REMEDY TICKET – 174855 Unscheduled Visits

- Unscheduled Visit action in Appt Mgt does not prompt to link to a consult
- Can’t discuss the appropriateness of using Unscheduled Visit but the ticket has been submitted and sent to Tier 3.

**Notes:**
Unscheduled Visit action currently does not allow for linking to consult request.

## Other Issues/Uses

- Some sites are using the GMRC/SD link to schedule patients for pick up of prosthetics items.
- Electronic Wait List (EWL) patients:
- Leave consult in pending status (PENDING, EWL)
- Manually receive w/comment indicating pt on EWL (ACTIVE, EWL)
- Schedule via CPRS (SCHEDULE, EWL)

**Notes:**
If the date the patient was placed on the EWL is AFTER the consult initiation date then an appropriate action has occurred.  The trick was to be sure that a report will show this fact.  Placement on the EWL does not change the status of any consult automatically.  If the patient is placed on the EWL in response to a consult request – that fact will be noticed when running the consult-scheduling management report.  Such consults will be given a PENDING, EWL or ACTIVE, EWL or SCHEDULE, EWL status [the last one only occurs if the consult was marked as SCHEDULED manually and not with the scheduling interface).

## CPRS V27 CONSULT ENHANCEMENTS/INITIATIVES	

- Reference
- NSR 20051008
- Add Desired Date to Consult Software
- Add earliest and latest desired dates to the Consults and Interfacility Consults software packages to monitor the electronic closure of consults in CPRS.
- *Dependent on Consults patch and possibly Health Summary patch

## CPRS V27 CONSULT ENHANCEMENTS/INITIATIVES

- PSI-04-012 (Part 4):  Consults completed without viewing reason for consult
- Added right-click option to note editing menu to display details of consult being completed while editing a consults-titled note
- 508 Compliance – CPRS/consults (in addition to Reminders, EFs, Orders)

## Monitoring for Performance Improvement

- Harold D. Bonds, MT (ASCP) SC
- Health Systems Specialist
- G. V. Montgomery VAMC
- Jackson, MS

## #226 – Consults: Kill or Be Killed Monitoring for Performance improvement

- Data for Monitoring may be collected from several sources:
- VistA Consult Package Reporting Options
- Care Management Query Tool
- VistA Fileman templates (requires some programming knowledge for obtaining information from the files)

**Notes:**
Since there is no one reporting mechanism for collecting all of the data in one report, data for monitoring the effectiveness of the Consult process must be collected from several sources and then compiled into workable programs such as Microsoft Excel, Microsoft Access, or some other database program.  What sources you use to collect the data will be determined by the information you wish to compile into your reports.  Data is available in all of the options listed here.

## #226 – Consults: Kill or Be Killed Monitoring for Performance improvement

- VistA System Consult Tracking Reports option:
-    ST	Completion Time Statistics
-    PC	Service Consults Pending Resolution
**   ****SH     Service Consults Schedule-Management Report**
-    CC	Service Consults Completed
-    CP	Service Consults Completed or Pending Resolution
-    **IFC****	****Interfacility (IFC) Requests**
-    IP	Interfacility (IFC) Requests By Patient
-    IR	Interfacility (IFC) Requests by Remote Ordering Provider
-    NU	Service Consults with Consults Numbers
-    PI	Print Interfacility (IFC) Requests
-    **PL****	****Print Consults by Provider, Location, or Procedure**
-    **PM****	****Consult Performance Monitor Report**
**   ****PR****	****Print Service Consults by Status**
-    SC	Service Consults By Status
-    TS	Print Completion Time Statistics Report

**Notes:**
In the VistA Consult Package, I have used these five options highlighted in bold to pull statistics on consults.  The most frequently used option is the “Print Service Consults by Status”.  However, this option does not include the ordering provider in the report.  When the ordering provider is needed, I have used the option “Print Consults by Provider, Location, or Procedure”.  

## #226 – Consults: Kill or Be Killed Monitoring for Performance improvement

- VistA System Consult Tracking Reports option:
**SH     Service Consults Schedule-Management Report**
- Benefits of this option are:
- Status of the consults:
- Service Connection Percentage (Priority Scheduling)
- Total consult numbers at a single glance
- Patient appointment linked with consult
- Pitfalls of this option:
- Ordering Provider not listed
- Reason for Request not indicated
- Completion, Cancellation, and Discontinued data not available

## #226 – Consults: Kill or Be Killed Monitoring for Performance improvement

- Service Consults By Status            Jun 14, 2007@15:01:02    Page:    1 of    1
- Service: Urology
- SUMMARY From: 04/01/07 To 04/30/07                                      06/14/07
- ==================================================================================
-         12  Active, Can By Clinic
-         14  Active, Can By Patient
-         14  Active, No-Show
-          1  Incomplete
-         17  Pending
-         37  Sch, Linked, Ck'd Out
-          9  Scheduled, Linked
-          3  Sch, Never Linked
- ----------
-        107  Total OPEN consults
-         22  Cancelled
-        137  Completed
-          8  Discontinued
- ----------
-        167  Total CLOSED consults
- ==========
-        274  GRAND TOTAL

## #226 – Consults: Kill or Be Killed Monitoring for Performance improvement

-  Urology 04/01/07 - 04/30/07
-                                    Consult                                  		                  Clinic           		Appointment      Stop
- Status                          Date      SC 	L4	Patient                             Appointment      	Date/time           Code
- ===================================================================================================
- Active, Can By Clinic 04-03-07  10%	0001 CPRS,PATIENTONE
- Active, Can By Clinic 04-03-07         	0002 CPRS,PATIENTTWO
- Active, Can By Clinic 04-04-07  0%	0003 CPRS,PATIENTTHREE
- Active, Can By Clinic 04-07-07  20%	0004 CPRS,PATIENTFOUR
- Active, Can By Clinic 04-09-07       	0005 CPRS,PATIENTFIVE
- Active, Can By Clinic 04-11-07       	0006 CPRS,PATIENTSIX
- Active, Can By Clinic 04-12-07       	0007 CPRS,PATIENTSEVEN
- Active, Can By Clinic 04-18-07  50%	0008 CPRS,PATIENTEIGHT
- Active, Can By Clinic 04-18-07      	0009 CPRS,PATIENTNINE
- Active, Can By Clinic 04-19-07       	0010 CPRS,PATIENTTEN
- Active, Can By Clinic 04-19-07      	0011 CPRS,PATIENTELEVEN
- Active, Can By Clinic 04-24-07       	0012 CPRS,PATIENTTWELVE
- Active, Can By Patient04-02-07       	0013 CPRS,PATIENTTHIRTEEN
- Active, Can By Patient04-02-07  30%	0014 CPRS,PATIENTFOURTEEN
- Active, Can By Patient04-03-07       	0015 CPRS,PATIENTFIFTEEN
- Active, Can By Patient04-04-07       	0016 CPRS,PATIENTSIXTEEN
- Active, Can By Patient04-05-07       	0017 CPRS,PATIENTSEVENTEEN
- Active, Can By Patient04-12-07  80%	0018 CPRS,PATIENTEIGHTEEN
- Active, No-Show         04-02-07       	0019 CPRS,PATIENTNINETEEN
- Active, No-Show         04-09-07       	0020 CPRS,PATIENTTWENTY
- Active, No-Show         04-10-07       	0021 CPRS,PATIENTTWENTYONE
- Active, No-Show         04-10-07       	0022 CPRS,PATIENTTWENTYTWO
- Incomplete                  04-26-07       	0023 CPRS,PATIENTTWENTYTHREE

## #226 – Consults: Kill or Be Killed Monitoring for Performance improvement

- Urology 04/01/07 - 04/30/07
-                         	Consult                                  		       Clinic                     Appointment      Stop
- Status             	Date        SC	        L4	Patient             	      Appointment           Date/time          Code
- =================================================================================================
- Pending              	 04-05-07  100% 0024 CPRS,PATIENTTWENTYFOUR
- Pending               	04-09-07  30%    0025 CPRS,PATIENTTWENTYFIVE
- Pending               	04-09-07       	      0026 CPRS,PATIENTTWENTYSIX
- Sch, Linked, Ck'd Out 04-02-07       	     0027 CPRS,PATIENTTWENTYSEVEN  GU-PROSTATE ONC  	05-08-07 @ 14:00  414
- Sch, Linked, Ck'd Out 04-03-07  0%	     0028 CPRS,PATIENTTWENTYEIGHT   GU CYSTO/CYSTOG  	05-02-07 @ 08:30  414
- Sch, Linked, Ck'd Out 04-03-07  70%     0029 CPRS,PATIENTTWENTYNINE	      GU-UROLOGY      	 05-16-07 @ 11:45  414
- Scheduled, Linked     04-02-07  40%	    0030 CPRS,PATIENTTHIRTY	      GU-UROLOGY      	 06-15-07 @ 10:30  414
- Scheduled, Linked     04-02-07       	    0031 CPRS,PATIENTTHIRTYONE	      GU-UROLOGY       	06-20-07 @ 10:15  414
- Scheduled, Linked     04-03-07      	    0032 CPRS,PATIENTTHIRTYTWO	      GU-UROLOGY       	06-15-07 @ 09:00  414
- Sch, Never Linked     04-02-07       	    0033 CPRS,PATIENTTHIRTYTHREE
- Sch, Never Linked     04-25-07       	    0034 CPRS,PATIENTTHIRTYFOUR
- Sch, Never Linked     04-27-07  10%	    0035 CPRS,PATIENTTHIRTYFIVE

## #226 – Consults: Kill or Be Killed Monitoring for Performance improvement

- VistA System Consult Tracking Reports option:
**IFC****	****Interfacility (IFC) Requests**
- Benefits of this option:
- List consults by Requesting or Consulting facility
- List status of consults by Requesting or Consulting facility
- Provides totals for each consult service by facility and overall totals by facility
- Provides basic status of consults
- Pitfalls of this option:
- Does not indicate Ordering Provider
- Does not indicate Reason for Request
- Does not indicate Completion, Cancellation, or Discontinue data
- No appointment data not available

## #226 – Consults: Kill or Be Killed Monitoring for Performance improvement

## #226 – Consults: Kill or Be Killed Monitoring for Performance improvement

## #226 – Consults: Kill or Be Killed Monitoring for Performance improvement

- VistA System Consult Tracking Reports option:
**PL****	****Print Consults by Provider, Location, or Procedure**
- Benefits of this option:
- Consult Statistics by Ordering Provider, Location or Procedure
- Individually
- System wide
- Pitfalls of this option:
- Reason for Request not indicated
- Completion, Cancellation, or Discontinue data not available
- No appointment data not available

## #226 – Consults: Kill or Be Killed Monitoring for Performance improvement

## #226 – Consults: Kill or Be Killed Monitoring for Performance improvement

## #226 – Consults: Kill or Be Killed Monitoring for Performance improvement

- VistA System Consult Tracking Reports option:
**PM****	****Consult Performance Monitor Report**
- Benefit of this option:
- Gives Consult Completion Statistics with Percentages
- Pitfalls of this option:
- No Individual consult information available
- No appointment data available

## #226 – Consults: Kill or Be Killed Monitoring for Performance improvement

- VistA System Consult Tracking Reports option:
**PR****	****Print Service Consults by Status**
- Benefits of this option:
- Allows each status to be reviewed/printed separately or together
- Provides numbers of consults in each status
- Provides patient information with ordering location
- Pitfalls of this option:
- No Ordering provider information
- No Reason for Request available
- No Completion, Cancellation, or Discontinue data available
- No Appointment data available

## #226 – Consults: Kill or Be Killed Monitoring for Performance improvement

- Consult/Request By Status                          FROM: May 01, 2006   TO: May 31, 2006
-    Number St   Last Action         	Req Dt   Patient Name            	Patient Location
- SERVICE: Urology
-    760020 x    CANCELLED           	05/31/06 CPRSpatient,O. (1111)  	CPRSclinic One
-    759955 x    CANCELLED           	05/31/06 CPRSpatient,T. (2222)  	CPRSclinic Two
-    759939 x    CANCELLED           	05/31/06 CPRSpatient,T. (3333)	CPRSclinic Three
-    759689 x    CANCELLED           	05/31/06 CPRSpatient,F. (4444)     	CPRSclinic Four
-    759576 x    CANCELLED           	05/31/06 CPRSpatient,F. (5555)     	CPRSclinic Five
-    759500 x    ADDED COMMENT      	 05/31/06 CPRSpatient,S. (6666)       	CPRSclinic Six
-    759377 x    CANCELLED           	05/30/06 CPRSpatient,S. (7766)       	CPRSclinic Seven
-    759372 x    CANCELLED           	05/30/06 CPRSpatient,E. (8888)       	CPRSclinic Eight
-    759176 x    CANCELLED           	05/30/06 CPRSpatient,N. (9999)      	CPRSclinic Nine
-    759153 x    CANCELLED          	05/30/06 CPRSpatient,T. (1010)       	CPRSclinic Ten
-    758738 x    CANCELLED          	 05/26/06 CPRSpatient,E. (1111)       	CPRSclinic Eleven
-    758883 x    CANCELLED           	05/26/06 CPRSpatient,T. (1212)       	CPRSclinic Twelve
-    758628 x    CANCELLED          	 05/26/06 CPRSpatient,T. (1313)     	CPRSclinic Thirteen
-    758161 x    CANCELLED          	 05/25/06 CPRSpatient,F. (1414)       	CPRSclinic Fourteen
-    758057 x    CANCELLED          	 05/25/06 CPRSpatient,F. (1515)       	CPRSclinic Fifteen
-    757938 x    CANCELLED          	 05/25/06 CPRSpatient,S. (1616)     	CPRSclinic Sixteen
-    757385 x    CANCELLED          	 05/24/06 CPRSpatient,S. (1717)       	CPRSclinic Seventeen
-    756934 x    CANCELLED           	05/23/06 CPRSpatient,E. (1818)       	CPRSclinic Eighteen
-    756754 x    CANCELLED          	 05/22/06 CPRSpatient,N. (1919)      	 CPRSclinic Nineteen
-    756305 x    CANCELLED          	 05/22/06 CPRSpatient,T. (2020)       	CPRSclinic Twenty
-    756166 x    CANCELLED          	 05/20/06 CPRSpatient,T. (2121)       	CPRSclinic Twentyone
- To Service Urology Total Requests Cancelled    21

**Notes:**
VistA Consult Package Print Consults by Status Report.

## #226 – Consults: Kill or Be Killed Monitoring for Performance improvement

**VistA System Consult Tracking Options:**
**There is no one option in the VistA Consult Package that will provide all the information that may be obtained from all five of the reporting options described.**
**There is not an option in the VistA Consult Package that will provide the Reason for Request **
**There is not an option in the VistA Consult Package that will provide the Completion, Cancellation or Discontinued consult information.**

## #226 – Consults: Kill or Be Killed Monitoring for Performance improvement

- Consult cancellation reasons can be retrieved by two methods:
- Manually looking at each patient’s Electronic Medical Record from a list generated with one of the VistA Consult Tracking Options.
- Searching and printing the cancelled consults with the reason for cancellation from the consult files.

## #226 – Consults: Kill or Be Killed Monitoring for Performance improvement

- Consult completion information can be retrieved by two methods:
- Manually looking at each patient’s Electronic Medical Record from a list generated with one of the VistA Consult Tracking Options.
- Searching and printing a list of the completed consults from the consult files with the associated results field populated.

## #226 – Consults: Kill or Be Killed Monitoring for Performance improvement

- Care Management Query Tool:
- Benefits:
- Provides report with differing criteria defined by user:
- Consult Service
- Ordering Provider
- Ordering Location
- Date Range
- Directly exportable report to Microsoft Excel Spreadsheet
- Pitfalls:
- Requires specific patient list for search
- No Appointment data available
- No Reason for Request
- No Completion, Cancellation, or Discontinue data available

## #226 – Consults: Kill or Be Killed Monitoring for Performance improvement

- Questions???
- Please write your questions on the 3 x 5 cards provided