MONTREAL – From code blue for cardiac arrest to code red for fire and code yellow for a missing patient, emergency room (ER) physicians and nurses are used to working in colour.
Even more so at McGill University Health Centre (MUHC) in Montreal, where a newly implemented emergency department information system (EDIS) is using colour-coded alerts and status updates to keep clinicians informed at a glance without the need to log onto a computer or refer to a paper chart.
The implementation is part of a paperless ER strategy at MUHC and, in fact, very little paper now remains. Automation begins when patients arrive at the ER and take a time-stamped ticket to signify the
start of their visit.
From there they move through triage where each step is computerized, including the recording of past history, current medications and the reason for the visit, as well as the downloading of vital signs from monitoring equipment.
Once admitted to the ER, everything from nurses’ notes to test results is also computerized and patient progress is followed on an electronic tracking board that displays information for each bed or stretcher in the unit.
“Patients who haven’t been seen are coded in either pink or orange, patients who have been assigned are white ... and patients who need to be re-assessed are yellow,” explains Dr. Marc Béique, head of
informatics for the ER at MUHC. “You have this big screen in the corner of the emergency and without even reading the names you can tell that there are no new patients waiting to be seen.”
The automation is a big change from two years ago when the only on-line systems were for diagnostic images and lab results. Prompted by legislation from the Quebec government, MUHC needed to implement software that would support ER data collection from an administrative perspective. The selection team chose Med-Urge from MédiaMed Technologies of Mont Saint-Hilaire, Que., primarily due to its strong clinical functionality, but also because of the vendor’s willingness to adapt the software, says
Dr. Béique.
“We added new functionality to help them work the way they want to work clinically,” says Dr. Jean Mireault, MédiaMed chairman and vice-president of clinical affairs. “It’s not how they’re supposed
to work with Med-Urge, but how Med-Urge is supposed to work with them.”
MédiaMed has 40 Med-Urge implementations throughout Quebec and is currently shifting its focus to the rest of Canada, where it is finding that existing emergency information systems don’t always offer the same level of clinical functionality.
The challenge moving forward, says Dr. Mireault, is to build interfaces between Med-Urge and existing electronic patient record implementations. “The question at the moment is, ‘What are you looking for from the ER system?’ Maybe we have more information than they need,” he says.
For MUHC, MédiaMed added wireless functionality to Med-Urge to enable nurses to incorporate mobile computer workstations into their routine. In addition to blood sample tubes and blood pressure monitors, the mobile carts are equipped with small laptops so that electronic patient files are always available, or, if they choose, nurses can also use one of 40 fixed workstations now located throughout the ER.
Once a patient is seen by a physician, Med-Urge generates an electronic care plan indicating every test that’s been ordered down the left side of the screen and the hours of the day along the top. A box is automatically generated to the right, using different colours to signify whether a test is already done, needs to be done urgently or can wait. Alerts also appear on the main screen to serve as a
reminder.
It took about a year-and-a-half to incorporate all of the requested changes into Med-Urge. During that time, the MUHC project team, led by Dr. Béique and including a senior nurse, members from the hospital’s transition office and two IT representatives, focused its efforts on publicity and training. In addition to ER staff, more than 500 clinicians were trained on limited use of Med-Urge.
“What made this work in particular was the fact that the hospital invested into setting aside a team to do this project,”notes Dr. Béique, noting that nurses were freed from full-time duty to take part in at least two days of training.
The communication and training effort worked so well, he adds, that within 48 hours of going live, the project team received a petition from nurses asking that a paper document – the only remaining piece of paper that had been retained for assurance only – actually be removed.
In the two years since going live with Med-Urge, MUHC has eliminated many manual processes altogether and reduced the number of steps required for others. The steps required to administer a medication, for example, are down from seven to two. Meanwhile, the only paper remaining is the handwritten physician notes and patient summaries which are currently printed and scanned into the overall hospital information system. But that’s soon to change too.
“It’s a technical problem; we don’t have enough workstations to allow people to monopolize them,” says Dr. Béique, noting that next steps include the implementation of a voice recognition dictation system for physicians and the automatic exporting of patient summaries from ER to health records. “It’s not a question of buy-in, it’s a question of buying the software.”