Harbor:ORCHID Downtime

ED Computer Downtime Emergency Instructions

• Identify affected systems and request a fix
  • Assigned Staff: Any tech savvy staff member.
  • Check which of the following systems are affected:
    • ORCHID
    • Computer network
    • Landline phones (VOIP)
    • Portable Cisco phones
    • Paging system
    • Synapse
  • Assign someone to see if any of the affected systems can be used from nearby locations outside the SE building, such as the psych ED, D-9, or the nursing administration office in the hallway leading to the cafeteria.
  • Call the Help Desk at 323-409-8000 to report the problem.

View the ORCHID 724 Backup

• 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. You have to log into the 724 viewer app on the desktop.

• 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
  • Gold Unit HARSE1F2572401
  • Psych ED Station #1
  • Psych ED Station #2
  • Urgent Care
• 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.

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.

• ORCHID Icon --> Read Only folder --> Firstnet Read Only
• Login using the ID and Password that will be distributed at the downtime.

Divert patients and notify necessary stakeholders

• Huddle with staff to brief everyone on downtime processes
• 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 (ALS) ambulances, remaining open to trauma, STEMI, and BLS ambulances.
    • Consider BLS closure (Nursing Clinical Director + ED Chair/DEM Admin on Duty (AOD) decision; must call MAC and discuss with their AOD)
  • “Internal Disaster” closes to ALL ambulances, including trauma and STEMI. Consider involving the trauma and cardiology attending or CEO/CMO/designee in the decision to go on internal disaster.
• Notify the nursing supervisor, who will call the hospital's AOD. Discuss whether to open the hospital emergency operations center (and activate hospital CODE Triage) 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.
• Consider activating the ED Emergency Operations plan, especially if a computer downtime occurs during a disaster.

Gather your forms

• There is plastic bin 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 at the AED nursing station.

• Order Sets:
  • ED Order Sets
  • All DHS Order Sets
    • Admission Order Set
• Or go: Harbor Home Page -> ORCHID Dropdown at Top -> ORCHID Team -> Downtime Resources -> Orders -> Order Sets

• Pre-printed discharge instructions are in each doc box in English and Spanish

• Other important forms (eg, commonly used order sets, restraints) for the ED at in the Harbor Home Page -> ORCHID Wiki Harbor Home Page -> Scroll down to ORCHID Wiki -> Downtime Resources -> Emergency Department

• 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

• Pharmacy Downtime Forms
  • • File:Prior Authorization Form (downtime access).pdf
    • File:Adult Heparin Continuous Infusion (low-dose).pdf
    • File:Pediatric Heparin Infusion (bolus + high-dose).pdf
    • File:Pediatric Heparin Infusion (no bolus, low-dose).pdf
    • File:Fentanyl Patch Inpatient Orders (Adult and Pediatrics).pdf
    • File:Oral Morphine & Methadone Order Set.pdf

Teams Downtime Tracking List

• There is a Excel online spreadsheet in Teams that simulates the Firstnet Tracking List.

Go to Microsoft Teams --> ED Downtime --> General --> Files --> ED Downtime Tracking Board

• The clerks will enter patients into the list.
• Staff will move patients on the list by cutting and pasting as they move through the department.
• Staff will update the board with patient assignments and other details.
• The board will NOT be used to communicate orders, but only to track status.
• When patients depart the department, move them to the designated sheets.
• The password to modify the setup is "Downtime". Please do not use it unless you are an administrator.

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Registration

• 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.
• For traumas and critical patients, registration will give a pre-made packet with MRN, FIN, stickers, wristband and flowsheet.
• For other patients, registration has a list of MRNs and FINs and will use the "Standalone" application to print stikers and wristbands as patients are arrived.
• Registration will use the Level 1 724 (if available) to look up the MRN of patients already in the DHS system. They will give them a FIN from the list of downtime FINs.

Waiting room and triage

• 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.
• 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 completed triage form 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.
• 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].
• Stable patients will wait in the waiting room and will be called to the registration windows for full registration.
• 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.

Medical Screening Exam/RME

• 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.

AED, PEDS, RME, Gold and Psych ED patient tracking

• Assigned staff member: Area charge RNs
• Use the Teams Tracking List.
• If Teams is down, 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 doc box.
• If the Teams Tracking List is unavailable, the 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.

Order Management

• Move each pod's chart rack to the front counter.
• The order sets are just guides and cannot be used to place orders.
• Order must write all order on the generic order sheets.
• The order sheets must be stickered and signed with a legible name, e Number, date, and time as the legal record of the orders. The lab and radiology requisitions are not part of the medical record and are discarded.
• Order sets are online at the locations in the "Gather Your Forms" section above.

Lab Ordering and Collection

• Providers will write all orders on order sets or the generic order sheets.
• Nurses will transcribe the lab orders to the requisition forms for each lab area.
• Nurse will draw (or call phlebotomy), label with timed patient stickers, and place in tube with requisitions and tube to lab.

Lab Results

• The lab will fax results 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
• A nursing assistant will watch the fax machine, taking one copy to the dox box of the team caring for the patient and the second to the patient's folder.

Radiology ordering

• Provider will write the order on an order set or generic order sheet.
• Provider will also fill out a separate requisition for each modality

Radiology Results

• If Synapse is down, you will need to view images on the machine on which they were shot.
• For CT reads, call the reading room.
• At night page the radiology resident at 5814 to come down and make preliminary reads on the scanner.
• If Synapse remains operational, residents may place preliminary reads in Synapse.

If the downtime occurs during StatRad hours, call them to fax their reports to the radio room. The feed from StatRad to Synapse depends on ORCHID, so if ORCHID is down, reads will only go into Synapse after recovery.

• A nursing assistant will watch the fax machine, taking one copy to the doc box of the team caring for the patient and the second to the patient's folder.

EKG Results

• 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 them the other copy.

Medication Ordering

• 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

• [45 minutes prior to a planned downtime, the pharmacist will print the MARs of all patients]
• 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.

Nursing documentation

• 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.

Physician documentation

• 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.
• Each provider team should keep a log of patients who leave during downtime with MRN and diagnosis so someone will be in the department after recovery can re-enter them.
• Attendings should write their attestation and co-sign the chart if they are able to do so before leaving. If not, write your name on the chart so the un co-signed chart can be brought to your office.

Admissions

• 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
  • For Internal Medicine Admissions, if unable to access Microsoft Team's Admission Template, then call Chief's office x66538 to have them bring down a printed version to keep at the AED Clerk station.
• 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.

Transfers

• 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

Discharges

• 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
• Common discharge instructions have been pre-printed with the downtime forms.
• Other 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. There are no custom DHS instructions. There is no record kept of what was written or printed.
• Nurses will move departed patients to the corresponding sections on the Teams Tracking list. Lab and radiology will ensure that the necessary orders are in on the back end as part of their recovery process.
• IF the Teams tracking list is unavailable, the ED clerk will keep a log of patient departure times and dispositions.

Lab/CCC Follow Up

• 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 must be completed if the patient already departed 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.

Follow Up

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

Orders for admitted patients

• Write on paper. Fax medications to pharmacy.

After recovery

Registration

□ Registration will quick reg patients back into ORCHD (making sure to select DOWNTIME = YES within the quick registration conversation and entering in the downtime MRN/FIN). Nurses will NOT do quick reg to avoid duplicates

• Nurses should NOT quick register patients to avoid creating duplicates.
• Patients who arrived during downtime and are already admitted will first be quick registered into Firstnet and then admitted using the admissions process.

Discharged Patients

□ The charge nurse will enter into ORCHID: chief complaint, arrival time, diagnosis, disposition, last providers, last room, and time left ED.

Active Patients

□ Nurses will re‐associate patients to their devices (e.g., bedside monitor, ventilator).

□ Nurses and providers will update the real Firstnet tracking list.

□ Providers will back enter all ongoing non‐medication orders.

□ Pharmacy will back enter all medication orders for active patients (patients in the ED who have not been discharged).

□ All medications charted during downtime will be entered into ORCHID for active patients. The clinician who administered the medications will back enter the medication administration whenever possible. If another clinician will be entering the medication into ORCHID, the clinician who administered the medication will be documented in the “Performed by” box of the medication administration window. Document Medication Administration Follow Up Tasks as “chart not done.” Select Reason Not done as “Other” and type “Downtime.” In the comment type “refer to downtime MAR”.

□ When a medication requiring a witness is entered into ORCHID, the witness is a witness of transcription and not a witness of the independent double check. The original witnesses name should be entered into the comment section along with a note to refer to the downtime MAR.

□ RT will enter their own medications.

For downtime less than 4 hours, enter:

□ All vital signs

• In situations in which vital signs are being documented more frequently than every

one hour, hourly vital signs may be entered and must include the last set of vital signs.

□ All intake and output.

□ POCT results for ONLY those devices do not normally send results to ORCHID.

For downtime greater than 4 hours, enter:

□ Most recent vital signs.

□ All intake and output.

• 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.

Paper Documents

□ Paper documents will be collected in bins for later retrieval by HIM. These documents will be scanned into ORCHID once the system is up.

- The white copy always follows the patient (unless departing the hospital)

- The pink copy is used by UR for admitted patients

- The yellow copy is collected at each nursing station for ED use and later collection by HIM.

Point of Care testing results

• POC devices that are interfaced (i.e., send results to ORCHID electronically).

□ Manually enter results for patients who were not in ORCHID prior todowntime (e.g., admissions).

- Do not manually enter results for patients who were in ORCHID prior todowntime (doing so will result in double documentation of results).

• POC devices not interfaced (i.e., clinician manually enters results in ORCHID).

□ Manually enter all results in ORCHID.

Medication documentation after recovery

□ Give carbon copied paper downtime charts to pharmacy for review and reconciliation of medications administered in the ED.

• 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.

Preparation Checklist for Planned Downtime

T-2 Weeks:
□ Check with Mario that forms are stocked. Assemble 100 packets of MD 253, nursing note/MAR page 1 (20 with peds nursing note for PED), MSE, and order form. Check that 10 EMTALA forms are in the AED.

□ Registration checks stocks of downtime forms, labels, wristbands

□ Check that 724 Level computers are working.

□ Check that pharmacy scanners are working.

□ Remind attendings to check their prescription pads.

□ Develop just-in-time training plan.

T-2 Days:
□ Registration checks that forms are ready to be moved to router

□ Get names of staff who will be on during downtime and add them to the team with the Teams Tracking List

T-3 hours:
Lab ordering will go to downtime forms. □ Put out forms on counters

□ Check that 724 Level 2 computers are running.

T-1:30:

• Medication and other orders than radiology and lab will go to paper.

□ Put the downtime forms on the counter in each area.

□ Check that there are sheets of labels in each patient's folder. Call registration if more are needed.

□ Print the 724 charts of patients in the waiting room.

T-1 hour:
□ Go on ED Saturation to EMS ALS. Remain open to STEMI and trauma

□ Registration will take over quick reg, but will continue entering patients in ORCHID up until downtime.

□ Pharmacy will print the MAR on boarding patients

□ Enter patients on Teams Tracking List

□ Obtain a username and password for 724 Access Viewer. These will be distributed approximately one hour prior to downtime via DHS email broadcast. If necessary, call the Enterprise Help Desk.

T-30 minutes:

• Patient arriving at this point will still be registered into ORCHID, but will have clinical documentation started on paper.

□ Print a copy of the patient lists from the 724 level 2 for each area/section/pod and distribute them. This is better than printing the screen from the normal FirstNet

□ For ED Boarders, Pharmacy will print Medication Administration Records from PharmNet prior to downtime. If Pharmacy is not generating MARs for your unit, print the MAR from the 724 Downtime Viewer. These MARs will have the most current medications and due times and can be used for downtime documentation. Must reconcile with most recent medications added/given.
Just before downtime

• Radiology orders can be placed in ORCHID up until the downtime.

After recovery:
□ Find and send unsigned provider documentation to providers for signatures.

□ Send all downtime documentation will to HIM for scanning.

□ Email appropriate staff in the ED (Mario, Ross F. Brad) there was a downtime so they can check the levels of downtime forms and replenish if necessary.

See Also

• Harbor:Main