OB Workflow

• All OB patients are found on the L&D Grease Board (right beside our Status Boards)

  • • “Labour Consult” workflow - rarely use this unless someone wants an actual inpatient consult to discuss labour analgesia, etc.

Epidural

1. You'll likely document all this after actually doing the epidural procedure itself, so you may be back-documenting lots of this

2.  Ad hoc Labour Analgesia encounter and anesthetic record. Click on a patient row then pressing “Labour” in the top row, or double clicking on a patient row and creating a “Labour Analgesia” encounter in the pop-up

3. The Preprocedure workflow is essentially the same as any OR case - anesthesia start time (BILLING START), history/medications/allergy review, pre-anesthesia evaluation with problem list, and ready for procedure 

• In OB patients, a third section will appear in your pre-eval note (beside physical exam and anesthesia plan), called OB/Gyn, which is basically an addendum to the problem list with OB specific review of systems questions

4. The Intraprocedure view will look a bit different (will go to Labour Analgesia view, but you can toggle back to Default View if you prefer to see the intraprocedure grid and vitals graph)

• Complete the quick events just like in the OR, 

• Make sure to add yourself as staff (it won’t be auto added like most ORs)

• You do not have to associate any device - your chart will automatically pull the ~10 sets of vitals after your anesthesia start time directly from the nursing flowsheet

5. Document epidural as a procedure note. Document medications (i.e. test dose, loading dose) either within epidural procedure note, or through the intraprocedure meds activity

6. Checking up on a patient / epidural rounding: If you return to an epidural chart to check in on the patient (i.e. epidural rounding) and/or to do a top-up, use the “Face Time” event on the left side of the intraprocedure view 

• • • 1. 1. You can free text into here any details you want, but also the Face Time event will pull another ~10 sets of vitals into the chart (i.e. for after you to a top-up). Then you can use the meds tab to document any top-up meds you gave

 7. Postprocedure navigator - nothing to do here (none of these are required to close the encounter, i.e. no handoff, no ins/outs, no postprocedure eval note)

• DO NOT file “Anesthesia Stop” - the chart will automatically file this at the time when the baby is delivered (and you can go back later to extend it by an hour for billing purposes if you want)

• Epidural charts will automatically be signed/closed ~24 hours post-delivery, as long as all of the encounter requirements are completed

      8. Don't forget FBC Epidural orderset!

Epidural Billing Documentation:

• • Epidural start time - just like OR, in the pre-procedure tab "Anesthesia Start Time"

  • Maintenance: to assume billing for an epidural when you come on call (continuation/maintenance of someone else’s epidural), it’s best practice to update the Staff tab to yourself

  • CSection (with an insitu epidural) - do not edit the Anesthesia Start time in preprocedure view. In the Epidural to CS Macro, file the epidural to CS event and use that as the CSection start time for billing.

CSections:

• To convert an epidural to a C/S: when you double click on the patient’s name in the Grease Board, you’ll encounter a pop-up asking if you want to continue documenting on the Labour Analgesia encounter, or if you want to document on the new procedure (C/S) that was booked - click on C/S. 

• Your next prompt will ask if you want to merge the running epidural anesthetic record with the C/S anesthetic record (yes you do), instead of making a whole new record

• When you link your anesthetic record to the new C/S procedure, it’ll prompt you to update the macro from the current one (labour epidural) - find the “Epidural to CS” macro that should guide you the rest of the way

• It’ll prompt you to update staff (if you weren’t the person who put in the epidural and you hadn’t changed staff when you came on call)

• It will also remind you to file the “Epidural to CS” event - you can use this event basically to start your C/S billing time (as the Anesthesia Start was filed at the start of the epidural), and you can also use this free text field under the event to write a quick updated pre op (i.e. something like “Urgent CS called for FTP at 7cm. Epidural in situ, working well. ASA 3E. Plan for epidural top up, discussed risk of GA conversion PRN.”)

• • Treat the remainder of the case just like any other OR case

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FBC workflow updates:

• We have two anesthesia-dedicated WOWs down on FBC (labeled as such by Rachel) - one that is being kept in the hallway beside the nursing station (for epidural documentation), and one back near PACU (for post-CS documentation)

• In ideal state, the FBC nurse/midwife will bring the anesthesia WOW into the labour room along with the epidural cart (though for the time being, they may need some reminding, or you can bring it into the room yourself). Makes epidural documentation really quick!

• Remember that after you do your epidural, do not file Anesthesia Stop (this will automatically file when baby is delivered), and the chart will automatically be signed/closed ~24 hours after that

Sending intraoperative labs:

• We can place the order on Epic (you can utilize the Quick Lists for easy one-click orders, or you can search for something in the order panel)

• The circulating nurse has to print the specimen label (to put on the blood tube) and mark it as “collected” in Epic before sending it to the lab (we do not have access to this apparently)

• The official APS list is “SJHC APS Patients”

  • Patients will appear on this list if they have “Patient on Acute Pain Service (APS)” as an active order

  • This new “Patient on Acute Pain Service (APS)” order is automatically checked on all of our APS order sets

• The second list, “SJHC APS Consults”, will only have patients who have an active “Inpatient Consult to APS” order - this is NOT our APS rounding list

  • We are planning to send out communications to the surgeons that they must accompany any Epic anesthesia/APS consults with a direct phone call (i.e. we should not be monitoring this list for consults that are not called about)

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• A reminder about the proper APS workflow:

  • Step 1: Input your APS orders, including the ““Patient on Acute Pain Service (APS)” order. Make sure that this order is signed active (without a phase of care), and NOT signed and held

    • 1. Patients now appear on patient list: SJHC APS PATIENTS (DO NOT USE APS CONSULTS LIST)

  • Step 2: Complete APS consult note (through Postprocedure navigator, or through the Notes activity tab at the top of the screen), and link the inpatient consult order to your note to “complete” the order. To search the template manually, type CONSULTS -> UNITY AN ACUTE PAIN SERVICE CONSULT NOTE

• Linking your consult note with the consult order will mark the consult as complete and remove that consult order (otherwise, you will not be able to sign your OR record if there is an outstanding APS consult order)

• • Step 3: Any APS rounding (and writing progress notes) can be done through the “Acute Pain Service” navigator found in the Patient Lists activity

• To do APS rounding, find the patient on your APS list, single click on their name, and press “Acute Pain Service” to enter the Pain Service Navigator. There should be sections in here for Consult Notes, Progress Notes, Procedure Notes (if needed)

• • Step 4: To sign someone off the APS service, go into their Orders (Active) and discontinue the “Patient on Acute Pain Service (APS)” order. This is akin to our previous SUNRISE APS workflow.

• Discontinue PCA/epidural/nerve block by entering the "Discontinue ___" order. 

• Then also manually discontinue the order for it (e.g., active IV PCA hydromorph order -> discontinue)

There is no "IV PCA (Elderly)" orderset, like there was in sunrise.

• We highly recommend making your own IV PCA smartset macro from the Adult PCA orders.

• I have made a macro for an IV PCA (Elderly) orderset that I modeled after the sunrise version. If you want to use the same as the sunrise version, simply copy my macro set. Follow these steps:

• My tools (top of epic) > User Smartsets > Enter "Tse" into User Versions > Single click the "IV PCA Elderly" smartset > click "Copy Version".

• This will open the elderly orderset as I filled it out, but make the creator you. You can change the title and make any micro edits that you want, and hit save.

• This set has the sunrise elderly PCA settings (0.1mg q6min with a 4h limit of 6mg, dose range 0.1-0.2). It also has celebrex 100 bid, tylenol 650 q6h, HM 0.5mg standing q6h, PO HM 0.5-1mg q3h prn, and IV HM 0.2-0.4 q3h prn. Usual antiemetics, bowel meds. No gravol. 

The below may no longer be uptodate, some nurses are asking for individual orders for each catheter. Not sure what correct thing is....

You only enter ONE order for a peripheral nerve catheter, even if you put in bilateral catheters.

• To simplify orders, regardless of whether it's a single side or bilateral catheters, you only enter one order set.

• When you select your drug, you will have the option of selecting the location and laterality of the catheter, including bilateral.

• Whatever dose you put it in will apply to EACH catheter separately. Eg. If you want our usual 15 ml q3h, and you have bilateral TAP catheters, you still only put in 15ml in the dose. Each catheter will then be dosed 15 ml q3h. 

  • This way, you can make a macro for 15ml q3h and won't ever have to change the dose regardless of whether its single or bilateral.

• We got rid of the "clinician top up bolus" from sunrise. Most of us are loading these in the OR, or ourselves in the block room. 

• The "Next dose in ____ minutes" starts from when the nurse attaches the pump. So, for example, if youre doing a liver resection and you load the tap catheter in the OR on closure, you might say "next dose in 150 minutes". Since our usual frequency is q3h (or 180 minutes), this would allow 30 minutes for closure/transfer to pacu, and would then queue the pump to deliver it in 150 minutes to total 3 hours between boluses. 

• If you want to bolus the tap catheter off the pump itself, you set an order for "next dose in 1 minute". Epic requires a positive integer to compute, so 0 minutes won't be accepted.

Group And Screen June 2025 Update

Re: Group and Screens

1. Confirm with blood bank whether they need a group and screen, or an ABO verification. Even if they only say they need one sample, that doesn’t mean it’s necessarily an ABOv. Clarify which.

2. If it is a group & screen: use the epic G&S order and request the nurses to click "collect" in addition to printing the label.

3. If it is an ABO verification: send a green sheet with ABOv, blood with a patient label, the time you collected the specimen (NO EPIC ORDER)

4. If blood bank needs both samples, do both steps 2 and 3.

They reassure me that they have reminded everyone down there that green sheets are being accepted for ABO verification.

(For what it’s worth, ABO verification orders exist in epic, but they seem to only be able to be ordered / released by certain people in certain situations, and have been rejected quite frequently these past few weeks. That’s why the green sheet is being used)

This is an entirely new orderset. It amalgamates our inpatient epidural orders, our intrathecal monitoring orders (e.g. for epimorph), and our same day discharge joint orders. 

The bottom line is: Anytime you perform a neuraxial anesthetic in the OR, you open this orderset.

The steps to using this orderset are simple:

1. Select appropriate monitoring (epidural or spinal),

2. Add intrathecal monitoring if used

3. Order medications - epidural if ordered + adjuncts.

Let's walk through this step by step:

1. Appropriate monitoring, including intrathecal opioid monitoring: 

• The Nursing Communication & Nursing interventions sections are all the standard INPATIENT APS monitoring things. You tick these boxes if you did a spinal or epidural, and the patient is being admitted. 

  • If the patient is an OUTPATIENT, you untick these boxes because there is no APS service following the patient. You also untick the "Inpatient consult to APS" because APS is not involved. 

• The Single Shot Epidural & Intrathecal Monitoring is self explanatory, but differs from our old orderset because you DO NOT have to specify what medication you gave, or what time. You just have to tick if its a long or short acting narcotic, and that's it. 

• Please note that if you do a spinal for any patient (in or outpatient, opioid or no opioid), you must tick the box that says "For ALL patients undergoing SPINAL anesthesia". You can still check this box in addition to the intrathecal opioid boxes, no problem.

• If you do an epidural, you check the Vital Signs for Epidural Infusions box.

2. Epidural medications

• No changes to the drugs or parameters from Sunrise

3. Adjuvant Analgesia

• No changes to the drugs or parameters from Sunrise, but just be aware that these drugs apply to both inpatients and outpatients. So, you can select these adjuncts (tylenol, nsaids, oral HM standing, PRN iv/po hydromorphone etc) for your epidural orders, spinal orders, and same day discharge orders - and it will be phased automatically to the floor, or to SDC. 

From a Macro perspective, there are several ways to parse this orderset to our daily workflow. You can consider the following macros:

1. Inpatient Epidural Orders (e.g. for a Whipple)

2. Inpatient Spinal Orders (e.g. hip fractures, admission hips//knees)

3. Same Day Joint Orders for Day 0 Hips/Knees, or outpatient spinals

For inpatient epidural orders, you would tick:

• The nursing communication and interventions, because the patient is an inpatient

• The long acting opioid monitoring, if a single shot of epimorph is given (though we're moving away from this as a group)

• The epidural vital signs section

• And the epidural meds, side effect meds, and adjunct meds.

For inpatient spinal orders, you would tick:

• The nursing communication and interventions sections, because the patient is an inpatient

• The spinal monitoring section, because the patient underwent a spinal

• The short or long acting opioid section if given

• Side effect & adjunct meds

For Same Day Joint orders, you would:

• UNTICK APS consult order, the nursing communication and intervention sections, because this patient is an outpatient

• Tick the spinal monitoring section, because the patient got a spinal

• Tick the short acting opioid monitoring if it was given

• Tick the side effect/adjunct meds. These exist in parallel to the SDC meds if you want to also fill out the SDC section of the PACU orders (up to you, just beware of duplicates). 

PAT Clinic Workflow:

• In addition to the “standard” pre-op workflow, there are a few PAT specific tasks to complete when in clinic

• “Order Review” tab at the top is where you’ll see all PAT orders that have been placed already (i.e. medical directive bloodwork) - you can review these and discontinue if you feel they’re not needed

• “Tasks” section: these are NOT orders, but just Epic-generated reminders based on coding/logic (i.e. “this patient is over 65, so we’re reminding you that you may want to order an ECG”). Some tasks also serve as a flag for the day of surgery - most common one you’d want to add in this section is “Unity Extended PACU Stay” for flagging the patient for SDC/PACU oximetry (but also one for pacemaker, pre/post-op FHR monitoring)

• “Responsible Provider” section: update this with your name for seeing the patient in clinic. We’re working on trying to auto-populate this based on scheduling (or having clerical/nursing do it for us), but TBD on that

• “Orders” section: for both extra PAT clinic orders (i.e. adding a BNP to the medical directive bloodwork)

• “Procedure Med Instructions” section: will auto-populate with patients home meds documented in “Medication Review” above - clicking into this section will give you options to give the patient med instructions for the day of surgery (the new version of the white paper sheet that pharmacy used to make) - these instructions go directly onto the AVS that gets printed and the patient takes home with them from clinic

• “Med/Preprocedure Instructions” section: you can create a note here that will go at the very top of the patient’s AVS (where I’d make a smart phrase for my most common instructions like NPO guidelines, any extra instructions you typically tell patients in clinic”

• After Visit Summary section: the very last section. The patients will have this printed by the nurse or registration staff at the end of their clinic visit, but you can preview it by pressing “Click to Preview”

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This can also be found by pressing F1 when you are in the Epic system - you’ll see a few other tip sheets here, and many more coming as they continue to be more developed! F1 is a good resource if you have any questions while you’re working in system.

A few specific callouts:

• Remember to use the “PAT Anesthesia Review” Task to document your start and end to your PAT visit

• You can mark the patient as “Not Ready for Procedure” if their case needs to be delayed or canceled for investigations, consults, work-up, other procedures, etc. - this will prevent the case from being scheduled until this has been resolved

• Changing SDC to SDA: the patient needs an “Admit to Inpatient” order in Epic. Unless you want to put this in yourself, it’s probably better if you call/email the surgeon to do this. I’m unsure if we need to CC the surgical coordinator as well

• Changing SDA level of care (i.e. ward to ICU): this patient should already have an “Admit to Inpatient” order in Epic, but we can edit this to change the expected level of care post-op (i.e. Admit to Inpatient - ICU). Probably good practice to inform the surgeon that you’re doing this

• If the patient needs pacemaker interrogation pre/post-op or FHR pre/post-op, add “Pacemaker” or “Unity Fetal Monitoring” (respectively) in the Tasks section to flag it, while also following current state practices of emailing all the parties involved

• The Tangent monitors (computer monitors attached to our anesthesia gas machines) are touch screen! Many people find it helpful to use the arm to bring it right beside/behind you when you are starting your case so that you can use the touch screen to time stamp your Quick Event sequence (induction, airway placed, etc.), then go back after your case is stable/underway and fill in the details

  • Also, the OR computer monitors have Imprivata single-sign-on built into the monitors themselves! Just tap your badge on the lower portion of the monitor (where it says tangent/RFID) to use it to log in/log off the computer

  • Currently, the computers have an automatic timeout period after 30 minutes of inactivity (decision set by Unity Health security team) - we’re applying for an exemption to try to increase the timeout period for the OR to be longer (60 minutes)

  • Even if your computer logs out, as long as you’ve started the process of vitals pulling into your chart, they will continue to pull into the chart even if your computer logs out or even turns off

I’ve attached a PDF of how to set up these apps. You can download the app directly from your App Store, then follow the instructions in the PDF. At some point it will ask you to scan a QR code to authenticate that you are adding the Unity Health environment - these QR codes are located in the PDF. The left-sided one is for Haiku, and the right-sided one is for Canto. I am certainly not the expert in this whole setup (but I can try to help troubleshoot) - any larger issues should be directed to the Help Desk.

As I have probably mentioned already, these apps have more limited functionality compared to the desktop workstations, and are not meant to replace them entirely. However, they can be a great resource to review patients, notes, labs, etc. if you’re on the go.

• They are not meant to replace any intraprocedure documentation (i.e. intra-op medication administration) - please rely on the anesthesia Tangent monitor for this

• The one big drawback of these (compared to a computer) is that, while you can write free-text written notes on the mobile apps, it does not support the NoteWriter functionality (the quick select buttons that we use for our pre-op/post-op evaluation notes, procedure notes, etc.). I am told that this is being actively developed on the Epic side, and may be available on Canto (the iPad app) within the next 1-2 years.

A few notes about the apps (although I haven’t played around with them too much yet - so there’s probably much more to discover). I’ll be providing some instructions as per the iPhone app (Haiku), so apologies if these don’t translate exactly to the same view on the Android phones or on the Canto app for iPad

• This will only show the Production environment (Hyperspace) - not SUP at all. So if you’re playing with it this week, your SUP patients will not show up in here

• It will send you notifications, but you can customize these through your profile (press on your name in the top right), then go into notification settings

• It will default to Guardian, which should bring up all of your actively running anesthetics. If you want to edit the default or the order of the tabs, you can press the three dots with “More”, then “Edit” in the top right corner

• In the “Status Board” section, it will default to the “My Procedures” status board (just like the desktop app). You can change your status board by pressing the little folder icon in the top left (you can change to all OR Cases, PAT, PACU, etc.)

• In the “Schedule” section, if you want to add PAT (because we don’t have our own clinic schedules), press “Schedule” at the top, then “Add department”, and search for “SJHC Pre-Anesthesia Assessment Clinic”. I’m still trying to find out if you can set this to be your “default” so that you don’t have to search it.

• In the “Patients” section, you can change the list that is being shown by pressing “Patent List” at the top, then “Lists” in the top left, then navigating through the folders. For example, our APS list would live in “St. Joseph’s Health Centre", then “Anesthesia”, then “SJHC APS Patients”. I’m still trying to find out if you can set this to be your “default” so that you don’t have to search it.

• Epic medical record numbers (MRNs) are going to be different than the patient’s current SJHC J-number. So, if you’re working on Epic and trying to find that same patient in Sunrise (i.e. to see historical data), you may have to use their name/DOB/other identifiers to find them in Sunrise

  • However, if you’re trying to find a Sunrise patient in Epic, you can search them by J number in the “Patient Station” search function (in the "MRN/HCN" search bar)

• Epic cutover data: a certain amount of data from Sunrise will be automatically pulled over into Epic so that it is available in the Chart Review section of Epic

  • See attached for a screenshot of how much information is going to be automatically pulled over

  • We will still have access to Sunrise on our computer desktops for anything older than this, it will just be in “read only” format

PACU procedures (ECTs and cardioversions):

• These are treated (from our perspective) as basically the exact same as an OR anesthetic - still using the Preprocedure/Intraprocedure/Postprocedure navigators will all of the same steps and requirements

• The main difference in the PACU is that we do not need to file Start Data Collection or associate a device with our chart

• The PACU monitor will already be associated with the nurses flowsheets and will be pulling in vitals directly - all we have to do is press “Pull Vitals” from the left hand side (and select the time at which you want this to start pulling), and then nursing vitals should start coming directly into our procedure chart

• This “Pull vitals” function should work the exact same way on the ward/CCU/ICU/ED if you were doing a procedure there (i.e. CCU cardioversion, ICU intubation)

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• As previously mentioned in training, unfortunately not all areas of the hospital will be able to push vitals data automatically into the Epic system

  • Monitors in the ORs (main OR, cysto, and FBC), block room, PACU, eye clinic, FBC (ORs and labour rooms), CCU, and ICU will all push vitals into the system

  • Places that use portable monitors (i.e. bronch suite, endoscopy, diagnostic imaging) are not currently in scope to be able to push data automatically into Epic, so any anesthetics provided in those locations will need to have manually inputted vitals - this is an area of active discussion and we’re trying to advocate for these to be built in the post-Go Live optimization period. This includes a renovation that Caroline is planning for the bronch suite to be able to accommodate automatic vitals in future state

• Specifically regarding the block room, both monitors are in system to push vitals data automatically to our anesthetic records. These are called “SJHC Regional 01” (left side bay) and “SJHC Regional 02” (right side bay) in Epic

  • I would encourage you to try out the workflow to see how it works best for you, but you need to manually associate the respective monitor to your patient’s chart for the time that you were using it in the block room (by using the “Device” button on the left-hand side of the toolbar in your Intraprocedure navigator), in order to see those vitals pull into your patient’s chart

  • For example, for a morning TKA in OR 10 - you would associate the “SJHC Regional 01” monitor with your chart from ~0730-0800 to pull data from the block room monitor, then associate your OR 10 monitor ("LACEY - SJHC ANCART 10”) from 0800 onwards to pull your intra-op vitals

  • If you don’t want to go through the process of associating and ending the association of the block room monitor from your chart, you can always manually enter vitals from that time into your chart

• If you’re called to do a procedure on the ward/ICU (i.e. lines, blocks, intubation), you’ll need to create an ad hoc anesthetic record/procedure encounter

• Find the patient on the Patient List, and double click on them - you’ll be prompted with a pop-up to create a new procedure encounter (the prepopulated options include Intubation, Nerve Block, Line Placement, Epidural Blood Patch, etc.) - if you’re doing something else, you can free-text it into “Other” and create your own anesthetic record

  • Most ad hoc records will not have many chart closing requirements (i.e. you shouldn’t need to do a pre-procedure or post-procedure eval

  • The most important things to document will be your anesthesia start/stop time for billing purposes, procedure notes, and medication administration. The preprocedure and postprocedure navigators are available to you if you need them, but they are not required to be filled out

• Difference/overlap between Medical History and Problem List

  • The simplest way of quickly documenting someone’s history is to primarily use the Problem List, and I suspect that this will be the most dynamic list that is updated by physicians throughout the hospital. Both the Problem List and the Medical History carry with the patient’s chart into the future. As mentioned previously, only physicians, NPs, and midwives can update the Problem List (unfortunately AAs are not included in that - an addition that we are trying to advocate for)

  • The Problem List was built to closely resemble the current front page of our anesthesia record (plus adding some things from SMH and some common diagnoses that we felt were missed from our current checklists)

• There is functionality to “Share” your note (see photo above), which essentially just means saving it to finish later instead of signing it for final chart viewing. This can be used if you’re pre-charting on a patient the night before an OR or PAT day, or if you just haven’t finished with your note and don’t want to publish it yet.

  • The note will be shared with the remainder of the anesthesia providers, but will not be published to the formal chart until it is signed

  • When you return to the relevant area (i.e. pre-anesthetic evaluation), you’ll see this note appear as “Shared” instead of “Signed” (see photo below), and you (or another anesthesia provider) can continue to work on the note by pressing “Edit in NoteWriter"

  • Note: in certain circumstances, the “Share” button may appear as “Pend”, but this will have the same functionality