Good morning, or good afternoon, depending what time zone you may be participating in this conference from today. Either way, we are very excited that you are joining us. I'm watching as the numbers are slowly picking up here. Our count was maxed at a thousand potential participants today, and we're continuing to track up. This is our first live ICU liberation session. And today's topic is entitled ICU Liberation Bundle Electronic Health Record or EHR Integration. My name is Martha Roberts, and I am your moderator for today's session. Been involved with ICU liberation for on and off for several years, and happy to have this opportunity to participate. Let us start today with a few housekeeping items. Please keep yourself on mute, unless I reach out to you to expand on a question. Please put your questions in the chat. I will be keeping my eye on the chat along with Christina from SCCM. And those questions will be handled in the sequence in which they are received. Next, we have our usual Society Critical Care Medicine disclaimer. I'm not going to read through this here for you, it's here for your reference. Just noticing we're having some in the chat comments on audio. I can hear, perhaps it could be an issue on their end. They can try dialing in as well. Okay, just didn't want to have that not be acknowledged. So please keep putting in the chat if you have any other additional technical difficulties. The agenda for today's presentation is really broken up into four parts. We have an introduction that will be short in about five minutes. That will be followed by an overview of the Epic Build, then an overview of the Cerner Build. And then we will have a few of our experts available to provide and share with us their user experiences and insights. And everyone will be here to help with our question and answer session, which will actually then target the specific items that those in attendance may have. So at this point in time, I would like to introduce Dr. Julie Barr. Dr. Barr is a staff anesthesiologist from the VA Palo Alto Healthcare System in Palo Alto, California. And she's going to provide us with a brief five-minute introduction to the A through F bundle. Julie, welcome. Thank you, Martha. Can everybody hear me okay? Okay, I have my Mickey Mouse slides on. I just want to say before I talk about this slide that I have no significant financial disclosures related to this topic. And as all of you know, the A through F bundle was created to translate the SCCM's ICU PAD and PADIS guideline recommendations into clinical practice. Now, the purpose of this bundle is to take an integrated approach to managing pain, sedation, and delirium in critically ill patients in order to facilitate ventilator weaning in mechanically ventilated patients, early mobilization of patients, and patient and family engagement. Several studies have demonstrated that bundle performance is associated with significant decreases in the incidence of deep sedation, delirium, and restraint use, the duration of mechanical ventilation, ICU readmission rates, hospital mortality, and SNF discharge rates. Bundle performance also has a dose response effect on these clinical outcomes. As bundle performance improves, these outcomes improve as well, with a 60% bundle performance rate being a significant inflection point for outcome improvements. Bundle performance is also associated with significant decreases in both ICU and hospital costs. Shea and colleagues demonstrated a 24% decrease in ICU costs and an 8% decrease in overall hospital costs with only partial bundle implementation. Fish and colleagues showed that bundle implementation in a single 24-bed med-surg ICU significantly reduced the duration of mechanical ventilation, ICU and hospital lengths of stay, and this saved the hospital over $1.6 million annually and $4.3 million over a five-year period following bundle implementation. Joan Brown and colleagues at USC demonstrated that EHR integration of bundle performance metrics, ICU staff data literacy training around these metrics, and giving staff access to weekly bundle performance reports significantly improves A-F bundle compliance, sustains bundle performance, and improves ICU performance. In addition to these metrics, A-F bundle compliance sustains bundle performance and improves ICU patient outcomes. The Society of Critical Care Medicine has created an evidence-based bundle performance metrics set specific to each bundle element known as the minimum data set. Here you can see the bundle performance metrics for the D, E, and C bundle elements. And here are the bundle performance metrics for the D, E, and F bundle elements. Over the past five years, SCCM has partnered with Epic and Cerner, the two biggest ICU EHR vendors, to incorporate this minimum data set into their basic ICU platforms. The ICU Liberation Committee is currently working with three other EHR vendors, including Pisces, CliniComp, and Philips and Telespace to incorporate the minimum data set into their ICU EHR platforms as well. The purpose of today's ICU Liberation session on bundle EHR integration is to give you an overview of the current versions of the A-F bundle and Cerner EHR platforms. You will hear from several subject matter experts who will share their experiences, insights, and recommended best practices for successful bundle integration into these two EHR platforms. This will be followed by a 30-minute Q&A session where we will address audience questions about bundle EHR integration. I will now turn the mic back over to our fearless moderator and veteran of the ICU Liberation Campaign, Dr. Martha Roberts. Thank you, Dr. Parr. That was a great recap of all the work that's been occurring over the last several years to lay a nice foundation as we now try to pull in more of the computer integration to help with the process. So at this point, I would like to now introduce Matt Aldrich and Matt Aldrich from the University of California at San Francisco, along with Patricia Posa from the University of Michigan. And they're gonna provide some groundwork here for EPIC in EHR integration of the bundle. Matt and Patricia. Great. Thanks, Martha. I appreciate the introduction. So hello, everyone. Glad to be with you this morning, this afternoon, depending on where you are. So I'm just gonna give a brief overview of what's included in EPIC Foundation to support all of your work with either implementation of ICU liberation or sustaining the work that you've already done. We've done a lot of work at the SCCM with both EPIC and Cerner, but I'll focus specifically on the work that we've done with EPIC to implement a number of new tools that we believe are helpful for both bedside staff and clinicians, as well as leaders in the ICU and hospital environment to better implement the bundle. So if you look at the new bundle tools in EPIC Foundation, you'll see that there's a storyboard column and a hover bubble where clinicians can rapidly review a patient's target arousal level. And then similarly, there's also a BPA to remind clinicians about the target sedation level that needs to be entered. We worked with EPIC to develop a respiratory recovery excavation protocol, and this essentially guides the coordinated process of an SAT and an SBT. There are a number of monitoring tasks for clinicians to also complete an EPIC that assists with your daily review of bundle implementation. The flow sheets have been redesigned to allow for smoother and more accurate documentation and monitoring of patient sedation level. And then there's a larger accordion report that we helped develop that really acts as the hub to see all of the bundle documentation that can then be used during your interdisciplinary interprofessional rounds with your critical care team to better understand where you are with each patient. We've also worked on developing a template that can be used to create a patient list. So you can basically look at a unit level to assess compliance with bundle implementation across a number of different patients. And next slide, please. So this is just an example or a demonstration of what the target RAS and the storyboard looks like and how the reminder works when an order is needed. And so this is the BPA. Essentially, you'll see this comes up and this allows just easier access to placing this target arousal order. In Epic. And then I'll just, next slide, please. I can show you some additional examples. So this, as I mentioned before, one of the challenges that I think many of us have working in the ICU is coordinating an SAT and an SBT and moving your patients towards extubation when appropriate. So this respiratory recovery extubation protocol is a visualization of where you are in this process in terms of assessing the patient for a spontaneous awakening trial, performing that trial, documenting success or failure, and then moving forward after the SAT towards an SBT assessment. So I'll turn it over to Pat. Yeah, I'm gonna take over and just talk a little bit about some of the other, show you the picture of what the other items look like. So this is a separate flow sheet for ICU liberation. So there's a tab that you can drop in or wrench in that has each of the elements of the bundle. You can use this to observe and review what elements have been documented on, or you can document on this flow sheet. One of the unique things, and as you build this into your system, is that wherever you document, so say, for example, I'm documenting someone's pain score, but it's on a different flow sheet, it will funnel into this flow sheet so that you don't have to double document. Also, you can see there on the right-hand side, there's some sidebar information that helps you identify what the compliance is for each of the elements. And that's based on that minimum dataset that Julie referenced. So for example, the compliance for pain is that you have six or more assessments completed in a 24-hour period. So go to the next slide. For the physicians, there's a specific view, and this summarizes each of the elements. And so that you can particularly see, and this can be used by the physician on multi-professional rounds. So it pulls all the elements together onto this one place. Go ahead to the next slide. Matt referenced this. This is the accordion report. So in your summary report, this is at the bottom of it. And so the summary report for you guys using Epic know that it has all your vital signs. It has, if you're on the ventilator, what infusions you're on, your INO. So everything that you need to assess where your patient is at is on that summary report. And at the bottom is the components, each of the components of the ICU liberation bundle. And so it will pull in documentation from the ICU liberation flow sheet or wherever you document in your workflow, the pain assessment, the SAT safety screen, and if you performed it, et cetera. So we're real nice. So this view can be seen by all providers. So this is a real nice thing to pull up during multi-professional rounds as well. And there are a couple compliance summaries that are available. This is the main one. So it's a patient list. So you create an ICU liberation compliance list and this gives you the ability in a one-stop shop to look at your whole unit, right? So say you're the intensivist rounding that day or that week or you're the charge nurse or the clinical nurse specialist and you wanna see how we're doing on the unit in relationship to compliance with each of the elements. This is a one-stop picture and you can see there's a legend there outlining what each of those symbols mean, but you can take a look and see, okay, I still have some opportunity here related to family and sedation on this first patient, et cetera. So it's a great way to take a quick snapshot of how bundle performance is happening throughout your entire unit. Epic is working on aggregate compliance reports. So this is a real-time compliance report, but you'll see in the Cerner that they have developed aggregate compliance reports and those are coming within Epic. All right, Martha, I'm gonna turn it back over to you. Thank you very much, Matt and Pat. Excellent Epic, get our feet wet, get our brains going as it's generated several questions in the chat. Now I'd like to turn it over though to Kelly and Julie who have the task of updating us on Cerner integration of the bundle into the EHR. Kelly and Julie. Hi everyone, I'm Kelly Drumwright and I will give a little overview of the Cerner bill. Next slide, please. This first slide here is a good opportunity if you're a Cerner user to scan that QR code you see on the screen or click the link. And this is an illumination session that Dr. Barr and myself partnered and gave a presentation with Cerner that gave an overview of the bundle itself and then from a few iterations and also let the Cerner consultants go over their product. So that's a great resource and that was recording 2021 but it's still got relevant information in there to check out. Next slide. This is a slide that goes over the standard model experience. So any users of Cerner right now, you have access to this. There is a model guide and to our phone link at the bottom also but basically similar to what they had in Epic. They have flow sheets both for the adult and pediatric bundle. There's a worthless organizer. And that is similar to what an interprofessional team might use to do rounding and get a snapshot of their entire group or unit. There's one for each, the PICU, I apologize, pediatric and adults. There's a critical care handoff page and that is going to be a tool that allows nurses perhaps communicate with each other how the elements of each, if the bundle were done per their patient and we're gonna see that on the next page. Also the analytics report that they were, Pat was teasing you about from speaking of Epic is what Cerner has right now and coming for them. Next slide, please. This is very hard to see here but all my Cerner users out there, you're gonna know what this is. This is the flow sheets that the nurses will do a lot of their documentation on. And it may look similar depending on your role because with these, with Cerner you log in based on your role. So they may have similar documentation. This is the band that is dedicated to the ABCDF bundle and similar to Epic also that if a nurse or anyone documents any elements of this bundle on another flow sheet, it's gonna pull it in. So you're not double documenting, triple documenting. It was hard to fit all on one page but this is basically one page that you scroll all the way down and can see the elements of the bundle documented. Let's go ahead to the next page. This is a little feature I like to highlight just from, especially from a nursing perspective. And I see some of the quality kind of questions in there. Like, how do you make sure your staff are documenting your RAS and CAM appropriately? Because I'm sure many of you have seen that people may chart, there's a RAS of negative two. So unable to assess CAM. So we were very thoughtful in trying to like, how do we drive that compliance in completing this or in a reliable fashion? So for example, what you're seeing on the screen, if a nurse or whomever documents a RAS at a negative three or above, it's going to allow, it will automatically open the next session, main section for the CAM. If you have a RAS of negative four or a negative five, it's not even going to open up the CAM. So those are like the two values that you would never be able to document CAM on. All right, next page. And here is another example of a little bit of conditional logic using the right pain scale appropriate on their ability to self-report or not. So previously to having available reliable tools like CPOT, we were probably guessing what the patient's pain was, just on looking at them using faces. So this prompts the nurse with a question, can they self-report or not? If they can, that's going to drive to you to probably whatever institution uses for a verbal pain scale. I'm with the VA. So we're going to use something called DPPRS. And if it's non-verbal, we're going to be driven to do the next step down with the CPOT. So I really appreciate that. The support nurse filling out the right scale. Next page, please. This is busy, but this is similar to what also EPIC had. This is the critical care work list. So if you have an entire unit or team dedicated to a set of patients, this is going to give you that snapshot of all the elements of the bundle, as well as some extras on there that might help support the team, like their diagnosis, vent settings. Those columns can be opened up and expanded a little more based on what you want to see. But it does have the core elements of the bundle in there. And like I said, extras in there like the vent setting. Next slide, please. This one is, if you were in the individual chart, this is called a workflow M page, and that's kind of a handoff. So I can quickly see across my shift or even over a series of days, how we have been compliant or non-compliant in filling out the elements of the bundle. And I just might have laughed here now that I'm looking at that because those numbers are not very good but what you would want to see if you run the clients with bundle, but we were reliant on some of the certain images, but this helps give the point of a nice, easy to view table there. Next slide, please. This is the analytics portion. And Julie, would you like to speak more on the wonderful use of the land of analytics? Or I can quick show them and let you talk a little more on how one might use these wonderful tools. You're on a roll. No, all right. Little Cerner speed dating here, everybody. Well, here's a link on the bottom there that you'd want to check out if you are using Cerner. This had been in testing for quite a while, but it's looking pretty impressive with what they built there. So anyone who's trying to do this by hand, this might move you to tears. It allows you to look at all the compliance and performance of each element of the bundle. If you want to check the next slide, please. That also breaks it down, overall bundle compliance, overall compliance with each element of the bundle also there too. And then it allows you to break it down by the dates, the facility. So if you want to have that collective, how do I compare all of my units in my hospital, or even if you're a larger system, how are we looking compliance-wise across the entire healthcare system? So I'm pretty impressed with what they've done here. And I'm really excited to see what Epic can do also. Would you like to try the next slide, please? This is one that shows kind of the other demographics you could break down and compare with. And even here's a world map, depending on where you are, how big your system is. You can select by patient encounters, unit wards, and you break it down by providers. So if you're kind of drilling down of how well is our bundle compliance doing when Dr. Barr is on board versus when Dr. Aldrich is on board. You might see like one helps support the team better than the other one. So it's kind of a nice tool to be able to look at your bundle performance based on provider. I think that is the last one we've got there for Cerner, but if Julie, you wanted to add any insight on that. Yeah, the healthy analytics I think is an incredibly powerful tool as those of you were looking carefully in the small font. The last two slides, you can really drill down compliance to a provider level, which is unheard of before in existing HR systems and hold individual providers accountable as Kelly implied. But also there are some health equity metrics in there in terms of geographic distributions, financial categories, et cetera. And then finally, it helps you to look at longer term outcomes outside the ICU in terms of their discharge disposition, which has the attention of CMS right now. So yeah, there's lots to chew on there. And we're really excited about this piece of it because providers really don't know what they don't measure. And so measurement takes a lot of forms across these two EHR platforms in terms of real-time measurement to see how individual patients are doing or a collection of patients in real time. But also longitudinally for QI purposes around the bundle, you can really see if the interventions that you're making to improve bundle performance are working. Great. Once again, an excellent review and comparative giving everybody a lot to think about here based on their systems. At this point, I'd once again like to thank everybody for their presentations. And now we would like to get transitioned into our question and answer section. So we have four participants today who have a lot of experience across the board with either Epic or Cerner. We have Dr. Seymour Aboul-Soltani, Chris Howard, Pat Posa, and Erica Setliff. And I'm gonna start off with like four very kind of quick questions. Actually, I'm gonna combine one. These questions were submitted early on via Connect. And then Christina and I have been keeping a pulse on the chat. So then we will slide over to that. So just to open the question and answer section for this afternoon, our first question, what challenges did you face throughout the process of implementing the bundle at your institution? And how did you successfully navigate the process? So can we start out first answer today? Can I direct that to Erica? Hey, thanks, Martha. So I'm Erica Setliff. I'm a clinical nurse specialist currently with our virtual critical care at Atrium Health in the Charlotte area. And interestingly enough, I've actually worked with ICU liberation in both Cerner and Epic. We had the original Cerner build and were part of the cohort that worked on that way back. I wasn't directly involved with it at that time. So I was more on the facility and implementing with what was there. And we really had a lot of good data support at the time that helped us to drill down into what we were doing. I would say from a challenges perspective, when we moved from Cerner to Epic, we did get the Epic Foundation, which has a lot of tools in it, but it was changing in the middle of where we had people used to a particular way of documenting and where we had really customized some of the builds. And it did take some time to work with our clinical informaticists to kind of reintroduce some of the familiar pieces, but also keep that foundation that had a lot of the good logic built in. Okay, thank you very much. Seymour, with your PD forte, how would you like to answer this question? Thanks, Martha. I think we have more challenges in pediatrics. I think the first thing is a buy-in. We didn't have guidelines. Even the initial cohort was a small cohort for ICU liberation. So I think the community, there's more increased interest of ICU liberation in pediatrics. And I think nationally for me, I think how things work is being involved at the SSAM ICU liberation and try to modify the minimal data set, the Cerner build, the Epic build to adjust for the tools and practices that are used in the PICU. That's nationally, just to make sure that, we speak the language that pediatric practitioners use. Locally, I think it's more challenging because the buy-in is difficult. You need money, you need support from IT to implement this. So we think about ICU liberation as a bundle, but unfortunately, six, seven years ago, since we didn't have that much of a buy-in, we did it as separate. So we introduced an SBT first and then introduced delirium mobility. And currently we're working as the Cerner build is being implemented to do it as a bundle, to put all of the documentation that we use over the years to do it as a bundle. So it's, again, now we think about it as a bundle that everybody, even pediatrics should try to implement it as a bundle. But I think over the years, I think many of us that they work with this as we are building it, they did it as pieces, not a full bundle. Thank you. Dr. Christopher Howard, your thoughts. Yeah, thanks. I think a lot of the success or challenges for implementation for us so far, we're kind of in the relatively early stages. I'm at Baylor St. Luke's, we're a large tertiary medical care center, but we're also part of 140 system hospital system, hospital system, a common spirit, and they all have their own protocols that existed prior to implementation of this. So for example, we had a very robust SAT-SBT and sedation tracking system. So we're adding these other elements in. So it's new from a practitioner standpoint and documentation standpoint, but also the processes that we had before aren't exactly in step with the process that are introduced by the bundle. So this has to do even with just the basics of an SAT eligibility clearance or an SBT screening clearance, the safety clearances that we all go through. There's small nuance changes in those. So we're in the middle of a discussion of trying to figure out, do we keep our local process? How much of the national system process do we adopt? And then the third component is how much of the SCCM specific components do we need to go back and argue about PEEP levels and safety and FIO2 levels? So it's really kind of made us kind of almost start back at the beginning of even just our protocols in general. So that is an ongoing sticking point for us that a lot of people are working hard on trying to reconcile. That kind of brings up a side point as to how much of the SCCM bundle are we allowed to change? I know there's a copyright questions that came up. I don't know if those are completely resolved, but I understand that we can make local modifications if we need to. And then the other big one was data entry that was mentioned earlier. This has been a challenge for us because we have data entry points that we again have been using for several years, some of which carry over into the SCCM mode, but actually some do not. And so we're working through that. And for those of you that may work in two or more hospitals with Epic, you know that not every Epic is exactly the same. And so those challenges have arisen as well. So we're still working through some of these integration components. Theoretically, it's such a fantastic tool, but we're still working through some of these integration elements. The report card I'll leave in case we have time at the end, we could talk about the data process on the background of what the reports look like. We've had a few challenges there as well, but I'll stop and let a few other panelists comment as well. Sure. Thank you, Chris. Pat, your thoughts on this question? Yeah, so challenges. So we were very fortunate at University of Michigan. We were able to prioritize bringing down the foundation Epic build for ICU liberation, but it took a while because you had to crosswalk the flow sheet rows, and maybe you had to find them a little bit differently. So you wanted to make sure that they aligned so that we were in compliance with both the SCCM ICU liberation guidelines, but also the minimum data set so that we were to ensure that when we then had data and our compliance was the same for that patient compliance list, the real-time one. And so just some nuances. And in answer to Chris, you had talked about what can be changed and what can't be changed. So the elements that are assessments like the RAS and the CAM, those cannot be changed, but you might need to change your SAT criteria. So like we've added an SAT fit or criteria to our safety screen of therapeutic hypothermia, because when the original ABC trials were done, that wasn't included in it, but clearly it's something that needs to be included. So we have made a few of those nuances, and I think that's kind of the position of SCCM. If it's an assessment tool, you can't change those, but you just have to be careful if you're changing criteria to perform SAT and SBT that you don't contraindicate everything, and then you're not really giving those patients an opportunity to be liberated from sedation or mechanical ventilation. So that was probably the challenge was getting all the stakeholders together to crosswalk and make sure we aligned so that the reports were there. So it took a while. It's not turnkey, download it, and you're set to go. All right. Thanks, Patricia. Next question for our group. Could you share some instances of effective strategies for seamlessly integrating the ICU liberation bundle into your system, drawing from your personal experience? Can we start this discussion with Chris? I'm gonna offer a highly probably impractical solution, but there are many times where I've had side conversations with my colleagues trying to get this implemented and saying it would almost be easier if we had nothing in place beforehand where we could just have a clean slate and just bring the SCCM process into and just start with nothing else and just use that alone. Or if you're in a position where you don't have any need to adhere to what you're currently doing and just adopt these policies and procedures and protocols, that would be easiest, but I think that would be a hard task for any hospital to take on because there's so much that exists in many different places. It just looks very different depending on where you are. So in terms of seamless, that's hard to do unless you're willing to start from scratch. This is a, I've really emphasized just, it's been an unbelievable multidisciplinary process, tons of communication, getting to know your IT colleagues extremely well. And that's really the best I can offer. It's not a, there's no kind of a special, I think, recommendation. That is the challenge, is how do you integrate this into your current system when it requires so many different pieces of your administration and your hospital and your expertise to do? And it's just not easy. It's just not easy. Thank you. Erica, how about process at your site or thoughts? I love the word, I love the word seamlessly in the question because unfortunately this doesn't have the staples easy button for implementing. It is just constantly keeping it on the forefront and finding new ways to try and engage the staff. I will say that, I feel like the process piece is on us as leaders to make sure that the structure is there, but really having to partner with, to use the word multidisciplinary team again, it's gotta be the whole team together speaking the same language. For example, we were having a really, we had a great work group going with our liberation standards, looking at our data, bringing new focus every month and trying to do that just great collaborative review. And months into the program, one of my physician champions actually said, hey, I'm a little embarrassed to say this, but at the time we had ICDS-C as our delirium screening tool. We now use CAM-ICU. She said, I trained CAM-ICU, the nurses tell me the ICDS-C score and I have no idea what it means. And that was one of my champions. And so making sure that we even use the same terminology when the nurses are reporting off about a score, are we all using the same language about that? If my process says that we should be doing an SAT on the patient and someone overrules that in rounds and says, oh, just leave them be for today. Great, can you explain why? Because we'd really like the default to be that we are doing our process. Mobility should be the process. I shouldn't have to ask permission to mobilize. If they pass the safety screen, we shouldn't be waiting on that prompt during rounds and asking permission, it should be automatic. So I think that some of the effective strategies we've used definitely have to have data, but I'm gonna advocate data in context. I think having some of the high level overall compliance data is good, but you really also have to drill down to the individual level. I would do liberators of the week and just go into charts till I found people who did 100% of their stuff for the day and bring them a Starbucks. Just, hey, you did the right thing. Great, you're my liberator of the week. We did the Go Forth and Liberate campaign, fourth of every month. We did a theme and here's what we're focused on and here's what we're doing for this theme. Theme of the week, putting it out there and just, we're all focused on delirium today, but it's gotta be the whole team and it has to be constantly in their faces because otherwise it's just, it's routine and it's noise. So it takes a huge team. It takes commitment, leadership, day shift, night shift, delirium contest. Who's gonna have the best compliance this month? It's gotta be the team and with that support so you can do prizes and recognize people for doing those right things for their patients. All right, thanks, Erica. Pat? Yeah, Erica, you hit the nail on the head for how to seamlessly integrate. Just like any other practice change, you wanna make sure your practice is consistent with the evidence, but in order to reliably provide those interventions each day, I think one of the best strategies is incorporating it into multidisciplinary rounds. And most of our ICUs took a, we took a hit and backstep on ICU liberation with COVID and so we've had to reboot it and reeducate. And so one of our units is doing exactly, Erica, what you said, picking a theme of the week or a letter for the week in our surgical ICU and they've done a great job having a fresh start and went back to the basics and then giving feedback to people and making sure it's incorporated in interdisciplinary rounds and that the nurse takes that role of, since most of the components on there, besides the SBT, the nurse has firsthand information on. So I think that's integrating it, you're putting it in multidisciplinary rounds. You can have the documentation, but if you're not following up, and like you said, Erica, and drilling down and making sure that, and I saw someone in the chat ask a question about, people are doing the RAS wrong or the CAM ICU wrong. Well, pulling it and having those documentations in your EHR aren't gonna fix that. You're gonna have to understand. I mean, I like the tool in Cerner that doesn't, that opens up the CAM ICU when you have a RAS of minus three or greater. One of our units is gonna put in a BPA for nurses when, if they're documenting a sedation level that is different than the target RAS. And to remind them, your sedation level, you're documenting a minus three and your target is a minus one, consider decreasing sedation. So lots of different ways to integrate it. And the EMR isn't the panacea that's not gonna fix everything. You still need to talk about it every day and provide feedback to staff. All right, thank you, Pat. I see Julie has her hand raised and I'll defer to her. And then we're gonna start with questions from the chat. So thank you. Yeah, I just wanna build on a couple of themes that Pat and Erica have alluded to that have also popped up in the chat. You know, EHR integration is not the magic bullet that's gonna help your organization fully implement ICU Liberations A through F bundle, but it's an important cornerstone to that process because if you can't measure performance, all your other efforts around education and team building and vying for leadership support in particular isn't gonna go very far. So EHR integration is what I call one of the four pillars, but also educating your staff. And that's such a challenge right now for two reasons. One, everybody's still short-staffed, I think. And two, the people that most of us are hiring have little or no experience with ICU Liberation and the experts in ICU Liberation within many healthcare systems have left in the wake of the pandemic. And that's the reality of it. So we are kind of starting from scratch. And the other barriers are a lack of leadership support for this and at risk of sounding callous about this, at the end of the day, it's about the money. And you need IT help locally within your organization to get ICU Liberation to float to the surface of your EHR, period, hard stop. There's no way around it. Some of these things that we've shown you today are canned and readily available. Some of these things you're gonna have to activate to see. So you have to get the attention of the people in the C-suite to allocate IT resources to help you with that. And that's a really important piece of this. So being able to make the business case for ICU Liberation, that FISH study in particular is powerful and contemporary is key. But as I think Pat said, even organizations that were doing ICU Liberation well before the pandemic have been set back. And there are two before and after worldwide surveys that show that ICU Liberation bundle performance dropped by more than 50% during the pandemic. So we have a long road back. Thank you for that perspective, Julie. We're gonna hop into the chat now and as we mentioned earlier, we will go in order of the questions as they appeared. I may need some clarification here. So the first question I'm seeing is, do you have any workbench reporting templates or dashboards built, I'm sorry, to use for a QI implementation? It looks like it came from HowlD2. Were you speaking about either Epic versus Cerner or in general? Can you just answer that question for me if you're still on? Yes, so the, hi there. So Dan Howell here at New York City Health and Hospitals. So Epic has a number of reporting capabilities including reporting workbench and dashboards. And they basically, reporting workbench would be able to give you a report of say, for example, hey, in the past month, how many of my patients that had a rascal order of zero to minus one actually had a rascal of zero to minus one documented in their way. So it's a way of looking at your data that you put into flow sheets. And then dashboard basically puts that data into a live, it's like a webpage basically that you can see every day. So you can say, hey, this patient's in compliance, this is not a compliance, this is in compliance. So it's kind of like a question for Epic. Okay, and it looks like Pat has her hand raised. Pat. So the daily compliance, you can see part of the bill that you can pull down is that patient list or that daily compliance. They have not, Epic has not put in aggregated reports yet like Cerner, but are in plans to where, and I think sometime early calendar year 24. We couldn't wait. We needed data. So we did work with our IT department and our quality analytics department and pulled in, I'm not sure if they use the clarity report writing or something else, but pulled data from the flow sheet rows. And we first started off with the minimum data set and built the minimum data set for each bundle. And then we'll expand to have questions like, answer questions like you just posed where, what percent of the time are you in your target RAS range, right? Which is a very important value to know because sedation drives all of the elements in the bundle. And so it's important to know that information. So some of that should be coming for Epic in early 2024. Great. Thank you very much. Next question in the chat, are the respiratory recovery extubation protocol view in the liberation flow sheet built in Epic such that we can just request them at our institution or would our individual institutions need to build them out? Respiratory recovery extubation protocol view. So Matt, that's the care path that you showed. Yeah. It's in foundation. Okay. So does their IT need to reach out? They do. And I will just say, I mean, I think one of the, this is a good question because I think it gets at some of the challenges people have with the implementation. If you go to the IC liberation website and you look at, you go into the EMR integration, you'll see that there are QR codes that you can download that will take you to the specific information you need about integrating the IC liberation content from foundation. And this is where I would say, as you're trying to make the connection with your IT professionals, I think this is where you need to direct them so they can see how this can be done. And they can see quickly in the background what content's available. Some institutions may desire a custom build at UCSF. We, because we had our very custom build Epic system, when we integrated the new content that was available in foundation, we did it through this sort of the standard Epic integration protocol. But so that took a little more work on our end, but it was there. We knew what content was available and we were able to get all of the content that we've highlighted so far in this meeting. So it's there. It just, it does take some work though. And that's why on the SCCM side, we've tried to make it easier for you so you can facilitate that conversation with your IT teams. Okay. Thank you, Matt. Next question in the chat. Are the current vent settings on the summary report? So on the summary report that I showed, yes, the vent settings should be there, but I don't know if we customized. Erica, can you, are they on yours? I don't know that our exact view looks the same, but what I have found is that working with your informatics team, a lot of times they are able to pull different pieces over. For example, we're working on integrating our mobility a little bit differently than what comes in, sorry, Epic foundation, so that it's kind of all in one place instead of just the two or three questions that are in Epic foundation. So they should be able to work with you on that if that's something that your team thinks would be useful. I don't know if it's on all of the builds, but it should be. Thank you from a Epic standpoint. How about Kelly or Julie from Cerner? Any answer or applicability of this question to your build? Kelly, do you want to take that? Yeah, this is Kelly. On the work list, I think that was shown on one of the slides where you can see the whole team and have all those columns. One of those did have vent settings and that is kind of, Pat, you and others have been saying that based on your site and your site's IT people, after you acquire the system, you may be able to tweak that a bit and customize it. But the core package is as what you are seeing on the screen and the links provided is like, here is the package created in partnership with SCCM and such. But yeah, if you wanted to use a different pain scale than what's in that standard content there, that might be where you and your IT department may have to work with Oracle or Cerner. And that may be based on your site's skillset if they're able to do it themselves. And I'm speaking for the VA, we had tried to try to standardize across the nation really limit the amount of, hey, site A, I wanna use this pain scale, this over here. So we're not dealing with that. So we're dealing with national contracts and that also helps with the comparison of data. So you're talking apples to apples, so. Very good. Thank you. Next question in the chat. How do you consolidate or resolve mobility events? Example, activity or exercise being charted by different groups? PT, OT, RM or CNAs into a coherent picture in this bundle? So we have them share the same flow sheet row. So physical therapy, nursing and techs will share the same flow sheet row related to activity. That it's part of the dropdown box in the different activities. Okay. I'll add just one small comment which kind of illustrates a larger issue that we're still walking through is, there are multiple people and multiple disciplines involved in one single process. Mobility is a great one. We kind of came to the decision, whether it's the right one or wrong one, we'll figure out that we kind of designated the nurse as the documenter. Because if that's missing in our report, that mobilization was not done or perhaps it wasn't just documented, we wanted kind of a single line, a kind of a chain of command in terms of understanding, kind of just accountability for documentation. So we initially, we were hoping to just involve anybody that's possible, just put it in that data line and that way we'll get it accounted for. But then we realized we were kind of losing, when it wasn't there, we were kind of losing accountability for who to go to and how to actually fix the problem. So even if the nurse isn't the primary mobilizer, for example, we were still asking the nursing to be responsible for the documentation. Again, just for that kind of line of accountability pinpoint, these are the details that take a long time to kind of work through at the working level to bedside. Totally appreciate that. And everybody has the nuances of their own unit sometimes to deal with with that. Next question in the chat. We have EPIC. Our RTs complain that they have to document in their usual respiratory flow sheet in addition to the liberation form. What's your comment to that point? So that's probably how you built it because the essence is anywhere you documented, it goes to the ICU liberation flow sheet. So you shouldn't have to double document. And Erica and Chris, are you finding the same? And Erica and Chris, are you finding the same? Yeah, actually in some places, yes. And it goes actually for our nursing as well. That's part of our process that we're walking through is trying to, when we're out of compliance, how do we go back and figure out which data cells specifically counted us as being out of compliance? And then we'll find sometimes where the cell is open, but we know that the nurse or RT documented somewhere else, we can go and find it. So we're still walking through that process. How do we make sure it's just one single place? And then how do we make sure that actually registers in the report card that we were in compliance to get that nice green check that we're all looking for? One more question from the chat, if we can keep to like it, because we're approaching the top of the hour. So about a two minute answer, because I know Christina has a few closing comments relative to today's event so that everybody's on the same page. So this next question is in the Cerner sedation band, could you bring in drips and rates? So Kelly or Julie. Hey, this is Kelly. For those snapshot views, we did not specifically pull the drips in there because that could end up getting a lot of real estate on the page. So I think just for the sake of, am I compliant with the minimum data set? We're not asking exactly what, that's something to be analyzed down the way, but it is available in a chart, a little quick click here, quick click there to see what is my current rate there. But just for the sake of a snapshot, we wanted to kind of be minimalistic. Okay. Actually, that was a very nice quick answer. So we'll see if we can squeeze in one more question. For Epic, is there any place for documentation for non-pharmacological interventions for patients who are positive for CAM-ICU? I can take that one. That's a field we're actually working to customize here soon as far as either prevention or treatment if a patient does become positive for delirium. And I really like putting lots of options here because I think sometimes documentation can be a prompt for nursing to think about some of those non-pharmacologic interventions. If you see it and have your constant clicks, it is a little bit of a prompt to go and do some of those pieces. So that's something I would work with, again, your local team, if you have protocols to specify. We're not gonna change the assessment tool, but we can absolutely customize interventions or preventions that should be in place based on our local delirium work. All right. All right, thank you. At this point, I would like to thank all of our presenters and experienced implementers, we'll call them. So thank you going out to Julie Barr, Matt Aldrich, Pat Posa, Kelly Drumwright, Samir, Erica, and Chris. And at this point, I'll turn it over to Christina for a couple of closing business items relative to today's presentation. I will note all of the questions from the chat, there will be follow-up emails to share information, and we did receive a lot of other questions as well. So please don't think that they're not gonna get answered, but can I turn it over to Christina now? Yes, thank you, Martha. And I would be remiss if I didn't also thank Martha for moderating the session today. So thank you, Martha, for that. We just wanted to quickly highlight some of the resources that are available on the SCCM website. On the landing page there, there is specific information for Epic users that you could essentially just, it's meant for the IT folks. And so if you ask them to scan these codes for both the adult build and the pediatric build, it will take them to information on the user web, which will help you get started with integrating the build. So I'll pause there just for a second, allow people to grab those. And then for the Cerner folks on the call today, Kelly did highlight some of these resources already, but there is a QR code that links out to the model page, another one that links out to the healthy analytics information, which contains the report information, and then a link out to the illumination session that was done with SCCM back in 2021. And for those who've been asking in the chat, yes, we will plan to share the reporting with all of you that attended today. And as Martha mentioned, for any questions we did not address in the chat today, we will be following up via email. And with that, I think we will go ahead and close our session and thank you all for attending. Thank you. Thanks, Christina. Thanks everybody. Everybody, bye-bye. Thanks everyone. Thanks for coming, bye. Thank you. Go forth and liberate.

ICU Liberation Bundle

electronic health record

EHR systems

Epic

CERNER

implementation challenges

seamless integration

buy-in from staff

multidisciplinary collaboration

bundle performance