Hi fellow Clinical Informatics, CMIO, CNIO, HealthIT, and other #workflow friends,
Sorry about the delay in following up my last post - As most people can probably understand, the COVD-19 pandemic has been a very busy time in healthcare.
Anyway, in my last blog post - I introduced the surprising complexity of a lumbar puncture - Not to complicate a fairly simple bread-and-butter clinical procedure that's performed in healthcare settings every day, but to help create clarity and understanding, set expectations, and help reduce clicks while delivering a great user experience that your providers can use to deliver great patient care.
To help understand the complexity of this workflow, I thought I'd even share this academic poster which was developed by Deandra 'Uju' Momah, MS4, an outstandingly talented medical student from UConn Med who I've had the honor to work with. At a recent AMIA conference, Uju presented her academic poster which very nicely summarizes the workflow issues :
The take-home point : Diagnostic LPs are not one workflow - They are at least four. (That is, if you carve out intrathecal chemotherapy, epidurals, blood patches, and therapeutic LPs.)
I recently had the opportunity to discuss LPs to an online audience of new Informaticists - below are some of the slides from my presentation, which I'll borrow and annotate here for clarity and educational purposes.
- There are some PRE-LP labs, that are typically collected 24 hours before the procedure, to help establish that it's safe to proceed with the lumbar puncture lab. (They often include a simple BMP, CBC, and PT/INR.)
- There are other PRE-LP serology labs, that are typically collected 1 hour before the procedure, for diagnostic purposes. (They often include a serum glucose, serum protein, and in some cases, oligoclonal banding.)
- There is the LP procedure order itself, used to schedule the procedure and plan charges for doing the procedure.
- There are four BASIC LP labs, that most docs use for general purposes, including a CSF cell count and differential, a CSF gram stain and culture, a CSF glucose, and a CSF protein.
- There are some additional speciality-specific CSF labs, which can be very complex and specialty-specific. (Some of these can be very expensive, and so care should be taken so that they are not ordered unnecessarily or by accident.)
- Finally, there are a limited number of nursing orders, mostly importantly a nursing communication order that allows the ordering provider to give the Interventional Radiology nurses a 'heads up' on any unique patient needs.
- FOR ATTENDINGS, FELLOWS, AND RESIDENTS - Routine diagnostic LPs - Mon-Fri 8am-5pm
- FOR ATTENDINGS AND FELLOWS ONLY - ROUTINE Malignancy Evaluations - Mon-Thurs 8am-12pm
- FOR ATTENDINGS AND FELLOWS ONLY - URGENT Malignancy Evaluations - Friday-Sunday 8am-12pm
- FOR ATTENDINGS AND FELLOWS ONLY - PRION Disease Evaluations - Mon-Fri 8am-5pm
And here, if an Infectious Disease provider were to click their section, the order set can now produce the tailored, specialty-specific orders that the provider needs :
- Scenario = Specialty, outpatient LP for collection in IR
- LP type = Diagnostic
- User = Attending, Fellow, or Resident
- Specialty = Infectious Disease
We are now working with our department Chiefs to help confirm the final orders (to appear in the fifth section of each specialty-specific area), and maybe once they are completed, I can help publish the final result here.
Remember, this blog is for educational and discussion purposes only - Your mileage may vary! Have any recommendations or tricks to share about designing lumbar puncture workflows? Feel free to share in the comments box below!
Excellent. I would like to discuss this with you in detail.
I am a Critical care Physician and work mainly in a NeuroIntensive Care unit and I am a Epic Physician builder.
Ernesto Brauer, MD
Both excellent, see my previous comments
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