Millennium Downtime Label Program

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Millennium Downtime Label Program

Purpose: When the Millennium system goes down, we still must continue to process urgent lab orders. This procedure describes the use of a stand-alone system to generate bar-coded accession labels that can subsequently be entered into Millennium after it is functional again. The system can also be used to ascertain whether samples for a specific patient have been entered into the down time program. This system works only as long as the DHMC network is functioning. If the network is down, the pre-printed label system described in the Millennium Downtime Procedures document should be used.

Procedure:

Downtime Notification and Management:

Upon notification from the IS Ancillary team that they system is truly down and expected to unavailable for an indefinite period of time, laboratory staff and staff in remote facilities will be notified of the event and the expectations of the duration of the downtime, if known.

During Week-day Business Hours:

The LIS Manager or designee will, after conferring with the IS Ancillary team, take the following steps: 1) an email broadcast to LABMHMH, LABRESIDENTS, LABFACULTY, and LABLISDOWN to notify them that the system is down, and to advise them to activate their down time procedures 2) request the Administrative Support staff to mass page all supervisors and pathologists that the system is down,

3) page or phone the Administrative Director of the lab (or designee) as to the status of the system and expectations as to the duration of the downtime, if known,

4) ensures that IS Ancillary has gotten a CIS Message of the Day posted, and a broadcast email to the IT Outages RSS feed.

Once these steps are accomplished management of the down time process will be turned over to the Administrative Director or designee. The Administrative Director will be kept informed by the LIS Manager and/or IS Ancillary team as to the status of the system, and will be the person who issues the “All Clear” to the users to resume using the system. The “All Clear” will be issued both in email and by mass paging the same groups that received the original notification of the system unavailability. During Off-Hours and Week-Ends

The IS Ancillary Team will call the lab at the 650-2200 number to inform the laboratory staff as to the status and expected duration of the down time. The laboratory will designate a staff member to act as Manager of the process until recovery from the down time is complete.

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Downtime Processing

For the Lebanon lab, this program is found at the following URL: https://DH658/catalog/labels.php This is a secure web site that can only be accessed from inside the DHMC intranet. For the Southern New Hampshire labs, the program is found at this URL: https://DH658/catalog/downsouth.php The only difference between the two programs is the list of printers in the drop down list.

1) When you first access this website, you will get a message saying “There is a problem with this website’s security certificate.” Click “Continue (not recommended)” to get to the program. 2) The following screen appears.

3) When you get into the downtime label program you must pick the printer you want the labels to print to from the drop down list. The ones listed are all that are available; if the printer you want isn’t listed, it’s not one you can use. Once you pick it, it persists until you exit the program and log back in. If you wish to use the system to find out if a specific patient’s samples have been entered into the system, pick the “Test Only” printer. If two people pick the same printer, their labels will both print to the same printer and may be intermingled. This should be avoided in order to reduce the possibility of labeling errors. The three digit Julian date on the label is different for each printer in an effort to make it clear where the tests were ordered in case there is a question about the information on the requisition

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4) Fill in the MRN or name (last_name, first_name) or both and click “Submit”. This will bring up a window showing all patients that match that MRN or match the name. Click the radio button next to the correct name with the correct physician and encounter to select it and then click “Select Patient.” Not all patients may be in the system; see point 11 below. If the patient is not in the system you will need to register them. If the patient is in the system but the encounters are discharged or incorrect, you may create a new “encounter”, which allows you to change only the location and the physician.

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5) Required fields are highlighted in red. The more complete the information the better, but the red fields MUST be completed. Admit means Admitting (or ordering) provider. The location is useful for the techs to know where to phone critical or STAT values should that be necessary.

6) Once in the ordering screen, the boxes under the title Procedures are where the test orders are placed. The collection date and time default to the current date and time, but can be changed

Registration Screen

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as needed. Using the usual Millennium test names, enter one test per box, tabbing to the next field. Priority of testing and report is selected with the radio buttons under the test name boxes. All the tests on a single patient will be ordered with the same priority; we do not have Millennium’s ability to mix priorities within a single accession number. Caresets can be ordered as well, see point 15. Note that Microbiology orders can be ordered as well.

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You can also see orders previously placed on this patient and labels can be reprinted, orders can be added on to already existing accessions, or those tests can be cancelled, if appropriate. The detail to the right shows what has been ordered previously. If you are using the program to determine what samples are in the lab, use the reset button to go back to the first patient look-up screen. You cannot find any results in this program; you can only ascertain that a sample has been entered in the down time system. You cannot tell where the sample actually is, just that it has been entered into the system.

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7) After entering the mnemonics for the tests, a screen will appear that will require you to pick the appropriate test from the drop down lists. All tests will display a drop-down arrow, but only some will require you to select the correct test. In this set of orders, both GLUC and Cre had multiple choices, and both need to have the correct test selected. You will need to check each test.

When the correct tests are all selected, click on the “Submit” button to submit the orders and the labels will print to the selected printer.

8) The labels are in two parts. The label on the left side (outlined here in red) goes onto the specimen; the labels on the right side (outlined here in yellow) are kept to be used to enter the work into Cerner after the system comes back up. This area includes a coded MRN, a bar-coded Accession number, the tests ordered, and the collection data and time so they can be correctly entered when the system comes back up. All the labels on the right hand-side should be stapled to the original requisition.

The small aliquot label below the specimen label (outlined here in blue) has the patient name, MRN, accession number and patient location. This is for the technical sections to place on their printouts so they have this information.

MRN barcode

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9) Micro Cultures can also be ordered in the Downtime Label system. The following is a screen shot of the ordering screen. Source and Site should be entered as they would be in Millennium.

10)The Microbiology labels are similar to the Gen Lab labels, but routinely print out two where the other blood labels print out one. A reprinted Micro label for any sample other than Blood Cultures will print out two more specimen and four more aliquot labels to be used in labeling media.

11)A special function has been added for Microbiology blood cultures so that those can be placed into the incubators properly labeled. Blood cultures are ordered in the downtime program as described above, and then the labels are reprinted, which causes the correctly formatted label for the incubator to be produced. Below are the two labels, the original label that printed for Blood Cultures and the second reprinted Blood Culture label, with the correct labeling for the bottles. This is the only Micro culture that has such a capability.

12)Requisitions should be segregated by priority with STAT’s and expedites as one set, and routines as a second set, in order to facilitate entering the STAT’s during the recovery phase first. They should be sorted by accession number as well, so that add-on orders can be placed in the same session but after the original order. Failure to do so will cause container ID’s to be erroneous.

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13)As much as possible, we try to incorporate into this database the demographics of all current inpatients and outpatients with visit dates in the next few days. It will not pick up patient demographics for patients admitted during the downtime; those will have to be registered by hand, see point 5 above. This extract is only run once a day, and therefore may be out-of-date in some particulars.

14)Because we extract the patient data once daily, it is possible that patient locations may not always be accurate; be aware of that possibility.

15)Tests that are caresets in Millennium can mostly be ordered as such in this program. In general, ordering of Molecular Pathology and Cytogenetics should be left to the staff that order them in Millennium ordinarily.

16)Depending on the decision of the Administrative Director in the lab, the requisitions for all outpatient work ordered at Level 3, 3K/HOC, Level 5, and PAT with their attached right-side downtime labels may be sent to Path West, as those orders will be entered into Millennium by the staff in Path West after the system has come back up. This will allow the larger staff in the main lab to enter the work while allowing the outpatient phlebotomy areas to continue drawing and attending to the outpatients without having to try to catch up all the downtime work at the same time. In the Southern Region labs, each lab will enter the orders they placed in the downtime system themselves.

Recovery Processing in Millennium

1) When Cerner comes back up, these orders will be entered into Cerner and will generate the same container ID’s as the down time program did only if the tests are entered into Cerner in the same order they were entered into the downtime system. The labels attached to the requisitions must be entered in the order they display on the first label, for the container sequence to be correct in Millennium. This is extremely important in order to assure that the container ID's and accession numbers match the downtime labels exactly. Add-ons must be entered after the original set of orders is entered.

2) Entry into Millennium MUST be done through Department Order Entry because it is the only ordering application that is designed to allow the assignment of a specific accession number. In the Department Order Entry window the Manual assign accession entry field (outlined in red below) is immediately after the Specimen Received by field.

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3) Patient demographics are selected as usual in DOE and the order process proceeds as usual for a collected sample at Path West or Micro (as appropriate), but before adding the order to the scratch pad, the manually assigned downtime accession number must be entered in to this field. You must do this for each test. Only the numbers will be entered. The container letter will not take.

4) The MRN and the downtime accession number can be scanned from the downtime label with a barcode reader to make the data entry easier. On the right side of the label the upper barcode is the MRN and the small barcode on the aliquot label is the accession number (see point 8 above.)

Be very careful when transcribing or scanning these numbers to be certain they are correct. There are multiple different Julian dates used to distinguish the different ordering areas from each other, so you must be certain that you enter the entire nine number string correctly. Hitting the Enter key in this field will enter in the current year and Julian date which is NOT correct for the downtime numbers. If manually entering these accession numbers, type in the accession number as a single string of digits: no dashes or tabs should be used or the number will not be correct. Take your time to do this correctly; mis-assigned accession numbers require a lot of work to get the results entered into Cerner, and could lead to results for one patient getting sent to the record of another patient.

To facilitate scanning the barcodes, after scanning the MRN, you can use a dark black pen to black out the MRN barcode so that you can scan the accession number barcode without interference.

5) Further instructions on the use of Department Order Entry can be found in the Millennium Department Order Entry procedure in the Pathology Department Document Control system under Support Services, Path West Specimen Receiving.

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6) Staff from areas besides Path West will be assigned by the Administrative Director to help enter the work after the system has come back up.

7) The labels that print as a result of this data entry are for the most part not needed for sample labeling, but should be attached to the requisition to serve as verification that orders have been entered into Millennium.

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Appendix A: Caresets and their tests.

Careset Tests

2 Hour GTT Gluc Baseline

Gluc 0.5 Hour Gluc 1 Hour Gluc 2 Hour

Gluc 0.5 Hour Gluc 1 Hour Gluc 2 Hour Gluc 3 Hour

Gluc 0.5 Hour Gluc 1 Hour Gluc 2 Hour Gluc 3 Hour Gluc 3.5 Hour Gluc 4 Hour Gluc 4.5 Hour Gluc 5 Hour

ANCA xCytoplasmic Neutrophilic Antibody

xMyeloperoxidase Antibody xProteinase-3 Antibody Antibody Neutralization Neutralizing Material

Antibody Neutralization Interpretation

Arginine Vasopressin Osmolality

xArginine Vasopressin-Quest Body Fluid Culture & Legionella C BF

C Legionella Body Fluid Culture, Aerobic & Anaerobic C BF

C Anaerobic Bone Culture, Aerobic & Anaerobic C Bone

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CF Respiratory Culture & Legionella C Resp CF C Legionella

CMGP Calcium

Magnesium Phosphorus

CSF Cell Count 1 xCSF Description 1

CSF Cell Count

xCSF Description 2 CSF Cell Count

xCSF Description 2 xCSF Description 3 CSF Cell Count

xCSF Description 2 xCSF Description 3 xCSF Description 4 CSF Cell Count

xCSF Description 2 xCSF Description 3 xCSF Description 4 xCSF Description 5 CSF Cell Count

xCSF Description 2 xCSF Description 3 xCSF Description 4 xCSF Description 5 xCSF Description 6 CSF Cell Count

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CSF Cell Count 7 xCSF Description 1 xCSF Description 2 xCSF Description 3 xCSF Description 4 xCSF Description 5 xCSF Description 6 xCSF Description 7 CSF Cell Count

xCSF Description 2 xCSF Description 3 xCSF Description 4 xCSF Description 5 xCSF Description 6 xCSF Description 7 xCSF Description 8 CSF Cell Count

xCSF Description 2 xCSF Description 3 xCSF Description 4 xCSF Description 5 xCSF Description 6 xCSF Description 7 xCSF Description 8 xCSF Description 9 CSF Cell Count DIC PT PTT TT Fibr Dimer

Disease Management Panel Fasting Glucose

HA1C Lipid Profile

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EDT Lytes BUN Creatinine Glucose PT PTT CBC ETOH Fungus Culture & Calc Stain C Fungus

C Calcofluor Fungus Culture & India Ink Stain C Fungus

C India Ink Fungus Culture Skin/Hair/Nails & Calcafluor Stain C Fun S/H/N

C Calcofluor

Giardia/Cryptosporidium Antigens Giardia lamblia Antigens

Cryptosporidiam Oocyst Antigen Hemoglobin Electrophoresis xHemoglobin Electrophoresis

xHemogram

LBC Lytes

Bun Creatinine Lower Respiratory Culture & Legionella C Resp Lower

C Legionella

MD Lytes

Bun Creatinine CBC

OCC Mumps Antibody IgG

VZV IgG HepB s Ab Rube Rubl

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Prenatal Screen CBC HBsAg Syphilis IgG

Rubella Antibody IgG ABORh Automated

Antibody Screen Automated

PTH by ICMA xPTH

Calcium Level Total

Same Day Surg Workup S.D. Accession Reference

ABORh SD Verify ABSC SD Verify Tissue Culture & Legionella C Tissue

C Legionella Tissue Culture, Aerobic & Anaerobic C Tissue

C Anaerobic

Type and Screen Automated ABORh Automated

Antibody Screen Automated

UA/DAU UA

DAU Wound/Asp Culture, Aerobic & Anaerobic C Wound

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Appendix C. Quick Reference Card Notification will be by email, pagers, or supervisors.

Once the system is down, remain out of Millennium until “All Clear” issued by Lab Administrator in Charge.

During Downtime

URL: https://DH658/catalog/labels.php

1) Printer MUST be chosen before you can proceed. 2) Enter MRN or Name.

3) Register patients if necessary.

4) Enter tests in Procedure box. Select appropriate priority. 5) Verify the correct procedure is elected and submit. 6) Micro: reprint labels as needed.

7) Label sample with left-side large label.

8) Send left-side small label to section for labeling printed results. 9) Staple right-side labels to requisitions.

Recovery Process:

1) All recovery order entry will occur in the 4th floor Borwell lab, if possible. 2) Use DOE only.

3) Order all work as Collected, in Path West, or Micro, as needed.

4) Order tests in the order they appear on the down time labels on the requisitions. 5) Barcode scanner can be used for MRN and Manual Assign Accession #.

6) Verify accession number in Manual Assign field before adding to scratch pad.

7) Labels that print are usually not needed, but should be attached to requisition for verification of entry into the live system.