Bad signs? New department

[ApplePineApple]

I’m debating about whether this is sketchy. I am good with computers. I like to learn how I can utilize the info to my benefit. I like how to do something/access info.

So we have epic and it is a fairly large package close to the top tier. It is not very customizable due to it being a large company that utilizes this package (like over 15 hospitals in a out 2-3 states) and this was maybe 4th to last hospital getting Epic over 5 years ago in the company besides new hospitals opening or merging. So it’s not like it is the first year of epic. They have had it.

I use both ED and the flowsheets because I have worked in both trauma centers and ICUs. I have traveled and worked multiple jobs at once. I like the flowsheets because once I memorize the tabs, I can basically chart an entire assessment using tab key and 1-6 keyboard strokes (like pupils 3;r;b populates 3 mm round brisk) instead of moving the mouse around which is slower. However, I do use both about equal to chart assessments. I do my hourly rounding for ED under the ED narrator (like they have a button that populates click boxes like “resting comfortably,” “no distress noted,” call light in reach, snacks, drinks, report called, patient updated, updated on results, etc. They push hourly rounding documentation in the ED like they push pain revaluation scores elsewhere.

How do they chart stuff like that? Blank notes. So an ED patient will average 5-18 blank notes in the chart. If I want to look at a prior ER visit, I ignore nursing notes from here because usually they are “patient resting on cot” or “patient in imaging.” Yeah... you have click boxes that can populate the fluff into the ED timeline without clogging up the notes. I’d rather see a note saying what lead to a patient coding or the patient freaked out and ripped the computer monitor off the wall and tried to beat the resident with it. I can see a running note of where it is one nurse note with times and the note has addendums with other info.

I also like to know where things are in epic. Each epic is different and they have had this epic for a long time so they should know more about it than me. They don’t.

Now, one of the supervisors told me that I am not expected to teach my preceptors and basically just agree with them because I tried to show my preceptor that they have a tab for documenting when the blood reaches the vein. My preceptor said “I don’t need you to show me anything.” Not exactly friendly or open to learning.

So I watched him basically butcher the sedation narrator. He did not use a single one step med for 15 doses given of the med and instead typed out the info in blank notes. Not joking. You can literally do 3 or 4 clicks instead of keying out “15 mg of medication given by Dr. Resident” over 15 times. It also adds it to the mar. I use blank notes sometimes in the sedation narrator if they don’t have a comment/blank box built in or something significant needs to be charted. Also, guess this hospital doesn’t require sedation scores/scales when sedating patients? They utilize RASS scores normally.

Oh and they’re not allowed to use trauma narrators because they miss too much stuff. Other hospitals in the company that are larger utilize the trauma narrator. I am guessing it is because they free text everything in the trauma narrator too.

The charge nurse tried telling me there is no way to access the ekgs once they are submitted so they don’t submit ekgs till respiratory does it once a day at like 2 am. I found the internal website in eight minutes of looking And pulled up the ekg I submitted. Yes, it does not show up to epic if done before the order is in but utilizing the old site you can pull old ekgs. It may be why they don’t print old ekgs anymore? I don’t think they know how to access it.

I ask questions like “do we send nebulizers home with pediatric patients” and that leads to blank stares and “wuut?” The RT who worked elsewhere knew that smaller hospitals do that was able to answer that question.

There are some practices that make me cringe. It does feel like this hospital has a core that has never worked elsewhere in an ER and so bad habits are passed down. Like the epic charting. It isn’t the first year of epic charting but they’re sold on “this is the way we do it and we will always do it this way” Uh OK. Once upon a time providers did 5 compressions to 2 breaths so should we be doing that still? Should we be inserting foleys into everyone just because they’re admitted?

I did come from a magnet hospital that actually researched and tried new things. Before that, I worked at a company that was pushing stuff like decreasing UTIs, pushing nurses to be responsible to identify sepsis, EKGs within 5 minutes, etc. I mean, that hospital system we had info about TPA times and who had the best times.

It just makes me worried if the staff is this against knowing how to utilize epic. If we have changes to standards, are they going to change or want to learn versus saying “we always did this.”

[Wuzzie]

The transition to a new job when you are already experienced is often fraught with pitfalls. Especially if you are moving from a larger facility to a smaller, less progressive one. "We did it this way where I used to work" in all its permutations whether spoken or implied is always, always going to be perceived poorly. Frustration with "backwards" processes is hard to suppress and just adds to the impression that you feel, somehow, better than the established staff without that being the actual case. My advice to you is to figure out a way to smile and nod through your orientation until such time that you can practice in the manner you are accustomed. If their processes are primarily inefficient but not harmful it's probably best to just go along to get along and when you're done orienting resume your use of Epic in the way that works best for you. I find what happens is you almost always end up teaching by doing. Someone will notice your epically cool (see what I did there? ?) charting and ask you to show them how. It will eventually spread and before you know it your currently reluctant colleagues will be using Epic to it's best advantage and you will be a hero. Push it now and you will be pegged as a "know it all" and your time there will be difficult. ASk me how I know this. ?

[ApplePineApple]

Thanks. I really just need to grin and bear it. The culture isn’t going to change and I’m not there to be friends. I am probably going to be getting a PRN job at my old hospital in the ICU so I can look at that as my actual job and this just does my insurance

[JKL33]

There's very little reason to even concern oneself with any of this.

Chart in the ways you know how and let them do what they do.

I will say, though, this absolutely reeks of the way that big places want everything to be done the same at all campuses, but they *will not* invest the same relative resources into making it happen at any place other than the mothership facility. So...what you find elsewhere is how people get by. Example: Big (Magnet) corp introduces [world's best EMR] to one of their properties by having a 1/2 day inservice 3 months before go-live and then nothing but an insane amount of emails that no one had time to read. Then go-live.

[ApplePineApple]

When company B went live, some of the staff talked a little bit about this company (A). I remember B saying it was a disaster and that the doctors rebelled successfully so the entire corporate education had to be redone so nurses could enter orders for them such as when patients were admitted. That has been phased out thankfully from what I have seen due to NPs for the hospitalist group and they have internal medicine residents at company A. I do know company B higher ups pissed off doctors when they basically told them to “go f themselves, go to company A because nurses are not putting in admission orders.” We were yelled at day 1 because “they took my orders yesterday!” A lot of people quit admitting patients directly too at company B.

But yeah, I guess B had a very in depth epic training program whereas A may have floundered when they went live. I wanted to go into informatics but I wasn’t sure if I could make a living in the immediate area after everyone transitioned so I guess learning about how things are charted and work has been an interest. It also amuses me to figure out how different epics are set up and how companies do things so different.

When I worked at hospital C (different region from A but part of the company so same epic) I always joked that the company broke epic because of their set up but I understood they can’t just change it on a whim due to the number of players. I do think they built their shell like 15+ years ago with minor updates. Like their ED shell uses features I have not seen other large users utilize like the announcements.

Thanks for posting. It is helping me to see things in perspective that I don’t know how it was originally and I was pretty lucky back in the day when company B went live. Like they had extra time explaining why the sedation narrator existed. My last hospital just added the sedation narrator with almost no education and I remember multiple neuro nurses watching me and asking about it during a ventric insertion because I told the NP not to order random meds for the sedation, we’ll document in real time with the orders/pushes.

[Mavrick, BSN, RN]

Is there any way to learn EPIC before you start a job? I'm going to a new hospital that uses EPIC. My current one was scheduled to go-live earlier this year but the COVID Plague messed that all up. Any on-line or Youtube tutorials you would suggest? I'm afraid I'm going to get shoved in front of a computer with 2 Post Op patients rolling through the door let the chips fall where they may.

And the terminology is foreign. Narrator? Blank notes?

.............................. help ................. glug, glug.

[kp2016]

On 8/20/2020 at 11:02 PM, ApplePineApple said:

Thanks. I really just need to grin and bear it. The culture isn’t going to change and I’m not there to be friends. I am probably going to be getting a PRN job at my old hospital in the ICU so I can look at that as my actual job and this just does my insurance

Hang in there. I think you will be surprised, 1 person can alter the culture of a unit (over time).

It will be rough at the start. As Wuzzie correctly noted preceptors tend to get very defensive / critical of you if you know more generally or have more experience than they do. I learned that one the very hard way, at my next job I stayed very low key during my orientation, did not offer any advise / opinion on any of the ways I was being taught. As soon as I was off orientation I quietly started doing my own thing, I did get push back from other staff but I noticed more and more staff were suddenly watching me and doing things the way I did them.

Your manager is probably trying to smooth down the ruffled feathers of your preceptor by stating it isn’t your job to teach them. Go with it until your off orientation, give it a few months and then reassess. By that time hopefully it will be evident to your new co workers that you have some tricks that may make their job a lot faster/ easier and are worth learning.

Best of luck!

[Wuzzie]

2 hours ago, kp2016 said:

As Wuzzie correctly noted preceptors tend to get very defensive / critical of you if you know more generally or have more experience than they do

Thanks for the shout out but that wasn’t actually what I meant. I meant that when you’re trying to fit into an established group and you come in acting like you know better it’s off-putting and hampers integration into said group. The experience of the preceptor isn’t the issue. As a preceptor there is certain information I am responsible for disseminating. I can’t do that if the orientee is spending all their time yammering about how this isn’t the way they did it at their old job and the like their way better. Makes me roll my eyes and think to myself if they liked it so much better they’re free to go back. Then I’m the one who has to smile and nod! The orientation period is for the new person to learn how things work at their new place not for them to “educate” the established staff. Once that period is over then all bets are off.

FTR: OP I am in no way implying this is what you did. I am making a general statement based on my experience both as a preceptor and as the new person. Which, BTW, I massively bungled a few times.

[Been there,done that, ASN, RN]

Takes a lot of chutzpah to orient to a new hospital and throw your advanced EPIC knowledge around. There will be plenty of time to teach your vast EPIC skills, after you have proven yourself. You sound like you have an attitude of superiority here. Wonder if your new coworkers are picking up on that.

[amoLucia]

Sometimes, it's not WHAT you say, but HOW you say it.

If your attitude was coming on too strong, then you'll hit resistance.

But if your attitude was more subtle, like 'hey, I know a neat shortcut', you may have piqued their interest. And THAT they'll appreciate.

Not a new know-it-all.

[2BS Nurse, BSN]

On 8/20/2020 at 8:29 AM, ApplePineApple said:

I’m debating about whether this is sketchy. I am good with computers. I like to learn how I can utilize the info to my benefit. I like how to do something/access info.

So we have epic and it is a fairly large package close to the top tier. It is not very customizable due to it being a large company that utilizes this package (like over 15 hospitals in a out 2-3 states) and this was maybe 4th to last hospital getting Epic over 5 years ago in the company besides new hospitals opening or merging. So it’s not like it is the first year of epic. They have had it.

I use both ED and the flowsheets because I have worked in both trauma centers and ICUs. I have traveled and worked multiple jobs at once. I like the flowsheets because once I memorize the tabs, I can basically chart an entire assessment using tab key and 1-6 keyboard strokes (like pupils 3;r;b populates 3 mm round brisk) instead of moving the mouse around which is slower. However, I do use both about equal to chart assessments. I do my hourly rounding for ED under the ED narrator (like they have a button that populates click boxes like “resting comfortably,” “no distress noted,” call light in reach, snacks, drinks, report called, patient updated, updated on results, etc. They push hourly rounding documentation in the ED like they push pain revaluation scores elsewhere.

How do they chart stuff like that? Blank notes. So an ED patient will average 5-18 blank notes in the chart. If I want to look at a prior ER visit, I ignore nursing notes from here because usually they are “patient resting on cot” or “patient in imaging.” Yeah... you have click boxes that can populate the fluff into the ED timeline without clogging up the notes. I’d rather see a note saying what lead to a patient coding or the patient freaked out and ripped the computer monitor off the wall and tried to beat the resident with it. I can see a running note of where it is one nurse note with times and the note has addendums with other info.

I also like to know where things are in epic. Each epic is different and they have had this epic for a long time so they should know more about it than me. They don’t.

Now, one of the supervisors told me that I am not expected to teach my preceptors and basically just agree with them because I tried to show my preceptor that they have a tab for documenting when the blood reaches the vein. My preceptor said “I don’t need you to show me anything.” Not exactly friendly or open to learning.

So I watched him basically butcher the sedation narrator. He did not use a single one step med for 15 doses given of the med and instead typed out the info in blank notes. Not joking. You can literally do 3 or 4 clicks instead of keying out “15 mg of medication given by Dr. Resident” over 15 times. It also adds it to the mar. I use blank notes sometimes in the sedation narrator if they don’t have a comment/blank box built in or something significant needs to be charted. Also, guess this hospital doesn’t require sedation scores/scales when sedating patients? They utilize RASS scores normally.

oh and they’re not allowed to use trauma narrators because they miss too much stuff. Other hospitals in the company that are larger utilize the trauma narrator. I am guessing it is because they free text everything in the trauma narrator too.

the charge nurse tried telling me there is no way to access the ekgs once they are submitted so they don’t submit ekgs till respiratory does it once a day at like 2 am. I found the internal website in eight minutes of looking And pulled up the ekg I submitted. Yes, it does not show up to epic if done before the order is in but utilizing the old site you can pull old ekgs. It may be why they don’t print old ekgs anymore? I don’t think they know how to access it.

I ask questions like “do we send nebulizers home with pediatric patients” and that leads to blank stares and “wuut?” The RT who worked elsewhere knew that smaller hospitals do that was able to answer that question.

There are some practices that make me cringe. It does feel like this hospital has a core that has never worked elsewhere in an ER and so bad habits are passed down. Like the epic charting. It isn’t the first year of epic charting but they’re sold on “this is the way we do it and we will always do it this way” Uh OK. Once upon a time providers did 5 compressions to 2 breaths so should we be doing that still? Should we be inserting foleys into everyone just because they’re admitted?

I did come from a magnet hospital that actually researched and tried new things. Before that, I worked at a company that was pushing stuff like decreasing UTIs, pushing nurses to be responsible to identify sepsis, EKGs within 5 minutes, etc. I mean, that hospital system we had info about TPA times and who had the best times.

It just makes me worried if the staff is this against knowing how to utilize epic. If we have changes to standards, are they going to change or want to learn versus saying “we always did this.”

"We've always done it this way" is the mantra of health care. I've given up on attempting to make changes for the better.

[BSN-to-MSN, ADN, BSN, RN]

I would avoid teaching your preceptor new ways of using EPIC. This looks like a newbie know-it-all. Instead, after you are done with orientation, be a resource for the staff, helping with navigating EPIC. Be in a learning mode during the orientation.