Instrument sets documentation

Specialties Operating Room

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We are in the process of changing our EMR to Cerner. In our current system, we document every instrument set and wrapped separate in the intraoperative record. I'm not finding any place for this in Cerner. What are your experiences or recommendations?

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Specializes in OR, Nursing Professional Development.

We do this via preference cards in Epic- it flows into the instruments/equipment section. Does Cerner not have the ability to have preference cards?

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Yes, we have preference cards but we do not have a bar scan system for the sets and individual wrapped items.

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Specializes in OR, Nursing Professional Development.
10 hours ago, Nurse deba said:

Yes, we have preference cards but we do not have a bar scan system for the sets and individual wrapped items.

Are you looking more for the SPD side of things or to actually document in the record? We have a totally separate system for SPD, where the system utilizes barcodes to tie a set of instruments/wrapped item/peel pack to a specific patient. We do not document the specific set (such as laparotomy pan 3) in the medical record.

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So, I'm guessing that SPD had a bar scanning system. I'm trying to understand how this process works. I really appreciate your response.

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Specializes in OR, Nursing Professional Development.

Yes, they have a system where they can register a case cart to a specific patient. Each instrument set is then scanned onto the case cart. The system also tracks the location of everything- when a case cart is returned from the OR, it is scanned into decontamination. Then it is scanned into the washer, then assembly, then the autoclave, then back onto the shelf or to another case cart. It is done via barcode scanning, but it is not at all connected to Epic. We can still trace an exact instrument set or peel packed item from a patient backwards through processing or from processing forward to a patient. It allows for live time ability to see exactly where a set is- let's say a biological indicator for autoclave 5 load 3 fails. We can go to the record and see everything that was in that load and where it is- on a shelf, in a case cart, actually already in use in a surgery (that would only happen in the case of an urgent repack).

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When we used cerner, our instruments came up on the pick sheet and we could mark if we used them but this didn't translate into anything used by CPD. So, we werent required to check off instuments as they were just there to know what to pull for the case. Our disposable supplies were tracked and charged this way, however.

Our CPD used a system called Alex Gold which was used to build and track instruments and sets within the facility.

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So...there are different levels of interoperability of different systems used in complimentary fashion in periop. *Some* instrument inventory management software *can* be interfaced with *some* EHRs. Not all can, and the process of integrating is expensive and lengthy - and not without risks. What you're seeing may be that the EHR and instrument systems are not talking to each other (the connection might not have been built or supported by the EHR vendor); or the version of Cerner bought by your institution may either not support barcode scanning, or not support the *same type* of barcode scanning previously used.

Our current practice is that we add trays to cases if they were not pulled in by preference cards associated with a case by adding the tray name. At this time, we are not specifying which specific instrument tray was used in which room within intra-op documentation (ex. we'll specify that we used the minor instruments - but not whether it was minor #1 or minor #3).
There is a separate tracking and scanning process in a different system for our instruments.

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