eCritical MetaVision Tip SHEET ICU Attending Physicians

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eCritical MetaVision Tip SHEET
ICU Attending Physicians
This information supplements the training on basic MetaVision function presented in the physician eLearning
modules and any in-person teaching undertaken. This information is specific to ICU Attending Physicians.
1. Signing on to eCritical MetaVision (MetaVision)
Sign in to MetaVision using the same Active Directory user name and password you use for AHS email. Note
this sign on/password is different than those used for Sunrise Clinical Manager and Alberta Netcare neither of
which are linked to the AHS Active Directory. Passwords expire every 90 days and must be changed – you will
be prompted to do so in one of these systems as the time to change approaches. Changing your password for
the email system will change the password for MetaVision and vice-versa.
Within the ICUs, for most computers you access MetaVision by clicking the MetaVision icon located either on
the toolbar or desktop. This will bring up a Citrix sign on box where you enter your username and password.
This will directly open MetaVision.
For computers outside the ICU but within an AHS facility, MetaVision is accessed via a web link to Citrix
(https://access.albertahealthservices.ca). This will require you to first sign in to Citrix and then choose the
MetaVision icon and then sign in to MetaVision. The user name and password for Citrix and MetaVision are
identical.
2. Looking at Clinical Information
As a physician, your access should bring up the MD Layout of MetaVision as a default. Though you can change
layouts to view additional information, the need for this should be uncommon given the major tabs from the
nursing, respiratory and allied health layouts are duplicated in the MD Layout.
The MD Layout is organized into buttons and tabs. Buttons are generally for charting or doing things. Tabs
are generally used for viewing information. There are two rows of tabs – click on the ‘arrow sign’ at the end of
the row of tabs to move to the next page of tabs.
A patient is chosen by either clicking on the patient on the Graphical Patient List (GPL) or via the Patient List
function. The GPL is a diagram showing patients and rooms matching the layout of the ICU they are located in.
The GPL will come up automatically for certain patients, for others it can be brought up by clicking on the GPL
button. Select a patient on the GPL by clicking on the room. The Patient List is accessed by clicking on the
‘Patient’ title on top left of screen and then select ‘Patient List’. From the list of patients you click on the
desired patient. Patients residing in the ICU currently are titled ‘Admitted’. Patients who have been
discharged from the ICU are titled ‘Released’. To select a patient from a different unit, change the
‘department’ (unit) by clicking on the ‘Patient’ title on top left of screen and then click ‘Select Department’.
Once you choose the relevant unit, a new GPL and patient list will appear.
The MD Summary Tab is a summary of key information from all tabs and is meant to display a snapshot of the
patient. More detailed information is displayed on the remaining tabs. A list of prior charted procedures can
be viewed using the ‘procedures’ tab. Current and prior lines, tubes and drains can be viewed using the ‘lines,
tubes and drains’ tab.
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Tabular views display information in 12 columns across the screen. Each tab opens with a default time interval
for the columns (e.g. hourly will display 12 hours of data on the screen, one column for each hour). The data
interval can be altered via the ‘clock’ function on the upper left of the tabular view – here different display
times can be chosen (e.g. every 5 or 30 minutes) in addition to being able to specify moving the screen to a
specific time (e.g. the date/time of ICU admission or a specific date/time of your choosing).
Scrolling through patient data is accomplished by the arrow buttons. The single arrow buttons move one
column at a time. The double arrow buttons move one screen (12 columns) at a time. The arrow button on
the far right brings you back to current time – this is used frequently when moving between various tabs to
bring the data view back to the current point in time.
Additional graphs, over and above the graphs present on the various tabs in the MD Layout, can be added
using the ‘Add a Graph’ button and choosing the desired graph. This will add the chosen graph, filled with
available data, to the existing tabular view. To remove the inserted graph, click the ‘hand’ icon on the upper
right of the graph and select ‘remove this view’. Alternatively you can change to another tab or click ‘refresh’.
Do NOT alter any information in any of the tabs, forms or graphs – the data is for viewing only.
3. Charting Procedures
Document ALL procedures in MetaVision using the forms accessed via the ‘Procedures’ button. Do NOT
document procedures in the written chart (unless MetaVision is down). Please REMIND trainees, Outreach
physicians and Bedside physicians to document procedures only in MetaVision. For procedures without a
named form, use the ‘other procedure’ form to document.
Prior charted procedures may be viewed using the ‘Procedures List’ tab. DO NOT alter information charted by
others in the procedure list or forms.
For the supervision question present in each procedure form – when entering a procedure you performed
choose ‘not applicable’. Trainees, Outreach and bedside physicians will use this to indicate direct, indirect or
no supervision for procedures they perform (Direct supervision = the supervising physician was in the
immediate vicinity during the time of the procedure; Indirect supervision = the supervising physician was
present in the hospital during the time of the procedure).
4. Physician Admission Form
The Physician Admission Form is to be completed ONLY by the ICU Attending physician. This form should be
completed within 24 hours of patient admission to ICU.
Key points:
1. Only one admission form is to be completed for each ICU admission. The admission form will open
blank when it has not been accessed before. It will open up with previously entered data when
information has been previously entered and saved. If the data needs to be altered or added to, enter
or alter the information on the form which comes up and resave with the original date and time (do
NOT choose new form session or alter the original form date and time).
2. The form needs to be completed fully for every patient (e.g. all questions answered and an APACHE
admitting diagnosis entered). The form can be saved with partial information and then re-opened
later to complete data entry.
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3. The form has a number of mandatory data items which must be completed at a minimum to allow the
form to be saved. These items are indicated in bold. Irrespective of these minimal data elements, the
form is to be completed fully for each patient.
Instructions for completion of the form:
Access the form by clicking on the button titled ‘Admission’. The form can also be accessed from the ‘Attend
MD Charting’ tab. The form is automatically assigned the date and time of admission to the ICU – do not alter
this default date and time.
The form is comprised of 4 sections:
Admission GCS:
a. Chart your best estimate of the patient’s GCS at the time of admission in the absence of sedative
medication (e.g. if not sedated chart the actual GCS measured; for a patient with normal brain
function comatose on Propofol, chart a GCS of 15).
b. For intubated patients, estimate the verbal score for GCS as 5 (if patient is clearly responsive and
oriented); 3 (if the patient is communicative but not clearly oriented); or 1 (if the patient is clearly
non-responsive). This advice is also displayed on the MD Admission Form itself.
Acuity Scoring:
a. Answer each question as indicated. Each question must be answered for every patient. Each
question has mutually exclusive answers to allow for an answer for every patient.
b. Choose operative (emergency or elective) admission category if the patient is admitted from the OR
or Post-operative recovery room AND an operation was performed. If an operation was not
performed, choose non-operative category. If a patient had an operation performed during the
hospital stay but was residing on a ward just prior to this ICU admission, choose non-operative
category. Patients admitted from all other locations are non-operative.
c. If an operative type of admission was selected, answer the question related to type of surgery
performed. Choose the best answer from the list provided (e.g. choose transplant surgery if that
specific surgery was performed; choose ‘other types of surgery’ when the specific surgery performed
is not in the list).
d. Advice/information related to many of the questions is available on the form itself (as indicated by
the parameter being underlined) – to access the additional information, click once on the underlined
question and the additional information will pop-up.
Disease Processes Present on ICU Admission:
These questions refer to ACUTE disease processes present on admission, not chronic conditions. Choose a
single answer from each of the 4 questions. Each of the 4 questions must have an answer selected. If one of
the specific disease processes listed within a given question is present, choose that disease process. If multiple
specific disease processes are present from the list provided, choose the single specific disease process most
important. If an acute disease process from the question category is present on admission which is not listed,
choose ‘other’ (e.g. if a neurologic process is present on admission other than the specific neurologic disease
processes listed, choose ‘other neurologic disease’). If no acute disease processes related to the given system
are present on admission – choose ‘none’ as the answer to that question.
Advice/information related to many of the questions is available on the form itself (as indicated by the
parameter being underlined) – to access the additional information, click once on the underlined question and
the additional information will pop-up.
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Chronic Health Conditions:
a. Answer each question as indicated. Each question must be answered for every patient. Each
question has mutually exclusive answers to allow for an answer for every patient.
b. Advice/information related to many of the questions is available on the form itself (as indicated
by the parameter being underlined) – to access the additional information, click once on the
underlined question and the additional information will pop-up.
APACHE IV Diagnosis:
a. A single APACHE IV admission diagnosis MUST be chosen for each patient. Only one diagnosis is
to be chosen.
b. The APACHE admission diagnosis should be based on information available within the first 24
hours of admission to the ICU. If the diagnosis is uncertain or less specific at the time of ICU
admission it is best to wait for 24 hours to assign a diagnosis in order to allow a more specific
diagnosis to be chosen (eg for a patient admitted with severe sepsis of unclear origin at the time
of ICU admission, it is optimal to wait for up to 24 hours to allow a specific source of sepsis (eg
bacterial pneumonia) to be chosen as the admission diagnosis as opposed to choosing a nonspecific
‘sepsis of unclear cause’ diagnosis).
c. Choose the ‘Operative’ diagnosis pathway for patients admitted from the OR or Post-operative
recovery room where a surgical procedure was performed. For all other patients, choose the
‘Non-operative’ pathway (including for patients who had undergone a surgical procedure during
the hospital stay but were transferred from the OR/PARR to a ward prior to ICU admission).
d. The admission form will take you through a hierarchical algorithm of questions based on the
APACHE diagnosis system rules for assigning an admission diagnosis. This will expose only the
minimal number of questions to arrive at a correct admission diagnosis – once an admission
diagnosis is chosen, no further questions will appear.
The basic principles embedded in the APACHE admission diagnosis section are:
i. For operative patients –
1. Was the operative procedure related to trauma? If yes, then differentiate
between trauma with or without a head injury. For trauma patients, choose the
trauma diagnosis which includes the most number of sites of trauma (e.g.
choose chest and abdomen trauma requiring surgery over just chest trauma if
both are present).
2. If the answer to the trauma question is no, the next question is: Was surgery for
coronary artery bypass grafting (CABG) performed? If yes then choose the
specific surgical procedure performed and answer questions related to number
of grafts performed, perioperative MI; preoperative LV function; and whether
internal mammary artery grafting was included.
a. Pre-operative LV function – if LVEF was quantified by ventriculogram
or nuclear or echocardiographic means then use a numerical value to
answer the question; if no quantitative estimate is available then use
a qualitative estimate linked to descriptors (e.g. mild, moderate..). If
no estimate of LV function is available pre-operatively then leave the
question blank.
3. For all other operative patients, choose the body system the surgical procedure
related to and then from within the indicated list, choose the most specific
diagnosis.
ii. For non-operative patients –
1. Did cardiac arrest occur as part of the patient’s acute presentation? If yes, choose
‘cardiac arrest’ as the diagnosis. Cardiac arrest as part of the patient’s admission to
ICU over-rides all other diagnoses (including the reason the cardiac arrest occurred).
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2. If the answer to cardiac arrest is no, the next question is: Is the patient’s admission
related to sepsis? If yes, choose the most specific sepsis diagnosis from the list
presented. Always choose a specific diagnosis (e.g. bacterial pneumonia) over a
non-specific diagnosis (e.g. respiratory infection) if possible.
3. If the answer to the sepsis question is no, the next question is: Did the patient
present as a result of trauma (which did not require a surgical procedure)? If yes
then differentiate between trauma with or without a head injury. For trauma
patients, choose the trauma diagnosis which includes the most number of sites of
trauma (e.g. chest and abdomen trauma over just chest trauma if both are present).
4. If the answer to the trauma question is no, the next question is: Did the patient
present primarily with acute MI? If yes, select ‘acute myocardial infarction’ as the
diagnosis and answer questions related to location of MI and use of systemic
thrombolysis to manage MI.
a. Location of MI – base this on all evidence available within the first 24
hours of ICU admission (echocardiogram, ventriculogram, ECG). If a
specific location is not able to be determined then choose ‘non-Q
wave’ as location.
5. For all other non-operative patients, choose the body system the most important
admission problem relates to and then from within the indicated list, choose the
most specific diagnosis. Always choose a specific diagnosis (e.g. GI bleeding, varices)
over a non-specific diagnosis (e.g. GI disease – other) where possible.
e. Errors in diagnosis can be corrected by unselecting any answers and moving back in the algorithm
or by choosing an alternate pathway at the beginning
If the patient is brain dead on admission, then the GCS should scored as 3 and the admission form should be
completed with the information that led to the neurological death.
5. Daily MD GCS Charting
Record MD GCS daily. The MD GCS represents your best estimate of the GCS for the patient in the absence of
sedative medication at 0800 each day (e.g. a patient with normal brain function comatose on Propofol would
have a best estimate of GCS of 15).
Enter daily MD GCS from the “Attend MD Charting” tab. This view is configured to show the previously charted
MDGCS values and an “Attending MD Charting Deficiencies” form which indicates any charting deficiencies
related to the Physician Admission Form and daily MD GCS charting. The form displays a red dot if MD GCS
values are missing for any of the days of the current ICU admission. The number of days MD GCS charting is
missing and the missing dates are also displayed. A green dot indicates MD GCS charting is up to date. A red
dot indicates GCS charting for one or more days is missing and needs to be completed.
To chart MD GCS values, click on the button titled “Go To MD Daily GCS” – this will open the MD Daily GCS
form defaulting to the current day at 0800. To enter the GCS data for today, select the appropriate values for
the 3 GCS components and hit ‘Save’ if there is additional GCS charting to complete or ‘Save and Close’ if not.
To chart MD GCS values for additional days, click the “Previous Day” or “Next Day” buttons on the MD GCS
form to move forward or backward in time as required. All days have a default time of 0800 selected – do not
alter either this time or the dates displayed on the form itself – only using the previous and next day buttons
to move to the required dates of charting. You are able to move back and forth with or without making any
changes to any existing data - previously entered data will be automatically displayed; if there was no GCS
entered for a date then all fields will be blank. Each time new data is entered or altered, you need to hit ‘Save’
for the data to be saved prior to moving to a different day. . Note: the missing dates and number of days
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missing on the “Attending MD Charting Deficiencies” form in the background will only update when the GCS
form is closed.
For intubated patients, estimate the verbal score for GCS as 5 (if patient is clearly responsive and oriented); 3
(if the patient is communicative but not clearly oriented); or 1 (if the patient is clearly non-responsive).
6. MD Charting Deficiency Indicators
There is a tab located at the end of the physician specific blue tabs titled ‘Attend MD Charting’. This tab
displays simple indicators reflecting the presence or absence of a fully completed Physician Admission Form
and the presence or absence of all daily MD GCS chartings. Green = all complete. Red = something is missing.
This tab only refers to charting deficiencies related to charting required by attending physicians.
For the MD Admission Form, a red indicator may mean a form has not been attempted or is incomplete – to
correct use the link on the ‘Attend MD Charting’ Tab to go directly to the Physician Admission Form, complete
the missing data, and resave the form using the same date and time originally assigned to the form (do NOT
alter the date and time attached to the form). When the data is complete, the indicator should change to
green.
For the MD Daily GCS charting, a red indicator means one or more days of charting is missing. The specific
dates missing are listed. To correct, use the link on the ‘Attend MD Charting’ Tab to go directly to the MD
Daily GCS Form, and enter data as per section 5 above. Repeat the process to complete all missing days.
When the data is complete, the indicator should change to green once the MD Daily GCS Form has been
closed.
7. Death Summary
Every patient who dies during an ICU admission must have a Death Summary form in MetaVision completed
by the ICU attending physician responsible at the time of death. This includes patients who become organ
donors. The form has a number of mandatory data items which must be completed at a minimum to allow
the form to be saved. These items are indicated in bold. Irrespective of these minimal data elements, the
form is to be completed fully for each death.
Only one death form is to be completed for each death. You can fill out the form partially and save it. The
death form will open blank when it has not been accessed before. It will open up with previously entered data
when information has been previously entered and saved. If the data needs to be altered or added to, enter
or alter the information on the form which comes up and resave with the original date and time (do NOT alter
the date and time of the form).
The date and time of death must be charted. Upon opening the form, the date and time of asystole recorded
by nursing will be displayed as a default if such data has been entered. If nursing data has not been entered,
the date and time of death field will be blank. The date and time of death can be altered as appropriate to
reflect the official time of death. For patients progressing to neurologic death, the date and time of death is
the time they are diagnosed with neurologic death irrespective of whether organ donation is undertaken or
not. If the date and time of death field is blank, click on the button adjacent to the date/time of death
parameter to bring up the current date and time which should be altered to the correct date and time of
death. For patients who do donate organs, the Death Summary can be completed anytime after the diagnosis
of neurologic death and the organ donation process is identified (e.g. you don’t have to wait until the time of
organ retrieval).
Every patient at a minimum must have the questions related to suitability for tissue donation and diagnosis of
neurologic death answered. The Tissue Donor Contraindications list is attached as a link at the bottom of the
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form for reference. For patients with suitability for tissue donation and/or neurologic death, the next set of
questions must be completed.
8. Downtime Process
During a downtime where MetaVision is not available:
a. Access clinical information using other systems (e.g. Alberta Netcare) and via the written downtime charts
which will be maintained by the nurses and respiratory therapists and present at the bedside.
b. Document procedures performed during downtime in the progress notes of the patient’s chart.
c. Document death information during downtime in the progress notes of the patient’s chart.
d. When MetaVision function resumes:
Retrospectively chart all procedures performed during downtime using the appropriate
electronic form in MetaVision using the date and time the procedure was performed
(irrespective of whether such procedures were manually charted or not).
If a patient was admitted during a downtime, retrospectively complete the Physician Admission
Form. If a patient died during a downtime, retrospectively complete the Death Form. Be sure
the date and time of death is accurately reflected on the form.
Retrospectively enter a daily MD GCS for all missing days during a downtime. Do this by selecting
the ‘Attend MD Charting’ tab to access the MD Daily GCS form. Complete the missing data as
per section 5 above.
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