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Policies,Clinical,UW Health Clinical,Medical Records and Communication,Medical Record

Inpatient Health Link Downtime and Recovery (3.2.6)

Inpatient Health Link Downtime and Recovery (3.2.6) - Policies, Clinical, UW Health Clinical, Medical Records and Communication, Medical Record

3.2.6


UW HEALTH CLINICAL POLICY 1
Policy Title: Inpatient Health Link Downtime and Recovery
Policy Number: 3.2.6
Category: UW Health
Type: Inpatient
Effective Date: September 29, 2016

I. PURPOSE

To establish a process for continuing the services and care of patients as related to Health Link in the event
of a planned or unplanned Health Link downtime for inpatient care areas and hospital outpatient
departments (HOD).

Areas Affected/Stakeholder(s):
All inpatient adult and pediatric units, the Emergency Department, Surgical Services and procedure areas
defined as HODs and live on Health Link at University Hospital, American Family Children’s Hospital, and
The American Center.

II. DEFINITIONS

A. Planned Downtime: Advance notice of Health Link not being available; typically lasting less than four (4)
hours. Exceptions for planned downtimes lasting more than four (4) hours may be made on a case-by-case
basis.
B. Unplanned Downtime: Unexpected loss of access to Health Link.
C. Health Link Downtime Environment:
i. Is an exact copy of the production database and is current up to the point in which the Health Link
production environment went down.
ii. Can be accessed via Downtime Icon on shared workstations or configured personal computers.
iii. Is dependent on network availability.
D. Designated downtime computer and printer:
i. Consists of a Business Continuity Access (BCA) computer and attached printer.
ii. The BCA computer contains select reports of patient information, such as problem list, active
orders, medication list, and narrative notes to support continuity of care.
iii. Both the BCA computer and the printer must be connected to an emergency backup outlet.
iv. Is used when the network is not available.
E. Health Link Downtime Binder: A reference binder created by the Nursing Informatics Department to assist
nursing staff during the downtime.

III. POLICY ELEMENTS

A. All departments and ancillary systems owners are responsible to maintain their own downtime procedures
(e.g. AcuDose, physiologic monitors, nurse call, etc.).
B. Patient care orders should only be written if they need to be carried out during the downtime.
C. Paper forms.
i. Clinical documentation will be recorded on Downtime paper forms to document patient
care/assessments and will be maintained in the paper chart until scanned into Health Link.
ii. Any form used during a downtime must be developed and approved by UWH Enterprise Content
Management Department and have a minimum of two patient identifiers recorded on the form.
iii. Laboratory and radiology forms must be labeled with patient’s full name, medical record number,
and date of birth.
D. It is possible for Rover, used on handheld devices to experience downtime independent of Health Link.
i. Medication administration documentation via the handheld scanners will be affected during a Rover
only downtime. All other clinical documentation will occur in Health Link. Documentation of
medication administration during a Rover Only downtime is outline in the procedure section
(IV.B.vi.d.) of this policy.
ii. Departments using Rover for specimen collection will be affected during a Rover only downtime. In
absence of a label printed from Rover, specimen requisition forms and labels should be printed
from Health Link to be used in the specimen collection process.
E. Surgical Services Department (SSD) and Anesthesia documentation (including medication administration)
will remain on paper during the duration of the care in the department. For planned downtimes, surgical
cases that will have the majority of the case during the Downtime should be documented on paper from the



UW HEALTH CLINICAL POLICY 2
Policy Title: Inpatient Health Link Downtime and Recovery
Policy Number: 3.2.6

start of the case. Cases that cross Daylight Savings Time are best done entirely on paper. The decision to
remain on paper for the entire duration of the care is dependent on the patient location within SSD, length of
care to be provided within each patient location in SSD, and length of downtime in the following areas.
i. Affected Areas:
a. University Hospital
1. Third Floor Surgical Services - First Day Surgery, Inpatient Operating Room (IP
OR), Inpatient PACU (IP PACU)
2. Second Floor Surgical Services - Outpatient Surgery Center (OSC) and
Ambulatory Procedure Center and GI (APC/GI)
b. American Family Children's Hospital (AFCH) Surgical Pavilion
c. The American Center
d. Anesthesia services when provided in any care area above and outside of the Surgical
Services Department
ii. During recovery phase, regardless of the type of downtime, Surgical Services will at minimum
document case tracking events and complete charge reconciliation and documentation. Paper
records will be scanned as described within this policy and other priority scanning practices.

IV. PROCEDURE

A. Downtime preparedness:
i. Downtime Supplies for Medication Management:
a. Downtime supplies for medication administration will be stored centrally in Pharmacy
Department.
b. Pharmacy Department is responsible for stocking the following downtime supplies:
1. Procedures and detailed instructions for pharmacy and nursing staff during the
downtime;
2. Medication transcription forms for pharmacy staff to order medications from
central pharmacy (two-ply yellow forms);
3. Blank Medication Administration Record (MAR) forms ;
4. Prescription pads.
ii. A copy of all downtime forms, order sets/treatment plan references, delegation protocols, policies,
etc. are available on U-Connect for printing or uwhealth.org.
iii. A Health Link Downtime Binder is available within each department/unit.
iv. A master copy of the following forms will be made available in the Health Link Downtime Binder for
use when the BCA computer is not available:
a. Physician Order (1280436-DT)
b. History and Clinical Notes (1280005-DT)
c. Pre Operative Pre Procedure Check List (1280544-DT)
d. General Purpose Flow Sheet (1280030-DT)
e. Health Link Downtime Unit Log
f. Health Link Downtime Event Form
v. Units may add additional UW Health approved forms to the binder as needed for their patient
population, and are responsible for ensuring the most current version is available.
B. During planned or unplanned downtime:
i. Communication: Information Services will communicate via scrolling banner alert, or other
methods as necessary, with known details of the type and duration of the downtime as defined in
Administrative Departmental Policy AD-POL-005 UWH Health IS System Downtime Policy.
ii. Chart Review:
a. If “Use Health Link Downtime Icon” is communicated, all clinical information can be viewed
via the Health Link Downtime Environment (available on shared workstations) in the Chart
Review activity and Summary Reports as needed.
b. If Health Link Downtime Environment is not available, downtime reports, such as problem
lists, active orders, medication list, and narrative notes can be printed as needed from the
Downtime Computer.
iii. Patient Admission/Discharge Transfers (ADT):
a. All patient admissions entering through the Emergency Department will be issued a
Medical Record Number (MRN) by the Emergency Department staff, as appropriate.
b. All other patient arrivals will be issued a MRN by the Access Service Department (Bed



UW HEALTH CLINICAL POLICY 3
Policy Title: Inpatient Health Link Downtime and Recovery
Policy Number: 3.2.6

Control), as appropriate.
c. All patients transferring to another unit or going off unit to procedure or to operating room
should have the following paper documents sent with them:
1. Med Admin Plan 1 day or Paper Downtime MAR (as applicable)
2. Downtime Report, Active Orders Report, Incremental Report (as applicable), and
Downtime Report – Notes
3. Completed Pre Operative Pre Procedure Check List (as applicable)
4. All other paper records created or received during the downtime (e.g.
lab/radiology results, consent, notes, orders, etc.)
iv. HOD areas where scheduling of patients occur: Refer to the Ambulatory Health Link Downtime
& Recovery policy 6.45 for registration and scheduling procedures.
v. Orders Management:
a. Orders should only be written if they need to be carried out during the downtime.
b. Write orders on paper physician orders form or applicable order set.
c. If using the 3-ply order form, clearly label each ply and send colored ply to receiving
department.
d. If using single ply orders, copies must be sent to receiving departments (e.g. Pharmacy,
Dietary), clearly marked as a “COPY”.
e. Lab and Radiology orders should be transcribed onto the appropriate lab or radiology
downtime request form.
f. The original signed order is to be filed in the patient’s paper chart.
g. After sending copies of an order via fax or pneumatic tube, call to confirm they were
received. In the event the pneumatic tube system is not operational, any available staff
should be utilized to hand deliver patient care and medication orders to the appropriate
location.
h. All verbal or telephone orders obtained during the downtime MUST be cosigned by the
provider within 48 hours according to UWHC policy 8.16 Patient Care Orders.
vi. Medication Administration Documentation:
a. For ED only, use Emergency Department Record Physician Order Sheet for medication
administration documentation for both Planned and Unplanned downtimes.
b. If “Use Health Link Downtime Icon” is communicated:
1. The Med Admin Plan 1 Day should be printed from the Health Link Downtime
Environment via the Downtime Icon (available on shared workstations).
2. The Med Admin Plan 1 Day is used to document medication administrations. Any
notations made during the downtime on this report must be transcribed into
Health Link during Recovery.
3. If the downtime is expected to last greater than four (4) hours, paper Downtime
MARs will be printed centrally for all patients by Pharmacy.
i. Paper Downtime MARs will be collated and placed in the respective
unit’s Medication Administration Record downtime binder for
distribution. Sequence of units for printing is prioritized by acuity of
patients.
ii. Medication administration documentation will be completed on the
paper Downtime MAR once available or appropriate HOD downtime
form.
c. If “Use Downtime Computer” is communicated or Health Link Downtime Environment is
unavailable:
1. The Med Admin Plan 1 Day should be printed from the Health Link Downtime
Computer.
2. The Med Admin Plan 1 Day is used to document medication administrations. Any
notations made during the downtime on this report must be transcribed into
Health Link during Recovery.
3. If the downtime is expected to last greater than four (4) hours, paper Downtime
MARs will be printed centrally for all patients by Pharmacy.
i. The paper Downtime MARs will be collated and placed in the respective
unit’s Medication Administration Record downtime binder for
distribution. Sequence of units for printing is prioritized by acuity of
patients.



UW HEALTH CLINICAL POLICY 4
Policy Title: Inpatient Health Link Downtime and Recovery
Policy Number: 3.2.6

ii. Medication administration documentation will be completed on the
paper Downtime MAR once available or appropriate HOD downtime
form.
d. If “Rover Only” downtime or wireless downtime is communicated:
1. The Med Admin Plan 1 Day should be printed from Health Link and used to
document medication administrations. Any notations made during the downtime
on this report must be transcribed into Health Link.
2. If the downtime is expected to last greater than four (4) hours, paper Downtime
MARs will be printed centrally for all affected units/departments by Pharmacy.
i. The paper Downtime MARs will be collated and placed in the respective
unit’s Medication Administration Record downtime binder for
distribution. Sequence of units for printing is prioritized by acuity of
patients.
ii. Medication administration documentation will be completed on the
paper Downtime MAR once available or appropriate HOD downtime
form.
vii. Clinical Laboratory Procedures
a. For planned downtimes, only specimens for critical and time sensitive test should be
collected.
b. For unplanned downtimes, labs needed to support continued patient care should be
collected.
c. Lab staff will call the unit/department with critical and STAT results. All other results will be
tubed to the requesting unit/department.
d. In the event the pneumatic tube system is not operational, any available staff should be
utilized to hand deliver lab specimens and results.
viii. Clinical Documentation: Downtime paper forms will be used to document patient
care/assessments and will be maintained in the paper chart until scanned into Health Link.
C. Recovery: Once downtime is over, the following recovery procedures will occur. Be aware the sequence of
recovery activities is important to ensure the patient's record is accurate.
i. Implement recovery activities in the following sequence:
a. Admission/Discharge/Transfer recovery activities
b. Communication
c. Order Reconciliation/Order Entry
d. Medication Verification by Pharmacy
e. Medication Administration Documentation
f. Clinical Documentation
g. Charging/Billing
ii. Patent Admission Discharge and Transfers (ADT): Access Service Department (Bed Control)
enters all patient ADT information in Health Link.
iii. Communication: Information Services will communicate via scrolling banner alert, or other
methods as necessary, to indicate the Health Link system is now available.
iv. HOD areas where scheduling of patients occur: Refer to Ambulatory Health Link Downtime and
Recovery policy 6.45 for registration and scheduling procedures.
v. Surgical Service Areas will at a minimum document case tracking events and complete charge
reconciliation and documentation. Paper records will be scanned as described within this policy and
other priority scanning practices.
vi. Order Reconciliation/Order Entry:
a. Orders received during the downtime that require transcription into Health Link should be
back dated/timed to reflect the original order date/time using the order mode of
“Transcribed”.
b. In general, it is the receiving department’s responsibility for entering the order back into
Health Link:
1. Diet orders > Nutrition services
2. Radiology orders > Radiology services
3. Medications > Pharmacy
4. Therapy or other ancillary consults > Receiving service
5. Patient care orders > Entered by ordering provider
6. Physician consults to other physicians > Entered by ordering provider



UW HEALTH CLINICAL POLICY 5
Policy Title: Inpatient Health Link Downtime and Recovery
Policy Number: 3.2.6

7. Laboratory orders > Laboratory services
i. Order is entered into the Lab Information System following receipt of the
paper order;
ii. Order will be generated in Health Link when the results are posted to
the patient’s medical record.
8. EKG, Echo, PFTs > Receiving service
9. Supply and equipment orders > Health Unit Coordinator/Patient Care
Technician/Emergency Department Coordinator
vii. Medication Administration Documentation:
a. If the Med Admin Plan 1 Day or the paper Downtime MAR was used, scheduled
medications with overdue warnings in Health Link, immunizations, and cumulative dose
medication administrations that occurred during the downtime will be documented with
appropriate “Downtime” MAR action.
1. New medications prescribed and completed during the downtime (no remaining
doses) will not be reconciled in Health Link. Exception: Immunizations and
Cumulative Dose meds must be documented in Health Link with appropriate
“Downtime” MAR action.
2. After completion of downtime, Pharmacy will use the Med Admin Plan 1 Day
and/or the paper Downtime MAR for charge reconciliation. Once Pharmacy
completes charge reconciliation medication administration forms will be scanned
into the medical record.
b. If ED form was used, medication administrations that occurred during the downtime will be
documented in Health Link and should be back dated/timed to reflect the actual
administration time.
viii. Clinical Documentation:
a. Critical patient data (e.g. weight, I/O. vital signs) that occurred during the downtime should
be entered into Health Link and staff should insert columns to reflect accurate date/times.
b. Lines, drains, airways, and wounds (LDA) should be reconciled if they were
placed/changed/removed during the downtime. This reconciliation should be done for
patient for all patients, including those discharged during the downtime.
c. The unit manager or their designee will enter a note in each patient's record, using the
.UWDOWN SmartPhrase.
d. Paper forms should be filed in the paper chart and scanned or sent to HIM for scanning
into Health Link upon discharge.
ix. Charge Reconciliation:
a. The unit manager or their designee shall compile a census of all patients on the unit
during the downtime.
b. A Daily Reconciliation Journal (DAJ) or Revenue and Usage report should be generated
via each cost center, based on the date that the charges were posted to the account.
c. The unit manager or their designee will cross reference the DAJ or the Revenue and
Usage report to their census report to ensure that all patients on the unit incurred the
correct charges during the downtime.
d. Charging errors should be corrected by the department, whenever possible. If the error is
beyond the department's control, contact should be made to the Chargemaster Team for
assistance.

V. REFERENCES

UW Health clinical policy #3.2.1, Patient Identification
UW Health clinical policy #3.2.5, Ambulatory Health Link Downtime and Recovery
UWHC policy #12.01, Safety Management Plan
UWHC Pharmacy Departmental policy #14.1, AccuDose Cabinet Downtime Procedure
UWHC Clinical Laboratories policy #1502.5.06, Acceptance Policy for Specimen Identification
Nursing Patient Care policy #10.19AP, Medication Administration Using Barcode Scanning Technology
(Adult and Pediatric)
Health Link Downtime Reference Binder

VI. COORDINATION



UW HEALTH CLINICAL POLICY 6
Policy Title: Inpatient Health Link Downtime and Recovery
Policy Number: 3.2.6


Author: Director, Nursing Informatics
Senior Management Sponsor: VP, Chief Information Officer
Reviewers: Representatives from Emergency Department, Hospital Information Management, Information
Services, Laboratory Services, Nursing, Nursing Informatics, Pharmacy, Providers, Radiology, Risk
Management, Safety, and Surgical Services
Approval committees: UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: September 19, 2016

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VII. APPROVAL

Peter Newcomer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VIII. REVIEW DETAILS

Version: Revision
Next Revision Due: September 2019
Formerly Known as: Hospital Administrative policy #6.37