MPA | Pharmacy News

Conjoined Twin Conundrum

Posted on September 13, 2019 in: Innovative Practice

By John Carr, CRT, clinical business analyst, Senior-ClinDoc Application Team, Michigan Medicine, Ann Arbor; Heather Somand, Pharm.D., BCPS, director of inpatient applications, Michigan Medicine, Ann Arbor

When you think of conjoined twins, news reports probably pop into your mind with pictures of babies connected in some way or another. You may wonder how the parents hold and nurture their babies in those situations and how difficult it must be to care for them, as well as, the challenges they will face down the road. If you put on your pharmacy hat, you may wonder about the challenges with medication dosing and how the pharmacokinetics may be altered, which are all good questions and considerations. One area we almost guarantee no one thinks about is the electronic health record (EHR) - and rightfully so, since we all expect it will just work as it should. But what does that really mean when it comes to conjoined twins? Should they share a medical record, or should each twin have his/her own record? When you order labs or procedures, what would make the most sense? 

Michigan Medicine recently delivered two sets of conjoined twins, and for those of us in Information Technology, it presented a unique situation that took some thought and planning to ensure it would “work as it should.” While the surgeons and neonatologists planned for the delivery and care of the patients, the teams supporting the EHR met to consider how two patients in a single occupancy room with the same or separate vitals depending on the situation, receiving medications, labs, and radiologic images should have separate medical records, orders and results. In the following paragraphs we describe the questions and considerations we considered in preparing for conjoined twin patients and the solutions we implemented to ensure safe and efficient care was provided. 

Patient monitoring becomes increasingly difficult when your patients share a varying degree of anatomical features and processes. Accurate and relevant vital signs capture and recording is extremely important when making medical decisions for our patients. To this end, we worked with providers and information technology teams to make the decision to create a special patient room that could house these patients while treating them like individual patients with individual charts. Our networking team had to ensure we had enough network ports activated in the room to allow for a second monitor for documenting vitals on each patient. We also worked within the EHR structure to create a second virtual bed in the patient room which allowed these babies to be cared for in one physical location, yet still allowed for the collection of vitals and the normal EHR documentation for each patient separately.

The anatomy of the patients determined whether one or two radiologic exams were ordered; however in either case the radiologist wrote two reports with one for each patient chart. When medications or labs were ordered for the twins we decided that all orders would be placed in baby “A” chart to avoid duplication. However, lab results were entered in both patient's charts, which was completed manually by the lab.

Once the decisions were made and all the pieces were in place, we conducted a “Day in the Life” validation session for these rooms. It is important that this "Day in the Life" validation occurs in situations like this so that workflow anomalies, technical issues and emergency responses can be tested before placing a living patient in a potentially harmful situation. In this validation state, test patients were “admitted” to these beds, patient simulators were connected to the monitors to validate vital sign capture to the correct patient. We validated that each patient in their respective bed was visible in our automated medication dispensing cabinets. Additionally, nursing staff validated that the configurations in place would allow them to care for these patients as they would for any other patient.

Thanks to advanced notice and proper planning with our healthcare partners, we were pleased to report the EHR “worked as it should” in our conjoined twin cases. It was a unique situation for which there is no playbook or build guide to follow, but with proper brainstorming and collaboration, we were able to properly care for our unique patients. 

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