Track
Stars
New technologies help surgery center streamline communications
and keep tabs on patients, scheduling, equipment, and personnel
By Scott Mace
July 3, 2003
Inefficient communication, lagging productivity, concerns over patient privacy and patient safety. These comprise some of nursing's biggest problems today. At Providence St. Vincent Medical Center in Portland, Ore., a three-year surgery expansion project provided the opportunity to apply new information technology to help solve these problems and bring about a quiet revolution.
Using a new wireless phone network, enhanced nurse call, passive infrared tracking devices and a browser-based electronic greaseboard, the Providence St. Vincent surgical services unit has optimized the process of admitting and caring for patients. These tasks include quickly locating patients and critical equipment, communicating impending patient arrivals, notifying staff that a room is ready or vacant or indicating a patient's readiness status, said Kristi Ketchum, RN, a certified ambulatory perianesthesia nurse at Providence St. Vincent.
A baseline analysis before the implementation of these new systems revealed alarming statistics. "Our survey indicated that our perioperative staff made an average of 11 phone calls per patient," said surgery information systems manager Deb Bahlman, MS, RN. "Each phone call was at least 15 seconds long. When you multiply that times 80 to 100 patients per day, that's a lot of time that could be used for patient care. Now that all communication is on an 'e-greaseboard,' no one has to make person-to-person phone calls, and you don't have to try to remember whom you told and whom you haven't told. It has totally changed the environment in the surgery areas. You walk into the units and the one thing you notice is how quiet it is, and [that] the phone isn't ringing."
Providence St. Vincent Medical Center is believed to be the only facility in the United States that has combined these technologies to create a complete system within a perioperative environment.
The expansion project created an upgraded, 60,000-square-foot space with 27 new operating rooms, 28 PACU and 53 short-stay beds and supply processing and distribution departments. This enormous new space challenged the staff to create new ways of communicating.
Distractions and delays were commonplace in the old OR and short-stay unit. Admitting personnel or even nurses themselves brought patients to short-stay rooms, leaving paperwork on admitting nurses' desks to signify a patient arrival, and recording arrival times on a big greaseboard.
The short-stay unit's secretary would receive so many phone calls, she created a series of codes to be sent to the nurses' pagers conveying various information. "She made a little chart for us," Ketchum said. "Otherwise, we wouldn't know what the codes meant." To act upon these pages or to get other info, nurses had to find a regular phone to communicate over any distance. The overhead voice pager system was reserved for doctors. "We had a hard time getting a hold of people," Ketchum said.
For the friends and loved ones waiting for updates of a patient's status, the old system provided delayed information, if any. "We would have huge discrepancies in the time from a change in a patient's location or status before even many personnel knew," Ketchum said. "Our records could show that the patient had never arrived in OR, simply because no one had recorded the event. It would appear we had misplaced a patient, when it was just a clerical error." Hours could pass before family and friends received updates.
A key target for automation was the large, centrally located greaseboard for surgical services. This ever-changing schedule matched up surgeries, rooms, personnel assignments of nurses, doctors, anesthesiologists and others, all the while patients were arriving early or late, or were subject to changing states of readiness for surgery.
New HIPAA federal privacy laws that restrict the way hospitals divulge information about patients meant the highly visible greaseboard had to go, to be replaced by information on computer screens.
Another tricky task was keeping track of portable, shared equipment like a blood sugar measuring instrument, which moved around the unit throughout the day, necessitating periodic searches for it. Buying lots of these devices is not cost-effective.
Starting in early March, all that changed. Now, tracking patients and equipment involves the careful integration of advanced communication and passive wireless tracking technology. In addition to receiving an armband, registration personnel give each patient a triangular, wristwatch-sized tracking badge to wear. The badge continuously emits infrared and radio-frequency signals to ceiling-mounted sensors in the expansion area.
In effect, the staff of the OR, short-stay and PACU units at Providence St. Vincent gained a system that could track patients in ways NORAD uses to track objects orbiting in space above Earth: precisely and in real time. With a glance at a computer screen, a keystroke or a mouse click, any staff member can know where a patient physically is located, from admission to release, and know which patient is in a particular room, and their status, in real time.
Replacing the old greaseboard was an "e-greaseboard" based upon new OR Tracker software from Healthcare IT Inc. OR Tracker shipped in early March, at the same time as it went live at Providence St. Vincent, which became the first installed location for the new software.
Here was a new, enhanced central nervous system for all the tasks the greaseboard had previously tracked, visible from the Web browser screen of every staffer's computer in the unit.
The e-greaseboard uses words, iconic images and maps to great effect. A patient list shows each patient's location, including bed or surgery suite number, as well as answers to important questions. Is the patient's name similar to another in the hospital's system? If so, a warning icon appears next to the case details, indicating to staff that a patient with a similar last name is also on the schedule. Is the patient allergic to latex gloves? Are there any roadblocks, missing prerequisites such as signed orders for consent, or physical exam results? Does the patient have a cold? The details are a glance or a click away. Or, is the patient ready whenever the OR is? If so, a green light appears next to their name. If it's a pediatric patient, an icon displaying little ABC blocks appears.
As the patient's discharge approaches, the e-greaseboard even shows staff if the patient stored valuables in the hospital's safe. In each case, a glance or click replaces what had often been a series of time-consuming phone calls to find the answers.
For the nurses scheduling use of the surgery suites, the e-greaseboard provides other immediately useful information. If a surgery is running late or finishing up early, all resources and people can be updated right away and personnel summoned or apprised of a postponement. Nurses can answer family and friends' questions right away. New, special hospital-provided pagers let guests wandering elsewhere at the hospital know right away when they should check in for important updates.
The e-greaseboard also leverages the graphical user interface of the browser. "If I hold the cursor over my last name, it shows my cell phone number and shows that I'm taking care of patient Abbott in Room 24," Ketchum said. Hold the cursor over the listing for the blood sugar machine, and the e-greaseboard shows its exact location-for instance, between room 24 and 25. An online map shows the entire short-stay unit. "If I hold the cursor over the map of an OR room, it shows me what procedure is being done there," she said. A red dot shows the location of the blood sugar machine. A separate screen shows how many patients the PACU unit has, and how long they've been there.
If the e-greaseboard is the new shared brains of the unit, the wireless phone system and upgraded nurse call system represent some of its new senses.
Today, when admitting personnel push one particular call system button in a short-stay room, it automatically rings the appropriate nurse's new wireless phone and tells him or her about a new patient to greet. After the nurse appears and greets the patient, pushing the "patient in" button lets all staff know the patient has been greeted. Pressing a "patient ready" button displays on the e-greaseboard that the patient is ready for surgery. Pressing a "dirty" button lets housekeeping staff know that a room is now empty or dirty, and pressing a "clean" button signifies to the charge nurse that the room is now clean and ready for use again.
While Ketchum says that implementation of the new system "was a breeze," it involved two years of careful planning and communication, including with some initially skeptical nurses. One of the first visible changes: Charge nurses and transport teams received the wireless phones. Other changes were more dramatic. Management decided to cut over to the new e-greaseboard all at once, so one day in early March, the old greaseboard was simply gone, and the e-greaseboard was in use. "We felt if we left a crutch, it would be used," Ketchum said. Instead, the downtime contingency plan consists of printing out the day's schedule in the morning, and referring to that if needed. There's only been one significant episode of downtime since March, she said.
Hospital management is conducting surveys to measure the effectiveness of the automation measures. "I know they're really tightening down on staffing, but now it's easier for them to track charges, which is helpful," Ketchum said. "The short-stay unit is kind of a dumping ground for any unit that closes after 5 o'clock. We're open until 11. Once a patient enters our unit from another unit that doesn't use patient tracking badges, a function of the way our system works is they will receive a tracker badge like any other patient. We can track how much time we spend on that unit's patient, and that time can be charged back to that other unit."
The majority of the nurses in the unit have drawn a line at wearing their own tracking devices, however. "We're working on that," Ketchum said. "Not to record their own time, but to record their interaction with patients. Staff is against this, mostly because they think someone will track their time in the bathroom or time at lunch. But the system can track a patient or person only if the infrared sensor was installed in that room. The sensors will not be installed in a staff room or lounge."
While other aspects of care at the unit, such as charting, still are awaiting automation, every day someone in surgical services thinks of a new way to use the new system, Bahlman said. "We are still tweaking the system to meet the needs of the patients and staff."