C A L I FOR N I A H EALTH C ARE F OU NDATION Equipped for Efficiency: Improving Nursing Care Through Technology December 2008 Equipped for Efficiency: Improving Nursing Care Through Technology Prepared for California HealthCare Foundation by Fran Turisco, M.B.A., research principal Jared Rhoads, M.S., senior research analyst CSC December 2008 About the Authors Fran Turisco is research principal and Jared Rhoads is a senior research analyst at CSC’s Emerging Practices, the applied research arm of CSC’s Global HealthCare Sector. CSC is a global consulting, systems integration, and outsourcing company based in Falls Church, Virginia. About the Foundation The California HealthCare Foundation is an independent philanthropy committed to improving the way health care is delivered and financed in California. By promoting innovations in care and broader access to information, our goal is to ensure that all Californians can get the care they need, when they need it, at a price they can afford. For more information on CHCF, visit us online at www.chcf.org. ©2008 California HealthCare Foundation Contents 2 I. Introduction 3 II. Overview How Technology Can Help 5 III. Technologies That Enhance Nursing Care Delivery Wireless Communications Real-Time Location Systems Delivery Robots Workflow Management Systems Wireless Patient Monitoring Electronic Medication Administration with Bar Coding Electronic Clinical Documentation Interactive Patient Technologies 2 4 IV. Summary 2 5 Appendices: A: Interviewees B: Vendors 2 8 Endnotes I. Introduction New technologies have the potential to create a better work environment for inpatient nurses by improving the efficiency, safety, and quality of care. Advances include wireless communications, real-time location systems, delivery robots, workflow management systems, wireless patient monitoring, electronic medication administration with bar coding, electronic clinical documentation, and interactive patient systems. When linked with these technologies, alarm/event messaging and biomedical device integration add significant value to the way nurses coordinate and provide care. Because nurses work at the center of a complex web of care delivery, their use of proven technological solutions can have a dramatic impact on hospital operations. This report, based on interviews with nurses and other professionals, describes the challenges that nurses face in everyday practice and how innovative hospitals around the country are applying eight leading-edge applications to overcome them. The results indicate that these systems have helped to create a better work environment for inpatient nurses and raise their job satisfaction, while also contributing to improvements in care. All of the hospitals that shared their experience are planning further enhancements or more widespread use of the technologies they have implemented to date. 2  |  C alifornia H ealth C are F oundation II. Overview Nurses prefer to work in hospitals where patient safety, quality of care, and nursing satisfaction are top priorities for hospital executives. Surveys over the years have cited common themes for high levels of job satisfaction among nurses: control and influence over their workday, workload, and workflows that enable them to be productive and efficient; an ability to deliver high-quality care and do their best for patients; and collaboration with fellow care providers in making decisions.1, 2 Nurses’ high job satisfaction also influences patient satisfaction. In one study, nursing care was the primary factor in how patients viewed their hospital stay. The more satisfied patients were with their nurses, the more satisfied they were with their stay.3 This report explores how technology can play a key role in creating such an environment. The focus is on emerging applications that are in early use, have demonstrated their value, and represent leading-edge technologies with great potential, as well as some already in the mainstream. For each technology, the authors interviewed nurses and others (see Appendix A) to learn how it enables them to do their work better and about the value it brings to them and patients. Appendix B lists representative vendors and products, as well as contact information. How Technology Can Help Inpatient care is provided by a team of professionals and support staff that rarely meets as a group but is in constant communication. Each team member is dealing with multiple patients and care management tasks, with many information transfers and patient hand-offs that must be reliable and coordinated if care is to be effective, safe, and timely. Meanwhile, nurses and others are also responding to requests for information and assistance from patients, family members, physicians, and ancillary services. Indeed, the average nurse spends only about 31 percent of his or her time on direct patient care.4 The result is a web of workflow and communications prone to resource or decision bottlenecks, communication gaps, missed or delayed tasks, and inappropriate use of valuable resources. Nurses are at the center of this web and spend considerable time performing many different tasks. Equipped for Efficiency: Improving Nursing Care Through Technology   |  3 Although difficult, unraveling the care process is K Improve collaboration and communication by necessary in order to identify specific workflow and routing and prioritizing messages and requests, as efficiency issues. Hospitals that scrutinize this process well as enabling immediate response to patients, can then incorporate technology to: caregivers, and staff. One example is wireless technology integrated with patient monitors that K Increase efficiency by removing nurses from the enable nurses to respond quickly to alarms. communication chain regarding tasks that do not require their attention, such as responding to a Some of the eight technologies described in this patient’s request for another blanket or walking to report address multiple areas of improvement central supply to restock bandages; (Table 1). K Improve patient safety and quality of care. Technology helps organize work and incorporate The following sections also describe two additional clinical knowledge and clinical decision support solutions — alarm/event messaging and biomedical to provide guidance and feedback on medication device integration — in greater detail, including the administration, vital signs monitoring, and other problems they help overcome and the benefits that patient care activities; particular hospitals have realized by implementing them. K Help deliver care by empowering patients and others to assume new delivery roles, thereby making nurses more efficient and effective. For example, patients at some hospitals use an interactive system to receive education about their medical condition or care received; and Table 1. Selected Technologies and Improvement Areas I m pr o ve m e n t areas S af et y a nd C are delivery C o llab o ration/ T echn o logy E f f icie n c y q u alit y assista n ce c o m m u n ication Wireless communication solutions 4 4 4 (including alarm/event messaging) Real-time location systems 4 4 Delivery robots 4 4 Workflow management systems 4 4 4 Wireless patient monitoring solutions 4 Electronic medication administration with bar coding 4 Electronic clinical documentation with clinical 4 4 decision support (includes biomedical device integration) Interactive patient systems 4 4 4 4 4  |  C alifornia H ealth C are F oundation III. echnologies That Enhance Nursing T Care Delivery Wireless Communications The Problem For nurses, even the seemingly simple task of contacting a pharmacy, laboratory, or other hospital department to ask about the status of an order involves an average of four to eight steps that consume nearly three minutes, according to one study.5 Another calculated that it takes 58 minutes each day for individual nurses to walk to the nurses’ station to answer the telephone.6 A major reason for the disjointed and inefficient workflow is that nurses must use multiple modes of communication — a unit desk phone, pager, and overhead pager — to get the job done. Some of these devices are in fixed locations, whereas nurses are highly mobile. Effective solutions must not only abet mobility, but also route a communication to the right person or team based on its urgency. The Solution Voice over Internet protocol (VoIP) technologies address these needs by tapping into the hospital’s wireless local area network. There are two such devices: telephone handsets and wearable, light- weight badges that can be clipped to a pocket or lapel, or worn on a lanyard. Telephone handsets and badges have different features and capabilities (Table 2). Table 2. eatures and Capabilities of Telephone Handsets vs. F Badges* T elephone handsets B ad ges Voice and data display capabilities Hands-free voice capabilities • Listen and respond (talk) • Listen and respond (talk) • View and respond (data entry) Pre-programmed keys and buttons Speech-recognition call features for specific requests and actions (by name, title, role) Call transfers, forwarding, holds; Call transfers, conferencing, conferencing; broadcasts broadcasts Ability to call outside of the hospital Ability to accept incoming calls via a PBX connection and accept via a PBX connection and ask for incoming calls outbound calls ∗ This report does not address cell phones or Blackberries because they do not offer the full range of communication functionality. In addition, they raise security, financial, and technology integration issues. Equipped for Efficiency: Improving Nursing Care Through Technology   |  5 Wireless communication technologies can be badges. Now, when the technologist calls, the used for point-to-point communication or, with assigned nurse can accept or refuse the call — if, for additional capabilities, to connect with other example, he or she is attending to another urgent technologies. These extra capabilities have many situation. Refused calls are automatically routed to different names: messaging or event-management the next nurse in the area or, if necessary, escalated middleware application, messaging integration up the chain of responsibility to the charge nurse, solution, workflow communication solution, and nurse manager, and so on. Once the two parties are event management solution. They are the “glue” connected, the telemetry technologist and nurse linking people, data, and patient events. In general, can discuss the arrhythmia alarm and the patient’s there are three main capabilities: current rhythm status. K Connectivity. Sending and receiving information to or from a wide range of information The impact on nursing response time to alarms technology applications, sensor devices, has been dramatic, dropping from 9.5 minutes on communication systems, and medical equipment; average to 39 seconds, well under the goal of no more than three minutes set by the hospital. The K Rules. Using logic to tie events to responsible communication loop is also closed 100 percent of parties. The rules identify a particular caregiver the time, compared with the previous 35 percent and the particular wireless communication device rate with pagers. This means that whenever there is he or she is carrying. They also assign a clinician a true alarm, the technologist can immediately hand to a room, patient, or medical equipment, and off critical information to the patient’s nurse.7, 8 govern escalation up the chain of responsibility and back-up; and Integrated with Telemetry and Nurse Call K Reporting. Keeping a full audit trail of all Application events. This includes tools to monitor events and At Children’s National Medical Center, a 283-bed resources. facility in Washington, D.C., the construction of a new inpatient tower presented an opportunity The Benefits to investigate fresh communication solutions. The layout of nursing units in the tower, which Basic Wireless has only single-bed rooms, is such that nurses At Beaumont Hospital, a 1,061-bed tertiary facility must cover a much larger area. Instead of a central in Royal Oak, Michigan, a close call involving a nursing station, there are alcoves with workstations telemetry patient prompted a rethinking of the throughout the unit. Senior leaders realized that communications approach. Trained technologists the facility needed technology to help coordinate constantly watch telemetry monitors centralized communications, prioritize requests for nursing in a “war room,” and when an alarm sounds, they assistance, and minimize unnecessary walking to and determine what action needs to be taken. Previously, from patient rooms. Additional goals were to better the technologist used a pager to notify the assigned manage group emergency communications (such as nurse. If the nurse did not respond within three code blue alarms), to triage calls from the patient minutes, the technologist paged the nurse again. rooms via the nurse call application, to support Frequent alarm pages began to desensitize nurses. one-on-one communications between care providers and ancillary support, and to augment patient- After a team analyzed the close call, which involved monitoring alarm notifications. an arrhythmia, it identified the need for hands-free, two-way communications between the technologist Initially, a multidisciplinary team spent months and nurses, and decided to implement wireless reviewing each process and then redesigning it to 6  |  C alifornia H ealth C are F oundation incorporate the new technology and modified work roles. Figure 1 illustrates the results for responses to “This [wireless communication] solution is a a patient monitor alarm. For all processes, the team built in escalation and back-up resources to ensure decision-support tool. It gives us information to that the communication loop would always be prioritize requests [which] allows us to be more closed. efficient and more responsive to our patients.” Improvements in response time were significant. — Linda Talley, R.N. The mean response time for alarms dropped from director of nursing systems Children’s National Medical Center 3 minutes 10 seconds to 34 seconds. Responding to patient calls dropped from 4 minutes 45 seconds to 1 minute 22 seconds. In addition, nurses reported fewer interruptions, better continuity of care, and improved workflow.9 Figure 1. Patient Monitor Response Process at Children’s National Medical Center Patient Monitor Alarm Sounds no response in no response in 10 seconds 30 seconds Patient monitor sends Escalation call sent out message to nurse call and to nurse manager wireless phone via wireless phone response in 10 seconds Nurse manager receives Nurse receives call (data) call (data) from from patient monitor patient monitor Nurse accepts call, Nurse manager accepts call, Nurse reviews monitor goes to patient’s room, goes to patient’s room, data, turns off monitor and turns off monitor and turns off monitor and determines care action determines care action determines care action Equipped for Efficiency: Improving Nursing Care Through Technology   |  7 Integrated with Multiple Alarm and Real-Time Location Systems Information Systems One of the most comprehensive implementations The Problem of wireless communications is at Sampson Regional As they deliver care, nurses need to coordinate Medical Center, 146-bed facility in Clinton, N.C., patients’ need with mobile equipment such as where the wireless telephone handset solution is intravenous (IV) pumps and electrocardiogram integrated with clinical applications, sensors, patient monitors, as well as other care providers. In a monitoring equipment, and the nurse call system. busy inpatient setting, just locating the necessary The project involved only wireless telephones when equipment is a difficult task, especially when the it started four years ago as part of a nursing unit facility is spread out or if the equipment is hidden or renovation. However, the benefits quickly convinced located on several floors. On average, nurses spend management to integrate the telephones with other 30 minutes per shift tracking down equipment.12 systems and technologies, and to make the set-up This inefficiency wastes hours of nursing time, ties part of routine practice in many inpatient units. up other resources, and delays the delivery of care. Hoarding equipment and supplies is common. Procedure for Responding to Panic Values Stories abound of equipment stashed out of sight in Lab Results in linen closets and smaller items such as medical At Sampson, panic values in lab results — those that require immediate action — are sent to the supplies hidden above suspended ceiling tiles. hospitalist and the nurse assigned to the patient. Hoarding is a short-term fix that exacerbates the Both must acknowledge receipt of the message. problem, as fewer items are available from the proper If they do not, the information is sent to the channels when nurses request them. It also distorts charge nurse, nurse supervisor, and then back to inventory, impairing the efficient use of assets and the lab. All notifications and escalations take place leading to over-buying of frequently used supplies in less than five minutes. and equipment by as much as 50 percent.13 Equally frustrating for nurses is the time they spend In a number of studies, the hospital has identified locating a patient who might be in the lounge or benefits for nursing, ancillary services, support in radiology for a procedure, or finding other staff departments, the emergency department, and members needed for patient care, patient transport, inpatient units. According to a management or support services. engineering analysis, 80 percent of nurses saved a minimum of 30 minutes each per shift. More The Solution surprising to the project team was the discovery, Hospitals can use a real-time location system thanks to reports accumulated by the technology (RTLS), also known as an indoor positioning itself, that most requests did not require a nurse’s system, to locate equipment, patients, and staff. attention. The ability to route those requests to unit Resources to be tracked are outfitted with small tags secretaries has freed up nursing time even further that communicate with transmitters and detectors and reduced interruptions.10,11 located throughout the facility. Through the use of complex positioning algorithms and signal detection technologies, the system can locate a particular resource or type of resource and display the information online. For example, if a nurse needs an IV pump, he or she selects the pump from a list of tracked equipment and the system displays an online 8  |  C alifornia H ealth C are F oundation map showing where the closest available pump is Ultra-wideband systems, which operate on very low located. Some systems also have remotely activated power output, are less likely to cause interference. flashing lights and buzzers — visual and audio cues However, the signals can still bleed, and the that help find the resource. To restrict movement technology is newer to the market than others. beyond a designated area, chokepoint devices at Infrared signals do not bleed, but the tags must entryways and exits set off an alarm when the tagged remain in the line of sight of sensors; they will not resource crosses the boundary. work if covered by a blanket, clothing, or any other opaque object. Several different types of technologies can provide real-time location tracking. The best-known is Finally, ultrasound systems share many of the best radio frequency identification (RFID). As the term capabilities of both radio frequency and infrared suggests, RFID tags communicate with receivers systems, but the short-range nature of sound through radio frequency signals. In hospital compared to longer-range radio signals may require settings, the tags are usually powered by small more detectors in a given area of coverage. To onboard batteries that enable them to “announce” determine which technology is appropriate, the their presence to receivers and detectors installed resources to be tracked and the necessary level of throughout the facility. As long as a piece of accuracy must be considered. equipment and its tag remain within range of the receivers, the RFID system can locate the item The Benefits to within the level of accuracy of the specific technology, ranging from 1 foot (bed-level precision) Equipment Location Tracking to 150 feet (zone-level precision). Before the installation of RTLS at Brigham and Women’s Hospital in Boston, a 777-bed teaching Other RTLS technologies include ultra-wideband affiliate of Harvard Medical School, nurses reported radio frequency, infrared beams, and ultrasound they spent a significant amount of time tracking acoustics. Ultra-wideband systems use short bursts of down equipment and hoarding critical items, such as radio signals across a very broad frequency spectrum IV pumps, if they knew they would need them later. to achieve better precision than regular RFID. On some shifts, nurses could save time by sending a Infrared-based systems use tags that give off pulses health care assistant to search for equipment, but this of infrared light detected by sensors installed in the only passed the problem to another staff member. walls or ceiling, similar to the way a remote control In addition, the hospital experienced inventory device communicates with a television or stereo. losses. To help prevent items from leaving the floor Ultrasound systems use tags that produce a periodic or hospital, staff were asked to send manual alarms “chirp” for identification. Detectors located in rooms to a generic alarm mailbox when they noticed that and hallways pick up the chirps, which are inaudible something was being removed. But because no to humans. one was responsible for tracking and monitoring equipment, oftentimes no one heeded the alarms. Each RTLS technology has advantages and disadvantages. For example, RFID tags can provide To address these issues, managers decided to room-level accuracy, but their signals tend to implement an RFID-based RTLS that targeted permeate or “bleed” between rooms and floors. medical equipment for patient care — equipment This can confuse the system as it tries to distinguish that would be a pressure point for quality of care or between information to use in the calculation and patient flow. This definition encompassed cables, information to ignore. pacers, defibrillators, portable monitors, data acquisition modules, and IV pumps, but not beds or Equipped for Efficiency: Improving Nursing Care Through Technology   |  9 wheelchairs. They also decided to install a separate Patient and Staff Location Tracking wireless infrastructure to reduce the risk of signal RFID tags worn by hospital staff and patients enable interference. a facility to pinpoint their location and analyze workflows, make staff members more accessible, Now, hospital staff can locate equipment and improve staff and patient safety. At Hospital St. automatically. Using a mobile telephone, nurses Louis, a 297-bed facility in Ettelbrück, Luxembourg, call either the unit secretary, who checks the RTLS nurses as well as psychiatry and neurology patients system to find the nearest device of a particular suffering from dementia receive wristbands outfitted type, or the biomedical department, which is now with RFID tags as a safety measure. Before, nurses much more likely to have the device in stock and had to walk the halls frequently to make sure ready. Although the hospital has not completed patients did not leave the premises. Patients who a formal analysis of benefits, nurses anecdotally were likely to wander required more attention and report better equipment availability and a significant more frequent bed checks, which took away time improvement in quality of work life. Nurses are no that nurses could have spent on other care-giving longer hoarding equipment because they are more tasks. confident they can find what they need when they need it. Hospital St. Louis started by successfully piloting the technology on the psychiatry unit. It then rolled RTLS also helped the hospital reduce equipment out the technology more broadly and integrated it losses by automating the alerts triggered when tagged with the mobile phone system. When a patient tries items are moved outside of defined areas. Based on to leave the unit, alert messages are sent directly to the results of an initial pilot project, the hospital nurses’ and security guards’ telephones. expects to lose 50 percent fewer pacemakers per year and no transmitters, defibrillators, or monitors, for In addition to keeping patients safe, Hospital St. total annual savings of more than $300,000. Louis uses RTLS to enhance workplace safety for nurses. Before, if a nurse was threatened by a patient, This success resulted not only from implementing security guards had no way of knowing where to go new technology, but also from redesigning roles in response; in some instances, nurses could not use and responsibilities for equipment tracking. Unit a telephone. Now, nurses wear RFID tags with an secretaries are responsible for locating and tracking emergency call button. They can request help very equipment. They have the time for this task because, easily and security guards can pinpoint the exact thanks to the implementation of advanced clinical location and respond more quickly. systems, they no longer need to transcribe orders. And because they coordinate equipment transfers, The hospital needed to address staff concerns they also know whether or not equipment should be about tracking people before it could implement leaving an area. the technology. Through a variety of educational sessions and multiple communication avenues, “ here is a huge cultural component to the implementation of technology. You can install a lot of technologies, T but if [a technology] doesn’t fit into the existing workflows, it won’t be adopted.” — Michael Fraai, director of biomedical engineering Brigham and Women’s Hospital 10  |  C alifornia H ealth C are F oundation hospital leaders reinforced the message that the Robots are more flexible than older technologies, purpose of the RTLS system was not to monitor such as pneumatic tube systems, because they can staff whereabouts at all times, but rather to improve deliver a wide variety of items. Furthermore, they safety. In addition, leaders educated patients about do not require any structural changes to hospital the RFID tags and asked them to sign a consent interiors. Using laser sensors and pre-loaded form. electronic drawings of hospital floor plans, and guided by an onboard computer, robots detect beds, water fountains, people, and other obstacles, and “ e are also planning to use the technology for W adjust their route to avoid collisions. They can even evacuation and disaster plans so we can track call elevators. Newer versions automatically attach to and detach from carts and hampers.15 and ensure the safety of every patient and nurse.” — Daniel Schartz information technology project leader The Benefits Hospital St. Louis Robots have a long track record of success in pharmacies and laboratories, including a quantifiable return on investment. Even though their role as a delivery assistant for nurses is relatively new, early Delivery Robots results are very promising. Providence Hospital, a 408-bed acute care facility in Washington, D.C., The Problem reports that a delivery robot can do the work of 4.2 Numerous studies of how nurses spend their time full-time-equivalent staff for about $2.85 per hour have generated some staggering statistics about how and haul loads of up to 500 pounds. Nurses now are much they devote to activities not directly related confident that deliveries will arrive on time and can to patient care. For example, a study at Ascension plan accordingly. In a University of Maryland study, Health, the nation’s largest Catholic, non-profit nurse satisfaction with pharmacy services increased health system, found that caregivers spent 48 percent 23 percent and confidence that pharmacists would of their time on tasks such as managing supplies, promptly fill and deliver new medication orders looking for equipment, doing paperwork, reporting, increased 50 percent after medication delivery robots making telephone calls, directing other staff, and were implemented.16 handling admissions and discharges.14 Many of these tasks — finding linens and supplies, and tracking Care Process Redesign down medications, for example — not only take Washington Hospital Center, a 926-bed non-profit up valuable time, but do not need to be done by a facility in the District of Columbia, introduced nurse. robots as part of a hospital-wide campaign to make the facility one of the “best places for nurses The Solution to work.” Taking a holistic view of the nursing Delivery robots can handle some fetch-and-deliver workflow and the tasks that make up a nurse’s tasks that nurses do. They also perform tasks done day, a team of nurses, physicians, pharmacists, and by other skilled personnel, which frees these staff administrative support staff redesigned workflows members to support nurses directly on care units. and recast roles and responsibilities to streamline Robots can reliably deliver medications from the nurses’ work. pharmacy to unit nurses on a scheduled or ad hoc basis, as well as meals, linens, supplies, and patient Initially, the team focused on medication charts, and deliver laboratory specimens to the lab. management and medical materials processing. Up to then, nurses were responsible for locating Equipped for Efficiency: Improving Nursing Care Through Technology   |  11 medications (stored in several different areas on the has eliminated six to ten 45-minute trips to the unit) and searching for a pharmacist or pharmacy pharmacy or materials management area per day. technician to answer questions and resolve problems. Pharmacy technicians working on the units, Work has already started on expanded use of robots occupied with transporting medication carts and to transport medical devices and linens, and to helping the pharmacist at the satellite pharmacy, deliver medical supplies routinely. Cabinets will still often were not available to assist nurses. If nurses be clearly marked to distinguish clean from dirty needed new or additional supplies, and supply staff linens and equipment, and, like the medication were not available to make a delivery, they would cabinets pulled by other robots, will be locked for typically retrieve the items themselves. security and safety. To minimize nursing time spent on tasks other than Workflow Management Systems patient care, Washington Hospital Center redesigned the workflow, incorporating robots. Two robots The Problem now deliver routine medication carts to the units. The increasing demand for inpatient services, The pharmacy technicians have been reassigned to combined with the many challenges of coordinating the inpatient units as part of the care team, which tasks and resources hospital-wide, often leads to makes them more visible on the floors and enables disjointed processes for managing patient flow. them to spend more time on new orders, one-time This results in frequent delays and inefficiencies. orders, answering medication questions, and locating Slowdowns in one area can create roadblocks in missing doses. They also stock individual patient other areas, exacerbating the problem. For example, medication carts. In effect, the robots took over tasks inefficient patient discharge procedures can force assigned to pharmacy technicians, who thus were hospitals to divert new patients due to a lack of able to provide a higher level of service to nurses. available beds. An internal survey of nurse satisfaction with One notable cause of this situation is the difficulty pharmacy services after the introduction of robots locating information. For example, to check the and workflow redesign revealed gains in every status of a bed, a nurse might have to refer to a measure. Forty-four percent of nurses indicated that, paper chart, check online, call the unit clerk or last before these changes, medications were available nurse assigned to the room, or physically walk to when they needed them — a figure that increased the room to see if it is occupied or has been cleaned. to 58 percent after the redesign. Nurses also missed If the nurse is waiting for a laboratory result before fewer doses and felt more comfortable that they starting a patient’s medication, he or she needs to call had the tools and support they needed to do their the laboratory or log in to the clinical information jobs. Pharmacy technicians like their new job system to see if the result has been posted. responsibilities because now they are more involved in patient care and not “just pushing a medication The Solution cart.” Workflow management systems, sometimes referred to as workflow automation tools, collect information To help with materials management, a third robot from multiple sources and integrate it into a makes regular deliveries of medical materials and single display that highlights key patient and bed ad hoc deliveries of additional linens and supplies. management information. Such a display serves as a In the four units that tested the robots, the hospital tracking board or “scoreboard,” providing caregivers estimates that robot-delivered medications (new with real-time information on which rooms are orders and those for urgent use) and supplies available, how long each patient has been waiting, 12  |  C alifornia H ealth C are F oundation which patients are at risk for a fall, which ones have bottlenecks. Quick access to this information can outstanding orders or new results, and other care save considerable time for nurses. In one vendor metrics and alerts. All of the information is displayed study, nurses recouped up to one hour per shift using color-coded icons overlaid onto an image of by eliminating seven to ten telephone calls and the nursing unit’s floor plan or a patient or room list. three to four workstation log-ins.17 In addition, the This “information at a glance” enables nurses and combination of placing patients in the right bed others to quickly determine when a room is ready, more quickly and reducing discharge delays can when a STAT order has been placed, or if a patient release five to ten “hidden” beds per day. request is pending. More Time for Patients and a Safer Work The displays can also show unit- and hospital- Environment wide utilization metrics that give staff continuous Oakwood Hospital and Medical Center, a 632-bed feedback on performance. Desktop views of the tertiary-care hub of the four-hospital Oakwood system can drill down to identify specific situations Healthcare System in Detroit, implemented a that are causing bottlenecks and provide a review workflow management system to replace its manual, of trends. For pending admissions and discharges, color-coded card method. In addition to bed status, a timer often displays the elapsed time since the the electronic scoreboard shows detailed flags, request was entered into the admission, discharge, values, and parameters regarding a patient’s care. For and transfer (ADT) system. instance, “FP” reminds staff to remain alert for fall prevention. “LANG” indicates that the patient has a In addition, the system can program alarms to call language barrier. “C,” “P,” and “A” are reminders of attention to scenarios that do not meet performance core measures for chronic heart failure, pneumonia, standards set by the hospital or The Joint or acute myocardial infarction, respectively. These Commission — for example, delivering antibiotics indicators help nurses prioritize work and identify for pneumonia within four hours of a patient’s patients who have special needs. arrival. Status updates, such as whether or not a room has been cleaned, can be entered directly into Oakwood fully implemented and integrated the application or via interfaces from the hospital’s the workflow management system in just a few clinical information, environmental services, and months. The effort was led by the nursing team and ADT systems. championed by the chief nursing officer. Formal training was minimal because nurses found the Some vendors of workflow management systems are system to be very intuitive. Within weeks, telephone integrating RFID technology to track the location calls regarding bed management had declined by 35 of patients and equipment. This combination of percent. The number of excessive four-hour waits in technologies enables nurses to know more than just the emergency department fell by one-half. And after the availability of a device. six months, the number of bed assignments available within 30 minutes jumped to 72 percent from 52 The Benefits percent. The system eliminated the need for twice- A workflow management system helps optimize daily “bed meetings,” enabling each nurse who had patient flow by providing a single view of attended the meetings to spend 30 more minutes per relevant, real-time patient information using day on bedside care. visual cues and indicators. By looking at the large screens placed throughout a unit, nurses and The work environment at Oakwood is now safer. staff are better equipped to prioritize their tasks, Before, isolation signs on doors could accidentally be respond to changes, and recognize and alleviate turned around, covered up, or taken down after the Equipped for Efficiency: Improving Nursing Care Through Technology   |  13 patient had been discharged but before the room had Workflow management has also speeded discharges. been cleaned. Today, the signs are linked to the ADT Before, there were often delays between the time system; nurses, environmental services staff, and the patient’s chart was dropped off at the front physicians can view them on-screen in real time. desk and the discharge was entered online. When a chart is dropped off now, the nurse can stop at any Quicker Patient Discharges nearby touch screen to indicate the change in patient Monongalia General Hospital, a 189-bed facility status, setting environmental or transport services in Morgantown, West Virginia, is known for its in motion. As a result, the hospital has trimmed heart care and surgical services. In response to new 30 to 60 minutes off the time it takes to process a Joint Commission requirements, the hospital’s discharge. patient flow committee examined the safety and timeliness of patient movement through the facility. Better Resource Utilization Across Hospitals Based on feedback from staff, the committee At Catholic Healthcare West in Nevada, a new knew that nurses were constantly exchanging workflow management system helped consolidate information by telephone and voicemail regarding management of internal patient flow, staffing, and changes in the status of patients and resources. A bed placement across three hospitals. Patient census previous solution — a red light above the patient had been very uneven among these facilities: St. room door signaling that the room needed to be Rose Siena often experienced many emergency cleaned — eliminated some calls to environmental department admissions and long waits for beds, services supervisors, but floating discharge cleaners while the other two hospitals occasionally had idle still had to walk constantly from floor to floor capacity. The new enterprise-wide system means looking for red lights. nurses can offer on-the-spot transport to other facilities where patients will receive care immediately. Now, using large, flat-panel displays, nurses can Knowing when beds are, or will become, available instantly alert environmental services about rooms helps staff increase the census and bed turns; it has ready for cleaning, regardless of where the room or reduced the number of back-and-forth telephone cleaning staff is located. This relatively simple change calls by 50 percent. Patients are now transported to has reduced calls to the housekeeping supervisor by open beds 260 times per month, up from 30 per 50 percent and calls back to the bed manager nurse month, and are better coordinated at both ends of by 20 percent. the transfer. Finally, improvements in utilization also mean “ he system is very intuitive to use — it doesn’t T more-balanced staffing. Instead of canceling nursing require any complicated interaction. Learning shifts at some locations while nurses elsewhere are overextended, Catholic Healthcare West now how to read the display board was more like a reassigns nurses as needed. show-and-tell than a training session.” — Johna Mowrey director of performance improvement Monongalia Health System 14  |  C alifornia H ealth C are F oundation Wireless Patient Monitoring The Solution In response to these needs, a new generation of The Problem wireless patient monitors with sensor technology has Failure-to-rescue cases, which account for 60,000 emerged to enable continuous, bed-level vigilance. deaths annually among Medicare patients younger These technologies can be integrated into the bed than 75, and patient falls, a leading cause of death or the mattress pad. Some feature electronic weight among people 65 or older, are important safety scales, blood pressure monitors, and sensors that indicators.18, 19 Patient falls are one of the most measure heart rate, respiration, and body movement common occurrences in hospitals. Of those who during sleep. If this technology is integrated with a fall, up to half may suffer moderate to severe injuries nurse-call or other communication system, it alerts that reduce mobility and independence, and increase a caregiver when a patient who is at risk for falling the risk of premature death.20 Equally important tries to exit the bed or when a patient who should be are inpatients who develop complications and lying flat has raised the bed’s angle. consequently suffer morbidity and mortality. The mattress pad-sensing devices make it possible The Joint Commission, the Institute for Healthcare to outfit an existing bed with advanced monitoring Improvement (IHI), and other entities are capabilities. One high-tech bed pad consists of paying greater attention to these issues. The Joint a zip-on mattress cover embedded with an array Commission’s 2009 National Patient Safety Goals of high-tech sensors. The sensors in the pad, or address falls and changes in patients’ condition, “coverlet,” collect continuous physiological data from and provide broad guidance on programs to the patient. Complex waveforms representing the institute hospital-wide.21 One of six recommended patient’s heart rate and respiratory rate are captured, interventions in the IHI’s 100,000 Lives Campaign decoded, and displayed on monitors at the bedside is deployment of a rapid response team of skilled and central desk. Caregivers can view current care providers when a patient’s condition starts values on the spot or review trends for the previous to deteriorate.22 Such patients must be connected 12 hours. The coverlet also contains pressure to monitoring equipment or under the close switches that can detect when a patient attempts to supervision of nurses checking their vital signs, leave the bed. All of these data can be monitored which may not be the case for general medical and automatically for comparison to hospital-defined surgical units. threshold values and be used to trigger alarms and pages, either as part of a self-contained network or Although there have been some improvements, one that works in conjunction with the hospital’s problems remain. In addition, there are several nurse call system. complicating factors. First, as of October 1, 2008, the Centers for Medicare and Medicaid Services To reduce false negatives and “alarm fatigue,” stopped reimbursing hospitals for costs related wireless monitoring systems enable hospitals to set to falls and associated trauma, which makes this up alarm templates and tolerances. For example, a financial as well as safety issue for hospitals.23 the system can be set to allow the bed head angle to Second, today’s medical and surgical units provide exceed the recommended limit for up to 30 seconds more than just basic care; rather, the care is similar to before it sounds an alarm, enabling incidental that provided by intensive care units in earlier years. adjustments and movement. Alternatively, alarms Third, due to the continuing nurse shortage, nursing can be selectively activated or suppressed, depending staff must care for more patients than they did in on what is appropriate for a given patient. the past. Equipped for Efficiency: Improving Nursing Care Through Technology   |  15 The Benefits of care due to an alert, often several hours before Wireless patient monitors provide a technological they were scheduled to be re-evaluated. One study safety net for busy caregivers who are caring for identified sizeable differences in ICU length of stay more and sicker patients. The ability to receive an (nine days in cases of pre-event transfers versus 14 alert indicating that a patient is trying to get out of days post-event) and mortality rate (11 percent bed, and to respond immediately through the nurse versus 41 percent).25 call system, improves productivity and workflow, and prevents falls. Fall rates at 636-bed St. Joseph’s/ Wireless patient monitoring improves nursing Candler Hospital in Savannah, Georgia, decreased workflow. One pre- and post-implementation from five falls per 1,000 patient days to 1.4 after it analysis concluded there were statistically significant integrated wireless patient monitoring with nurse increases in the time nurses spent on direct and communication technologies.24 indirect care. Eighty-six percent of nurses agreed that wireless patient monitoring helped them provide Continuous centralized monitoring also promotes quality care, and 77 percent agreed that it helped patient safety by reliably enforcing safety protocols. prevent falls. In addition, they spent 4.4 percent less Beds with built-in percussion and vibration therapy time on administrative activities, and there was a 24 help prevent ventilator-associated pneumonia by percent drop in the need for bed sitters.26 Nurses alerting nurses when the therapy session is done strongly supported the new technology as an “extra so suction can be performed in a timely manner. set of eyes” that improves vigilance and patient care. Similarly, customizable timers can prevent skin complications by reminding caregivers to shift Electronic Medication Administration patients before bed sores develop. By incorporating with Bar Coding accurate timers, reminders, and alerts, these technologies save nurses the administrative time they The Problem would otherwise spend tracking all such activities Medication errors occur frequently in hospitals. manually. Numerous studies have analyzed the contributing factors and resulting harm to patients in different At the James A. Haley Veterans’ Administration hospital environments and patient populations. Hospital, a 327-bed tertiary care teaching facility in National attention to the issue started with Tampa, Florida, a bed pad-based wireless monitoring publication of a landmark Institute of Medicine solution enables continuous patient observation. In report. Although the often-quoted statistic of 98,000 a pilot study, the hospital implemented this solution preventable deaths a year relates to all types of in a single-floor, 21-bed general medical unit that medical errors, medication errors that harm patients cares for patients with a wide variety of conditions, (“adverse drug events”) are the most common, affect ranging from chronic obstructive pulmonary disease a substantial number of patients, and account for a to pneumonia and other infectious diseases. The sizeable increase in health care costs. Annually, about study concentrated on the impact that automated 400,000 preventable adverse drug events occur and monitoring of respiratory and heart rates had on medication errors cost an additional $3.5 billion, nurse workflow, workload, and satisfaction. according to the report.27 Results showed that patients received care more Inpatient medication management is a complex rapidly than they would have otherwise. Timely process involving different departments, professionals alerts prompted nurses to adjust care parameters from various disciplines (nurses, pharmacists, about 10 percent of the time. In addition, about 2 physicians, and pharmacy technicians), and percent of patients were transferred to a higher level multiple hand-offs. Errors and adverse events can 16  |  C alifornia H ealth C are F oundation occur at every step, many of them while nurses are Figure 2. he eMAR Medication Administration T administering medications (Table 3). Process Table 3. dverse Drug Events During Medication A Management Nurse enters patient’s room with sta g e Adverse drug events medication cart, laptop, and scanner Prescribing 49% technologies used tasks Transcribing physician order 11% Dispensing 14% Administering 26% eMAR application Nurse reviews patient Source: Physician Order Entry: Costs, Benefits, and Challenges. A Case Study displays active medication record Approach. First Consulting: January 2003. medications from cart and selects meds Medication administration is the last opportunity to catch an error created during the other three steps, so Nurse starts Scanner IDs nurse any changes at this stage to reduce errors will have an administration as care provider immediate impact on patient safety. process —  eMAR displays meds self identification The Solution Software called electronic medication administration (eMAR) with bar coding can help reduce many Scanner IDs patient Nurse confirms via bar code or types of errors that occur during medication RFID on wrist band right patient administration. When nurses have access to better information about the drug and the patient, they have a much better chance of preventing a mistake. eMAR presents legible information about Scanner IDs each unit Nurse confirms dose med package right medication the medication, which means the nurse need not via bar code or RFID and dose transcribe it from the physician order; when it was last administered; and when it needs to be given. eMAR checks data A hand-held scanner tethered to the nurse’s laptop Nurse verifies right and displays route of administration or connected to it wirelessly is part of the technology patient safety alerts and time and reminders solution. The scanner quickly identifies and verifies the “five rights” checklist — patient, route, dose, time, and medication — by scanning barcodes on eMAR prompts Nurse confirms the medication package and patient identification nurse for additional no problems, band. The ability to verify the five rights as each data and stores med administers meds and admin event documents event medication is administered adds significant safety to the process. Figure 2 illustrates how this process works. The nurse uses a mobile medication cart and performs the tasks at the bedside. Atop the medication cart is a laptop or personal computer and scanner. The computer runs eMAR and interacts with the clinical Equipped for Efficiency: Improving Nursing Care Through Technology   |  17 Table 4. Rationale at St. Clair Hospital for Using Bar Coding vs. RFID C o m p o nent BAR CODING RFID R easons TO USE Patient wristband 4 • o line of sight requirement for scanning; no need to adjust patient N if wristband is not visible. • RFID tag does not wrinkle (wrinkles can cause incorrect scans). Caregiver ID 4 • afer — performs two-factor authentication more easily; RFID tag is S more difficult to replicate. IV bag 4 • Manufacturer’s bar coding is inadequate for IV identification. • lexibility of bag and fluid content wrinkle barcode labels, making F correct scans difficult. • Height of IV pole creates a difficult barcode scanning angle. Unit dose medication 4 • 80% come pre-packaged with barcode. • Easy to scan due to flat surface packaging Source: Patient Safety at the Bedside: Prevent Errors with RFID and Bar Coding. Vendrome Group: May 2007. information system (through a wireless connection The Benefits to the hospital’s local area network) and the scanner. At Doylestown Hospital, a 208-bed facility near Philadelphia, barcode-assisted medication As Figure 2 suggests, this set-up can accommodate administration was part of a larger effort to revamp two identification technologies: bar coding and radio this task. frequency identification (RFID). Hospitals most commonly use bar coding, although newer scanners Because of the priority that Doylestown placed support both, which a growing number of hospitals on improving safety, the eMAR project — from have found to be more effective. St. Clair Hospital, a planning to full implementation — took just 329-bed facility in Pittsburgh, Pennsylvania, started six months. The entire hospital has adopted the with barcode identification only, then migrated technology, resulting in an estimated reduction of to using RFID for IVs, patient wristbands, and nearly 40 percent in potential medication-related caregiver badges (Table 4). The net result was a 10 errors (Table 5). percent increase in the use of eMAR. Table 5. edication Error Reduction at Doylestown M Nationally, only 23 percent of hospitals have Hospital Using eMAR and Bar Coding adopted eMAR, according to a survey. However, P OTE N T I A L more than one-half of hospitals plan to implement it E rrors Patient Sa fet y parameters Prevented * within the next three years. Continued emphasis on eMAR • Legible medication information 23% technological advances and improving patient safety • Checks for duplicate orders are driving adoption.28 • rug interactions and allergy D checks • lerts to check latest lab values A “ arcode medication administration technology B for specific medications • Dosing alerts makes the environment not only safer for the Bar • Right patient 16% patients, but for the staff taking care of them.” coding • Right medication — Patti Stover, R.N., director of patient services Doylestown Hospital *Estimates based on an internal study at Doylestown Hospital, 2007. 18  |  C alifornia H ealth C are F oundation Electronic Clinical Documentation Nurses are very mobile and do much of their work at the bedside. Electronic clinical documentation The Problem becomes part of that routine (sometimes in patient Nurses spend a significant portion of their time rooms), thanks to a combination of mobile and fixed completing forms and documenting care. One workstations. Nurses who have electronic resources study found that for every hour of time spent at their disposal are likely to use a mix of mobile on patient care per shift, a nurse spends 30 devices, including wireless laptops on the medication minutes to one hour on paperwork.29 According cart during medication rounds, hand-held tablets, or to other studies, documentation — admissions subcompact notebooks for other tasks. and other nursing assessments, medication administration, progress notes, care plans, vital The Benefits signs, and discharges — requires two to three hours Hospitals adopt electronic documentation primarily per nurse per shift.30 Manual documentation is to do a better overall job of providing care. However, time-consuming and often incomplete or illegible. today’s applications and integration technologies can also save time for nurses, although the results In addition to being the official record of care vary depending on factors such as the portion delivery, clinical documentation is the source of of documentation that involves nursing, system much of the information needed to monitor and design and configuration, and the implementation improve patient care, as well as improve performance approach. An analysis of multiple studies concluded overall. Culling this information from paper charts that electronic solutions can reduce the time spent is so time consuming and expensive that often it is on clinical documentation by up to 24 percent.31 only performed after the fact for external reporting Biomedical devices connected to an electronic purposes and does not contribute to the broader documentation system also save time by transmitting quality improvement agenda. data automatically for review and incorporation into the electronic record. Each such device can save a The Solution nurse one to two minutes per reading task.32 Hospitals implement a suite of clinical applications to incrementally move paper documents with There are workflow benefits, too. The latest information about patient histories, assessments, generation of clinical documentation systems orders, notes, and the care they have received into generates work lists and reminders as “an electronic an inpatient electronic health record. Ultimately, helping hand” to nurses as they manage a plethora clinicians from all departments and disciplines of patient care tasks. Alerts tell them which must be perform all care planning and documentation completed and when per the care plan, and include electronically, but the journey from a paper-based the specific electronic form that ties actions to system takes place in stages over a period of years. documentation of the care delivered. In the ideal electronic setting, caregivers capture Florida Hospital, a seven-hospital system in Orlando, information only once, in real time and often at migrated from a combined paper and electronic the point of care. Each member of the care team patient chart to a totally electronic environment. builds upon information that is already available. Among the more than 250 electronic forms are all Templates and other decision support tools guide of the nursing and ancillary documents in medical the documentation process and ensure that hospital and surgical units, the emergency department, and protocols and care standards are applied consistently critical care units. They include flow sheets, which in support of effective patient care and the hospital’s were particularly challenging in the transition to quality improvement agenda. electronic format because staff had been used to Equipped for Efficiency: Improving Nursing Care Through Technology   |  19 a tri-fold paper document that displayed vitals, sheets with pulse, respiration, and blood pressure physiological inputs/outputs, and drips on one sheet. data; and Patient consent and signature documents are the few K Coordinating tasks and reminders to manage remaining paper forms. work and ensure compliance with regulatory and patient-safety documentation requirements. A primary goal was to reduce documentation redundancies. For example, the emergency Implementation team leaders at Florida Hospital department nurse electronically records a patient’s believe that the two most valuable gains are medications, medical and surgical history, data-sharing among caregivers and task management allergies, problems, and current interventions. support, including alerts for providers that “push” Because the new system supports interdisciplinary electronic forms. These features have improved both documentation and adherence to data and care the efficiency of documentation and effectiveness of standards, it enables clinicians in all areas to work care delivery. An unexpected benefit is the “helping from the same information base. Now, when patients hand” that the task management functions give to are admitted, nurses use what was documented novice nurses. Using the automated work list, nurses online in the emergency department as the starting see all of the work that needs to be done and the point. electronic forms they must complete. Florida Hospital’s new system improves clinical Interactive Patient Technologies documentation by: Most technologies profiled in this report address K Providing standard templates for assessments, a single operational challenge, such as bridging plans, and notes ensure complete data collection. communication gaps or improving patient Information already captured is displayed for monitoring or some other aspect of care delivery. review and update; Interactive patient technologies can lead to improvements in multiple areas, including nursing K Allowing users to perform documentation of workflow, efficiency, and care delivery. an exception, pull data from prior stays, and select from menus rather than having to enter An interactive patient system is a digital platform text, which minimizes typing and increases for two-way communication and delivery of standardization; multimedia content at the bedside. The system K Enabling the integration of bedside devices on the enables communication with the nurse and support critical care unit to automatically populate flow personnel, delivers patient education videos, Table 6. Features and Functions of Interactive Patient Systems Patient E ducation Hospital Services Entertain ment • ducational content available on E • ervice request routing to nursing, housekeeping, • ocal and premium S L demand or at scheduled intervals. environmental services, and other departments television options • ontent can be customized based C • lectronic communication about, and submission E • nternet access, including I on patient-specific diagnosis and of, complaints email and Web browsing parameters. • eal-time satisfaction surveys R • ovies on demand M • ontent can be purchased from vendors C • ain assessment surveys P • usic and audio books M or generated by the hospital. • nformation for family members and visitors I • M/FM radio A • nd-of-session quizzes confirm the E patient’s understanding of the materials. • atient-customized food menus and online P • ideo games V ordering 20  |  C alifornia H ealth C are F oundation handles patient requests, and provides a range of Figure 3. atient Education Workflow: P entertainment and Internet services, usually over a Manual vs. Interactive Systems dedicated network. Table 6 (see previous page) lists the educational, hospital-services, and entertainment Interactive Manual Patient Sy ste ms features and functions of such a system. (analog) (digital) start start Patient Education Locate audiovisual Add video to Patient education is often an inefficient, equipment on patient’s queue the floor upon receipt of time-consuming task for nurses, who must doctor’s order coordinate video equipment, educational materials, Wheel equipment and patient and family availability. The nurse sets into patient room, Patient plug in watches video up the system, either a freestanding cart with a television and video player or the hospital’s closed- Locate correct System prompts circuit TV; comes back when the session is over; and videotape in patient for asks questions to confirm the patient’s understanding central repository comprehension of educational content of the materials. The nurse then notes in the chart Rewind/cue that the patient has received the required education. videotape to/at System documents If the patient is unavailable, gets interrupted, or correct starting point that patient has completed does not feel well enough to watch the video at a Verify that video educational convenient time for the nurse, the process is repeated plays properly and requirement at a later time. patient can hear it finish Patient Interactive patient systems make the delivery of watches video patient education vastly more efficient because Return to room, online videos, diagrams, and animations are delivered   Nurse activities unplug equipment directly to the bed (Figure 3). In-room monitors   Patient activities can access videos from a central online resource at Wheel equipment out of room, find a any time. As soon as a patient has finished watching place to store it an educational video (or, optionally, after the patient has answered a set of questions to test his Return to room, or her understanding), the clinical application is ask patient about educational content automatically updated to reflect that the information was successfully delivered. Document that patient has completed education Interactive patient systems make education requirement convenient for patients and their families, make it easy for nurses to deliver, and help hospitals comply finish with Joint Commission requirements. One study found that such systems reduced the time nurses needed to initiate an education session from 19.1 minutes to 5.2 minutes — a savings of nearly 14 minutes per session.33 Equipped for Efficiency: Improving Nursing Care Through Technology   |  21 Hospital Services to conveniently look up information about their Nurses are often the first point of contact for any medical condition. Over time, however, the hospital type of patient request. Many requests — for a found that the system freed nurses to focus more missed meal, a change in room temperature, or an on providing direct care. In its orthopedic unit, additional blanket, for example — are unrelated to for example, where rooms easily become cluttered nursing care. The nurse either fulfills the request with equipment and where trash cans fill quickly, or finds someone who can. This is an inefficient patients may send room service requests directly to use of nurses’ time and adds to their already busy environmental services, which means they get a faster work schedule. Given the way nurses are used as response. middlemen for administrative requests, it is not surprising that more than half think support services In addition, Winchester has extensively used the are inadequate.34 system’s instant feedback capabilities, implementing patient-compliment and patient-suggestion features. The instant request function in interactive patient Via email, compliments go directly to the nursing systems removes nurses as middlemen. The patient director and suggestions to the patient service enters a request online and the system routes it to recovery team. Issues related to cold food or excessive the appropriate department or service. This function noise during the night, for example, can be addressed can include escalation notifications when responses during the patient’s stay. are overdue. Some versions are more closely integrated with other hospital systems, enabling The system also has reduced the burden on staff patients to order meals directly or adjust room to educate patients individually, and the related temperature from the bedside. documentation and compliance are significantly easier. Winchester enforces “safety pathways” that Entertainment prompt patients to view videos on topics such as Interactive patient systems can also help occupy hand-washing and fall prevention at pre-set intervals patients during their stay by replicating many of the after admission. Other videos can be added or amenities and entertainment options they enjoy at deleted from the queue based on their relevance to home. The entertainment choices range from TV particular patients and their diagnosis. Within the and movies to games and Internet access. first month of system implementation, patient use of educational videos increased 15 percent. By offering such features and services, hospitals keep up with changing patient demographics and Baptist Medical Center South, a 62-bed hospital consumer expectations. Many patients, accustomed in Jacksonville, Florida, uses an interactive patient to the conveniences and personalized service they system to guide patients throughout their hospital receive from other industries, now expect to have stay—from the welcome message they receive upon such capabilities at their fingertips. Interactive admission to the education, entertainment, and patient systems give them more information about communication technologies that allow them to their condition, more choices regarding how to customize their experience and request services. For spend their time, and a greater sense of control. example, every patient receives education about proper hand hygiene twice within 24 hours of The Benefits admission, to increase retention and emphasize the Winchester Medical Center, a 411-bed non-profit topic’s importance. facility in Winchester, Virginia, initially installed an interactive patient system to give patients and Bedside communication also means patients families access to the Internet, and to enable patients get answers to their questions more quickly and 22  |  C alifornia H ealth C are F oundation consistently. And nurses find it easier to include family members in the care process because education is more accessible and videos can be repeated at relatives’ convenience. Baptist is planning to expand the system, enabling patients to order food and participate in surveys. Interactive patient systems can improve the patient experience and the way patients and family members view an organization. For example, leaders at Inova Fair Oaks Hospital, a 182-bed facility in Fairfax, Virginia, believe that their system contributed to improving patient satisfaction with specific aspects of care. Officials have reported a 9 percent improvement in such ratings regarding ease of communication with staff, and a near 10 percent increase regarding timely response to their needs.35 Equipped for Efficiency: Improving Nursing Care Through Technology   |  23 IV. Summary The technologies described in this report help create a better work environment for inpatient nurses and increase their job satisfaction by improving the efficiency, safety, and quality of care. Only when hospitals experiment with such technologies in combination and evaluate the impact will they understand the full potential for improving nurses’ work, nursing care overall, and hospital operations. Early results suggest that the potential could be substantial. 24  |  C alifornia H ealth C are F oundation Appendix A: Interviewees Kim Bonzheim Kimberly Krakowski, R.N., Certified Director, cardiac services Clinical specialist, pharmacy liaison Beaumont Hospital Washington Hospital Center Royal Oak, Michigan Washington, D.C. Susan Clark, R.N. Johna Mowrey, M.B.A. Clinical educator Director, performance improvement Winchester Medical Center Monongalia Health System Winchester, Virginia Morgantown, West Virginia Sonia Collazo, R.N. Daniel Schartz Nurse manager IT project leader James A. Haley Veterans’ Hospital Hospital St. Louis Tampa, Florida Ettelbrück, Luxembourg Lori DeVore, R.N., Certified Patti Stover, R.N. Process architect for clinical documentation project Director, patient services Florida Hospital Doylestown Hospital Orlando, Florida Doylestown, Pennsylvania Mary Diehl, R.N. Linda Talley, R.N. Central staffing critical care nurse Director, nursing systems Florida Hospital Children’s National Medical Center Orlando, Florida Washington, D.C. Monica Donofrio, R.N. Wendy Yontz, R.N. Administrative director, care management and Operations Center director, St. Rose Dominican patient access Hospitals Oakwood Hospital and Medical Center Catholic Healthcare West Dearborn, Michigan Henderson, Nevada L. Michael Fraai David Ziolkowski Director, biomedical engineering Senior vice president and chief information officer Brigham and Women’s Hospital Sampson Regional Medical Center Boston, Massachusetts Clinton, North Carolina Equipped for Efficiency: Improving Nursing Care Through Technology   |  25 Appendix B: Vendors V endo r / P roduct Contact Infor mation Technology Category AeroScout 1300 Island Drive, Suite 202 Real-time location systems Unified Asset Visibility Redwood City, CA 94065 www.aeroscout.com (650) 596-2994 Aethon 100 Business Center Drive Delivery robots TUG Robot Pittsburgh, PA 15205 www.aethon.com (412) 322-2975 Ascom 598 Airport Boulevard, Suite 300 Wireless communications, Wireless VoIP Phones, MedUnite Morrisville, NC 27560 alarm/event messaging www.ascom.us (877) 71ASCOM Capsule Technologie 300 Brickstone Square, Suite 203 Biomedical device integration DataCaptor Andover, MA 01810 www.capsuletech.com (800) 260-9537 Cerner 2800 Rockcreek Parkway Clinical documentation, medication Cerner Clinical Documentation and Kansas City, MO 64117 administration technologies Medications Administration www.cerner.com (816) 201-1024 Eclipsys Three Ravinia Drive Clinical documentation, medication Clinical Documentation and Atlanta, GA 30346 administration technologies Medications Administration www.eclipsys.com (404) 847-5000 Emergin (Philips) 6400 Congress Avenue, Suite 1050 Alarm/event messaging Integration Suite Boca Raton, FL 33487 www.emergin.com (866) 363-7446 Epic 1979 Milky Way Clinical documentation, medication Clinical Documentation and Verona, WI 53593 administration technologies Medications Administration www.epicsystems.com (608) 271-9000 GetWellNetwork 7920 Norfolk Ave. 11th Floor Interactive patient systems PatientLife:)System Bethesda, MD 20814-2500 www.getwellnetwork.com (877) MEETGWN GlobeStar Systems 7 Kodiak Crescent, Suite 100 Alarm/event messaging ConnexAll Toronto, Ontario, Canada M3J 3E5 www.globestarsystems.com (866) 556-3377 Hill-Rom 1069 State Route 46 East Wireless patient monitoring VersaCare Bed Batesville, IN 47006 www.hill-rom.com (812) 934-7777 Hoana Medical 828 Fort Street Mall, Suite 620 Wireless patient monitoring LifeBed Honolulu, HI 96813 www.hoana.com (808) 523-5410 26  |  C alifornia H ealth C are F oundation V endo r / P r o d uct Contact Infor mation Technology Category InnerWireless 1155 Kas Drive, Suite 200 Real-time location systems PanGo Richardson, TX 75081 www.innerwireless.com (972) 479-9898 iSirona 2211 Hwy. 77, Suite 101 Biomedical device integration SmartAdapter, DeviceConX Panama City, FL 32444 www.isirona.com (866) 202-2124 Magnet Health 785 Bedford Street Interactive patient systems Patient Experience Platform Whitman, MA 02382 www.magnethealth.com (781) 447-9500 MEDITECH MEDITECH Circle Clinical documentation, medication HCIS, Closed Loop Medication Westwood, MA 02090 administration technologies Management www.meditech.com (781) 821-3000 McKesson One Post Street Workflow management, clinical Horizon Enterprise Visibility, San Francisco, CA 94104 documentation Clinical Documentation www.mckesson.com (415) 983-8300 Radianse 200 Brickstone Square, Suite 302 Real-time location systems, Radianse RFID, Radianse Reveal Andover, MA 01810 workflow management www.radianse.com (800) 974-9302 Siemens Healthcare 51 Valley Stream Parkway Clinical documentation, medication Soarian Malvern, PA 19355 administration technologies www.medical.siemens.com (888) 826-9702 Skylight Healthcare Systems 12777 High Bluff Drive, Suite 150 Interactive patient systems ACCESS Interactive Patient System San Diego, CA 92130 www.skylight.com (858) 523-3700 Sonitor 8250 Bryan Dairy Road, Suite 120 Real-time location systems Ultrasound Indoor Positioning System Largo, FL 33777 www.sonitor.com (877) 477-9767 Spectralink (Polycom) 4750 Willow Road Wireless communications Wireless Telephone Systems Pleasanton, CA 94588-2708 www.spectralink.com (800) 765-9266 Versus Technology 2600 Miller Creek Road Real-time location systems VISion Enterprise Locating Solution Traverse City, MI 49684 www.versustech.com (877) 9VERSUS Vocera Communications 525 Race Street Wireless communications Vocera Communications Badge San Jose, CA 95126 www.vocera.com (800) 331-6356 Equipped for Efficiency: Improving Nursing Care Through Technology   |  27 Endnotes 1. American Nurses Association. “Survey of 76,000 13. Swank, K. “A look at a promising new technology nurses probes elements of job satisfaction.” designed for hospital use.” RFID Product News: NursingWorld: April 1, 2005 (www.nursingworld. May 2007 (www.rfidproductnews.com/pages/search- org/FunctionalMenuCategories/MediaResources/ view.php?key=look%20at%20a%20promising%20 PressReleases/2005/pr04018524.aspx). new%20technology%20designed%20for%20hospi- tal%20use&p=issues/2007.05/webonly.asset.php). 2. “Survey results demonstrate improved nurse job satis- faction.” Alberta RN 2005;61(6): 14. 14. Hendrich A., Lee, N. A Time and Motion Study of Health Care Workers: Tribes of Hunters and Gatherers. 3. Huff, C. “Job satisfaction: why your job isn’t a bowl Unpublished report: 2003. See also Transforming Care of cherries.” NurseWeek: October 23, 1997 at the Bedside. Institute for Healthcare Improvement: (www.nurseweek.com/features/97-10/jobsatis.html). 2004 (www.ihi.org/IHI/Programs/StrategicInitiatives/ 4. Hendrich, A., Chow, M., Skierczynski, B.A., and TransformingCareAtTheBedside.htm). others. “A 36-hospital time and motion study: 15. Grey, M. “Hospital goes robotic.” Healthcare how do medical-surgical nurses spend their time?” Informatics 2007;24(7): 18 – 20. Permanente Journal 2008;12(3): 25 – 34 (xnet.kp.org/ permanentejournal/sum08/time-study.pdf). 16. “Aethon enhances TUG navigation system with advanced laser vision technology.” Business Wire: 5. ROI Study at St. Agnes Hospital. HCT Project Volume March 11, 2008 (www.reuters.com/article/pressRe- 2. Vocera Communications: July 2004. lease/idUS154435+11-Mar-2008+BW20080311). 6. Optimizing Wireless LANs for Voice 17. Horizon Enterprise Visibility. McKesson Communications. Web seminar. SpectraLink: (www.mckesson.com/en_us/McKesson.com/ March 13, 2007. For%2BHealthcare%2BProviders/Hospitals/Enterpri 7. Bonzheim, K. Process and Workflow Improvements se%2BPatient%2BCare%2BVisibility/Horizon%2BE Through Technology Adoption. Health Information nterprise%2BVisibility.html). and Management Systems Society: June 29, 2006. 18. Kremsdorf, R. “Failure to rescue and errors of 8. Kim Bonzheim, personal communication, omission.” Patient Safety & Quality Healthcare: July/ May 2008. August 2005 (www.psqh.com/julaug05/ails.html). 9. Linda Talley, personal communication, May 2008. 19. “Reducing harm from falls.” Institute for Healthcare 10. David Ziolkowski, personal communication, Improvement (www.ihi.org/IHI/Topics/PatientSafety/ May 2008. ReducingHarmfromFalls). 11. Real ROI: Smart Integration with Wireless 20. Ibid. Communication Improves Hospital Workflow. 21. 2009 National Patient Safety Goals. Joint Health Information and Management Systems Commission: 2008 (www.jointcommission.org/ Society: February 25 – March 1, 2007. 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Personal Intelligent Medical Assistant: an Interim Report (PIMA-3). Hoana Medical: November 2007. 27. Kohn, L.T., Corrigan, J.M., Donaldson, M.S. (Eds). To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press, 2000. 28. Survey of U.S. Hospitals and Health System Adoption and Implementation of Health Information Technology. American Society of Health-System Pharmacists: February 2008. A survey summary is available at www.ashp.org/import/news/pressreleases/pressrelease. aspx?id=471. 29. Patients or Paperwork: the Regulatory Burden Facing America’s Hospitals. PricewaterhouseCoopers: 2001. 30. Poissant, L., Pereira, J., Tamblyn, R., and others. “The impact of electronic health records on time efficiency of physicians and nurses: a systematic review.” Journal of the American Medical Informatics Association 2005;12(5): 505 – 516. 31. Ibid. 32. Addressing the Issues of Nursing Shortages and Patient Safety Through Bio-Medical Device Integration (BMDI). MindGent Healthcare Services: 2005. 33. Results Brief. Skylight Healthcare Systems: March 2006. 34. Aiken, L.H., Clarke, S.P., Sloane, D.M. “Hospital restructuring: does it adversely affect care and outcomes?” Journal of Health and Human Services Administration 2001;23(4): 416 – 442. Equipped for Efficiency: Improving Nursing Care Through Technology   |  29 C A L I FOR N I A H EALTH C ARE F OU NDATION 1438 Webster Street, Suite 400 Oakland, CA 94612 tel: 510.238.1040 fax: 510.238.1388 www.chcf.org