If a barcode can track a package around the world, why can't it track a patient's every move in a surgical facility? As you'll see in the profiles of three surgery departments in the pages that follow, patient-tracking software and devices can do that and a whole lot more.
Providence St. Vincent Medical Center in Portland, Ore., does between 90 and 110 cases a day in its new 60,000-square-foot surgery department that includes 27 ORs, 56 pre-op beds and 27 recovery beds - and is running more smoothly than it did before its expansion to the current size.
How? Working with several software and hardware companies, Deborah Tuke Bahlman, RN, MS, and St. Vincent's periop team designed what may be the ultimate patient-tracking system.
"When we were setting out to build this surgery expansion, we started asking, 'How are we going to communicate? This place is huge,'" says Ms. Bahlman, Providence Health System's regional manager of surgical services information systems. "We were more than doubling our workspace, and we couldn't imagine trying to use the same communication methods or tools and be efficient at the same time."
Ms. Bahlman helped design the system, which interfaces passive infrared/radiofrequency badges (Versus Technology), a Web browser-based electronic greaseboard (Healthcare IT), a wireless phone system (Spectralink) and a nurse-call system (Rauland-Borg). Live for a year-and-a-half, the integrated system does more than simply monitor patients' locations. It tracks how long a patient spends in each area of the surgery department; alerts doctors, nurses, anesthesiologists and housekeeping staff to where they need to go and what they need to do; and does it all in real-time (the system refreshes every 90 seconds).
No patient left behind
Here's what a patient's trip, admission to discharge, looks like in St. Vincent's surgery department:
- Admitting. At check-in, the patient is given a tracking badge, which is attached to his wrist, next to the hospital ID bracelet. The badge emits continuous IR signals to ceiling-mounted sensors throughout the area. It also has a unique barcode associated with the patient that is typed into the OR Tracker system.
- Let the tracking begin. The tracking - of time and location - now starts and doesn't end until the patient is discharged or admitted to the nursing unit. For each milestone (such as entering the surgery suite or recovery) that the patient reaches, a new sub-clock begins, so nurses can determine how long patients spend, for example, in the waiting room, in the pre-op room and prepped and waiting to go into the OR. Location is always tracked; even if a patient is in the restroom, the patient's location is on the board where everyone who needs to know can view it.
- Pre-op arrival. The patient heads to a pre-op room, escorted by a member of the admitting staff. She presses the a call button labeled "patient in" on the room's wall, and two things happen: a light mounted outside the room lights up to signal that a patient is in the room, and a text message is sent to the cell phone of the nurse and nurse's aide assigned to that room.
- Readied for surgery. The assigned pre-op nurse arrives in the room, completes final documentation, starts the IV and preps the patient. When all pre-op tasks are completed, the nurse pushes the next call button on the wall, "patient ready." The indicator light outside the room changes, and an icon shows up next to the patient's last name on the e-greaseboard (OR Tracker), the many intranet-connected monitors staff check to determine patient location and progress.
- To the OR. By looking at the e-greaseboard, OR staff now knows the patient is prepped, and an anesthesiologist and surgery nurse go pick him up. Before the patient is wheeled out, the "room dirty" nurse-call button is pushed, which changes the room dome light color and sends a text message to the housekeeper's pager. (There is one staffer for all 56 pre-op beds.) The room status also shows up on OR Tracker so another patient isn't assigned to the room until it's clean. After housekeeping has cleaned the room, the "room clean" button is pushed, which turns off the indicator light and clears the room for use on OR Tracker.
- In the OR. When the infrared /radiofrequency sensors detect the patient's arrival in the OR, an icon - a little face with a surgical mask on it - appears next to the patient's name on the e-greaseboard. The procedure start time is shown next to the scheduled start time. When the surgery is complete, before the patient heads to recovery, a nurse pushes the "change over" button, which signals that the room needs to be cleaned and prepared for the next case. A text message is sent to the crew who clean the room. A nurse then pushes the "short stay" or "PACU" call button, depending on where the patient is headed. The area where the patient is going gets a request via the e-greaseboard that the patient's arrival is pending. The charge nurse assigns the bed number, which is instantly communicated to the OR and all the monitors.
- Recovery time. The patient is wheeled to the proper recovery area; the infrared/ radiofrequency sensors detect the patient's arrival and remove the patient name from all monitors but those in recovery and the front desk. A PACU nurse assigned to care for the patient is alerted to his arrival via the e-greaseboard. The badge is removed at discharge and disassociated with the patient.
"All these systems are interfaced and talk to each other, so we don't spend so much time on the phone trying to find patients and communicate their statuses," says Ms. Bahlman. "We do talk to each other on things that matter most. But we make better use of the time we do talk to each other, allowing us more time with patients."
The time savings realized is immense. Before patient tracking, staff in St. Vincent's surgery department made an average of 11 phone calls per patient, estimated at 15 seconds per call. For 110 cases per day, that meant about five-and-a-half hours wasted each day.
"In the beginning, we spent a lot of time outlining our workflow and communication processes and realized how inefficient we were," says Ms. Bahlman. "We then outlined how we though we should work and designed the new system around it. With asynchronous communication like this, information is entered once and everyone can glean info when they need it."
Icons and color-coding make everything even easier to understand. For example, a face with a surgical mask appears next to a patient's name when he is in the OR, and a stop sign appears when a patient's progress is put on hold for any reason (such as a missing element on the history and physical or no consent). Add-on cases show up in pink on the monitors.
"Text is hard on the eyes, and we want everyone to glean information quickly," says Ms. Bahlman. "If you give people visual clues, they spend less time reading - and you don't need a phone call from the control desk to the OR just to say 'I just added a case to your room.'"
And the system is HIPAA-compliant: In certain areas, only the patient's last name and first initial are visible on the screens. The system is secure; only those who need the information can get it - a person accessing the system has to enter a username and password to access patient information; and in the waiting room, volunteers have access only to patient name and status so they can answer families' questions about patients' progress.
One of the enhancements in the works is automatic updating of the start times of following cases. For example, if the first case of the day was slated for 7:30, but it didn't start till 7:40 and it's a two-hour case, the monitors would still show the next case as scheduled for 9:30 - even though it would also show a 7:40 start for the first. Ms. Bahlman is working with Healthcare IT to make the necessary changes so that the second case (and any cases to follow) will automatically get a new start time if there's a delay in the preceding case. Another addition will be an announcement section on each department's view, so directors or supervisors can communicate to the staff important pieces of information pertaining to the day's activities.
"We're also working on process improvement, such as evaluating wait times and communicating delays to families," says Ms. Bahlman. "We have a lot of data we never had access to before."
Okay, so maybe you don't need that much technology, because your facility is too small - or you don't want that much because it's too large a chunk to bite off. You can pick and choose the technologies you need, like Valley Presbyterian Hospital in Van Nuys, Calif., and New York-Presbyterian Healthcare System in New York did.
Radiofrequency ID bands
When Sallie Naber, Valley Presbyterian's director of general services, was looking into ways to increase compliance with JCAHO's national patient safety goals, radiofrequency ID wristbands (Precision Dynamics) came to the fore as an easy way to meet that objective. The patient-information tracking is a side benefit.
When a patient checks in, he is fitted with a wristband containing a microchip that stores his information, including surgery type and site, allergies, and blood type - all the information you'd find on a paper chart. The data is transmitted via radiofrequency. When the patient is in the OR, during the pre-surgery time-out, a nurse scans the wristband with a handheld device to confirm the correct site, patient and surgery type. In recovery, the PACU nurse has to do only a quick scan to double-check the patient and any post-op instructions or dosage information.
"Of course the paper chart is your back-up," says Ms. Naber, "But errors are generally going to come from a handwritten document, as opposed to something that was generated out of a computerized system, and this decreases the potential for such errors. And you don't have to disrupt the patient if they've got clothing on and they're sleeping - the scanner will go through quite a few layers."
Valley Presbyterian is piloting the wristbands in its outpatient surgery department over the summer and will probably start expanding their use hospital-wide by the end of the year, says Ms. Naber. "This is just a baby step we're taking," she says, "but the near-future focus is to tie it in to infusion pumps, drug-delivery systems and monitors to increase patient safety."
Documentation, tracking, billing
New York-Presbyterian Healthcare System found its answer to patient-documentation and -location tracking in SmarTrack (Picis).
With this active system, the nurse electronically enters patient and procedure information as the patient progresses through the surgery department (admissions, pre-op, OR, PACU). When the information is entered, the patient's color-coded status changes on the grid monitors viewable by surgery department and staff. Icons that will pop up next to patient names are in the works. To maintain compliance with HIPAA regulations, not all staff have access to the same monitors. The nurses in PACU can see who's coming, where they are, the operating surgeon and what procedure they've just had done. When monitors are installed in the waiting room, family members will only be able to see a patient-ID number and patient status.
"Patients' families will be given given a system-generated case record number that has nothing to do with name, procedure or surgeon," says Pattison Youngren, RN, an IT project leader for perioperative applications. "They'll be able to look at the monitor and see that the patient is in the OR, but not when the patient is expected out of the OR."
Specific procedure information isn't available on the monitors, but as the notes are entered, case reports are developed, which the surgeons sign off on after the procedure. SmarTrack is interfaced with New York-Presbyterian's billing system. "It doesn't actually bill," says Ms. Youngren, "but it creates the parameters to send to the billing system, which then creates the bills."
The patient-tracking system has brought some issues in the facility's workflow processes to the fore as it's been implemented. "We've had to rethink some things, especially for first cases," says Ms. Youngren. "If we've got 19 patients coming in for our 19 ORs, we've got to figure out how one person can handle that. We've been forced to not cut corners and to figure out how to rearrange the workflow to accomplish everything."
Suit your needs
As you can see, you have several options for going as big - or as small - with patient tracking as your needs dictate. See "Key Questions to Ask Yourself" for some guidance in assessing what you want patient tracking to do for you.