Christiana Hospital Honored for Groundbreaking Project

Bill Briggs, Senior Editor
Health Data Management Magazine, March 2006

Before November 2004, Christiana Hospital had a hard time keeping track of the 100 or more patients in its emergency department. Manual data entry often lagged patient movement. The hospital's research found that multiple phone calls and walking tours to canvass the ED were needed to locate about 20% of admitted patients.

For Linda Laskowski-Jones, R.N., director of trauma, emergency and aeromedical services, knowing where ED patients were 80% of the time wasn't nearly good enough for her and other nurse managers.

"Imagine distraught family members coming in and asking 'where's my mother?'" Laskowski-Jones says. "In the past, in the time it took to get information into the ED system the patient might have been moved more than once. We would send the family to a room but their mom might be in radiology getting a CT scan. Now we have a higher level of confidence that we know where patients are."

The Newark, Del.-based hospital solved its patient tracking problem by implementing a passive tracking system using wireless infrared and radio frequency identification technology. In the 12-month period after implementation, the hospital reported a 20- to 45- minute reduction in length of stay for patients treated and released, and about 35 minutes for patients admitted, among other measurable results.

Christiana's efforts earned the 780-bed facility Health Data Management magazine's inaugural Nursing Information Technology Innovation Award.

The hospital, which is one of two in the Wilmington, Del.-based Christiana Care Health System, has plenty of emergency patients to track. Christiana Hospital's ED treated about 94,500 patients in 2005 in its Level 1 adult and pediatric trauma center.

It has 76 treatment rooms and seven triage assessment areas. Patients are seen by any of 43 attending and 53 resident physicians and the ED staff includes more than 200 emergency nurses, technicians and clerks.

No input

Keeping up with patients meant the former tracking system needed a makeover. "We needed a passive tracking solution that didn't require a staff member to input most of the information," Laskowski-Jones says, "and that would be accepted by all levels of personnel."

Laskowski-Jones began researching tracking technology in 2001, but could only find systems that required manual data entry and other staff input to maintain. The search would stretch on for two years. "I became aware in 2003 that passive technology existed," she says. "I found some that were marketed well, but there were no successful implementations."

Then one day in fall 2003, out of the blue stepped a salesperson representing three vendors of passive tracking technology: Patient Care Technology Systems LLC, Mission Viejo, Calif., which markets the Amelior EDTracker application; Versus Technology Inc., Traverse City, Mich., a supplier of tracking hardware including badges and sensors; and ADT Security Services Inc., Boca Raton, Fla., a vendor of anti-theft systems including door alarms.

Together, the three technologies seemed to meet Laskowski-Jones's criteria, so the next step was to check out existing implementations.

She assembled a group of ED leaders for a presentation of the EDTracker software from Patient Care Technology Systems. "Then we did some site visits and they all seemed very satisfied and felt the vendor came through for them," she explains.

A project steering committee including Jones, the ED nurse manager, the physician director and an I.T. representative then recommended the EDTracker system to the delivery system's leadership group. That group, comprising C-level executives, endorsed the project and agreed to fund it.

The passive tracking system cost about $690,000, but a state grant for emergency response preparedness helped defray a third of that cost, says Steve Hess, Christiana Care Health System's CIO.

The state had received federal funding for bioterrorism preparedness and had given Christiana Hospital a grant to devise ways to increase the state's readiness.

Laskowski-Jones, in turn, made a strong case that some of the funding should be used for the ED tracking project. The majority of the grant then was applied to the project, which was intended to help in mass casualty or bioterrorism events by helping track patients and health care workers who might be exposed to harmful substances.

They wear the badge

The tracking system uses infrared/RFID sensors and plastic badges embedded with tracking chips to passively monitor the location of patients and staff in real-time.

When patients arrive at Christiana's emergency department they receive a triangular badge-which measures 2.5 inches by 1 inch-that clips to their clothing. Once the badge number is activated in the tracking system, whenever patients enter a new care area the badge sends a signal to the tracking application.

Clinicians then can call up a self-developed electronic dashboard on a computer that shows the patient's location anywhere in the emergency and radiology units. Nurses, ED clerical staff and radiology technicians also wear badges that identify and record patient interaction and location.

Before its November 2004 rollout, vendor and hospital technicians installed more than 300 infrared and RFID sensors in the ceilings throughout the ED and radiology units, which combined are 50,000 square feet. Most sensors are infrared-the RFID technology kicks in when a line-of-sight signal is obstructed.

All 300 ED staff received badges and as of January more than 100,000 patients had worn the badges, Laskowski-Jones says.

To Laskowski-Jones and Hess, the project's success flowed directly from the ED clinical and administrative staffs' willingness to change how they work.

The ED triage process was redesigned to take advantage of the electronic tracking system, Laskowski-Jones notes. On arrival at the emergency department, patient conditions are assessed, and that data-along with registration information and badge number-is entered into the hospital's admission-discharge-transfer application, from McKesson Corp., San Francisco.

The system interfaces with the EDTracker application using messaging standards from Ann Arbor, Mich.-based Health Level Seven Inc.

Lab and radiology test results flow electronically to the tracking system as well. In addition to coming back to the ED faster, results are entered only once, cutting out redundant labor, Hess says. The lab and radiology applications are from Cerner Corp., Kansas City, Mo.

Once patients are brought into the ED for full assessment, they receive a badge and the triage nurse decides what action to take. If a patient is to be admitted, bed management staff is notified electronically.

When the bed is assigned its number is displayed on the tracking system dashboard, which also can be used by nurses to request patient transport to the inpatient unit.

The dashboard also enables hospital administration to view ED demographics, such as the number of patients and those waiting to be admitted, from a PC, PDA or cell phone, Hess says.

Warehousing data

While the EDTracker system is meant for nurses and doctors to manage patient workflow, it also supports the hospital's overall operational workflow, Hess says.

"We are now exporting a lot of tracking data to our data repository to analyze things like wait times from an operations perspective," he says. Data from the clinical repository-from Cerner-then populates a "scorecard" on the dashboard, which enables administrators to pull data to see trends over time, Hess adds.

That's another positive result from implementing the passive tracking system, Laskowski-Jones says. "Because we are now able to measure specific intervals of care in the emergency department, we can better direct system performance improvement efforts." Administrators also now have timely information pertaining to ED status to make appropriate hospital-wide capacity decisions, she adds.

Other benefits of the passive tracking system include:

* In Christiana Hospital's first flu season after installing the system, patient turnaround time decreased 5% despite an 8% increase in volume.

* At one time 5% to 6% of patients were leaving the ED untreated. Patients are brought into treatment rooms 39% faster now, which helped cut the number of untreated patients to 1% to 2% and boost patient satisfaction.

* Also as a result of seeing patients more quickly, the number of hours the hospital is on "ambulance divert," when it can't accept more emergency patients, has plunged from more than 60 hours per month to 11. That improves community service.

Most of the gains from the tracking system return a scarce commodity in emergency departments: time. Christiana's nursing team can spend more time with patients now because they are spending less time following up on the status of orders and looking for other patients, Laskowski-Jones says.

Patients by the busload

Tracking patients quickly and accurately is vital when Christiana's emergency department treats children involved in school bus accidents. These types of mass casualty events occur about five times a year and can be the result of serious or relatively minor accidents.

Some school districts follow a policy that requires all students involved in a bus accident be treated at an emergency department. So whether injuries are major or minor, each child brought to Christiana gets a tracking badge, which helps worried parents find their children quickly. The badges also come in handy when children are not seriously injured and decide to spend their time exploring the ED. "It's a day off from school and they can get creative, so we track them too," Laskowski-Jones says.

The old technique for handling bus accidents involved bringing a hospital volunteer to the ED to list and track patients on paper or a grease board, says Karen Toulson, R.N., ED nurse manager. That process quickly overloaded list keepers, and the problem was amplified when upset parents came rushing into the emergency department. "The new system makes it easy to reunite parent and child," Toulson adds, whether in the ED, X-ray or an inpatient unit.

Abandoning such manual tracking methods also was easy. ED nursing staff's willingness to change many other processes produced positive returns on Christiana's investment in the tracking technology, executives believe.

Hess notes that the I.T. department assisted with the technology, but nurses and Charles Reese, M.D., the ED chairman, "made our job easier."

Laskowski-Jones initiated the project and Toulson played a major role in getting input from other nurses for the new system's design. "They were more dedicated to process improvement than the technology," Hess says, even though they were solidly behind the application.

Nursing staff buy-in was the key that unlocked another, enterprisewide benefit. It led to a greater "spirit of innovation and creativity to embrace I.T. projects across the board," Hess says. "We've used the ED's success to sell process improvement through information technology."

As a project co-leader, along with a member of the I.T. department, Laskowski-Jones found that one of the great challenges was making nurses understand that the project was about process improvement, "not just putting in software."

Organizations like Christiana Hospital are successfully implementing nursing information technology because clinicians are taking the initiative more often, says Peggy Rodebush, R.N., clinical transformation COO and chief nursing officer in the consulting division of Perot Systems Corp., Plano, Texas. That involvement helps ensure the technology meets the ultimate test.

"At the end of the day, the value of technology is how it helps clinicians do their job," Rodebush says. "It's refreshing to see how more and more clinicians are aggressively looking for how to make changes to enable patient care to reach higher quality levels and dispel safety fears."

Provider organization executives are increasingly aware that they need clinician involvement to improve the speed of access to and accuracy of information behind health care decisions. The result is that health care is moving into a more "appropriate" level of technological awareness, Rodebush notes.

"Nurses and other clinicians are stepping forward to drive change," she adds. "That's where change needs to come from and to evolve."

Christiana Hospital's successful deployment has hinged on five critical success factors that, coincidentally, Perot Systems consultants preach to their health care customers, Rodebush says. They are:

* Culture. A big project requires understanding an organization's culture and what is required to transform a department or the whole hospital.

* Commitment. A strong executive level of support is needed, beyond nurse leaders. "You need the CEO and the board because there are always bumps in the road," Rodebush says.

* Communication. The question that needs to be answered for each person and department: What's in it for me? Communication means explaining why the organization is embarking on a project and why it's good for everyone involved in the care process.

* Accountability. Establishing measures and outcomes of I.T. implementations to gauge success is a necessity.

* Pace. A major I.T. project requires understanding of and preparation for the fact it takes longer to get where you're trying to go than it appears in the beginning.

Emergency department process redesign figured heavily into the planning as well as the successful deployment of the tracking system, Laskowski-Jones says. She took a business planning approach to the project by applying a change management model to prepare for the implementation.

"My nurse management team, in collaboration with emergency physician leadership and our I.T. department, spent considerable time mapping existing workflows in order to identify dysfunctional processes," she notes. "We then defined success for our department and designed our future patient flow that integrates passive tracking."

Toulson, the ED nurse manager, oversaw nursing staff contributions to the design and implementation of the system through process planning meetings and emergency department staff meetings over the course of five months.

Several ED nurses were trained as "super users" who participated in staff education before and after rollout, Laskowski-Jones says. Each nurse in the ED underwent approximately three hours of education before system go-live.

"Virtually the entire nursing staff readily adopted the system," she says. "In our first year since going live, our nurses have utilized the time-savings provided by the system to devote more time to caring for patients and keeping them better informed about key aspects of their ED stay."

Christiana Hospital illustrates two trends among hospitals, says Denise Tyler, R.N., board member and secretary at the American Nursing Informatics Association, San Clemente, Calif. "The processes that we used to do on paper are becoming more automated," says Tyler, who also is a clinical specialist in information systems at Kaweah Delta Health Care District, Visalia, Calif. "And nursing is key in making that work."

The technology supporting nursing I.T., such as documentation applications, is improving and expanding to help fuel the growth, she notes.

Technology tools are here to stay and therein lies a significant challenge to further use of nursing I.T., Tyler says. "Nurses need to understand they have no choice: it's here. Technology really does improve documentation."

At Christiana Hospital, getting nurses to change their way of doing things was a steep hill to climb, Laskowski-Jones says. But a yearlong internal marketing program helped break down resistance among nurses who feared minute-by-minute monitoring.

"They thought it was going to assess their personal productivity, but they realized that's not what we had planned." As the system's capabilities unfolded, nurses began to see the value of knowing who had been where, she adds, to document caregiver health risks such as staff exposure to patients with lice.

From a technology standpoint, glitches with badges were the biggest challenges. About 600 badges were lost in the first year of the passive tracking system's use, Laskowski-Jones says.

Many of those went out with the laundry and never came back. In other cases, staff lost some and patients walked out with them.

Most exits now have sensors that detect badges to prevent walkouts, although one problem still being addressed is when the wearer walks dead center through a doorway and the badge goes undetected.

Other solutions include installing sensors on laundry chutes to detect badges and adding neon green labels to help raise their visibility.

Such obstacles haven't put a damper on the project, key players say. In fact, the solutions to many problems have come from the close working relationship between nursing and I.T., Laskowski-Jones says.

"The I.T. department helped us go through the business planning approach and together we defined future outcomes and understood we would be accountable."

CIO Hess says the passive tracking project set the bar for future I.T. implementations. "We assisted with vendor management and the technology, but the nurses and Dr. Reese did it-and made our job easier," he says.

For more information on new technologies visit the Nursing I.T. portal on our Web site: www.healthdatamanagement.com.

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Honorable Mention: Under Pressure to Prevent Bed Sores

When pressure ulcers go untreated they can be deadly. Nurses need to identify when there's a problem and notify wound care specialists to remedy the situation, but with so many responsibilities and dwindling numbers, sometimes ulcers go unreported.

In 2002 pressure ulcers were above the national average at Naples, Fla.-based NCH Healthcare System. NCH is a two-hospital, 539-bed delivery system serving southwest Florida. A survey determined 12.8% of NCH patients had pressure ulcers, a third more than the national rate of 8.5%. Heel ulcers accounted for 6.7% of the pressure ulcers, says Carrie Skifton, R.N., vice president and chief nursing officer at NCH Healthcare System.

The delivery system deployed patient charting software within an electronic medical records system from Cerner Corp., Kansas City, Mo.The wound care nurses worked with the information technology department to develop electronic forms to document skin care.

Nurses use the Braden Scale to determine the risk of pressure ulcers and look for them during admission and daily assessments. The computer is used to tally the score and will automatically generate a consult with a wound care nurse if necessary. "Before the nurse would have to remember that a patient had a pressure ulcer and call the wound care nurse," Skifton says.

Deploying the electronic medical records system and adding the wound care components for nurses helped decrease the pressure ulcer rate. The overall prevalence rate was 5.1% within 10 months after the implementation, with heel ulcers accounting for 3.2%.

Further steps over the past few years, including new mattresses and pressure-relieving boots, helped reduce the pressure ulcer rate to 1.7%

The new system also was able to trim admission time about 20 minutes, enabling pre-admission nurses to complete 27 patient admissions in a normal workday. That's a marked improvement compared with past numbers: 23 in a workday that also included two hours of overtime and left no opportunity for a lunch break.

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Honorable Mention: Online Checklists Replacing Paper Forms

Typically there's a lot of paperwork when a nurse starts a new job at a hospital.

Hospitals need to keep these records for regulatory purposes to prove that the staff is properly trained, but paper orientation checklists have a tendency to get lost or aren't always filled out properly or completely.

This problem caused Bellingham, Wash.-based St. Joseph Hospital, part of PeaceHealth, to create an electronic orientation checklist and clinical information reference system, says S. Lynne Brengman, R.N., performance development specialist in the education department at the institution. Bellevue, Wash.-based PeaceHealth operates facilities in Alaska, Washington, and Oregon.

The 253-bed St. Joseph Hospital created the system because of problems with paper forms and the amount of time it took to complete them. Also, reference tools were not always readily available.

Because of this, Brengman and others at St. Joseph decided to make some changes. They rewrote the nursing job descriptions using The University of Iowa College of Nursing's Nursing Intervention Classification System and placed them online with the orientation checklists. They also created an online reference system where nurses could look up any procedure.

The reference system was developed in-house using Net.Data from Armonk, N.Y.-based IBM Corp. The new system also worked with the hospital's Infinium business management software from SSA Global, Chicago.

Now when nurses start at St. Joseph Hospital they fill out the checklists online and all the records are stored electronically. Nurses also can validate other skills through the Web site as they become accredited. The reference site includes videos and manuals on how to perform various tasks.

The new orientation system enables nurses to better track their competency and skills while also reducing the time it takes for them to fill out forms, Brengman says. It also has enabled managers to know what skills nurses have in order to place them in different units.

In addition, the online reference tool cuts down on nurses having to remember what order sets need to be performed for certain procedures. "We used the system to round up all the information we had out there that really wasn't organized," Brengman says.

The emergency department nurses were the first to use the system and results were seen immediately, she says. Instead of the one hour required to assemble a paper orientation packet in the past, new nurses now just go online.

Previously, paper checklists were lost more than half the time, so the automated system was a worthwhile investment, Brengman says. "Lost orientation checklists were such a problem," she says. "It's cost-effective because it took a lot of time to rework the lists." She declines to say how much the technologies cost.

For a manager to know the progress of the paper checklists they had to physically locate it; the electronic list enables a manager to check it from any computer.

The vast majority of nurses are using the online orientation and reference systems, Brengman says. Eventually, the hospital will introduce the system to other clinical disciplines, such as physical therapy and radiology.

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Honorable Mention: PDAs Bring Data to Point of Care

Until last spring, there was very little clinical data available at the bedside at Virtua West Jersey Hospital Voorhees (N.J.).

The Voorhees hospital is one of four in Virtua Health, a Marlton, N.J.-based delivery system. Virtua Health is planning to build a new hospital and wanted to review some new point-of-care technologies. The different types of devices in testing now will eventually be used in the new hospital once it's complete.

Two of the first technologies nurses reviewed were PDAs from Round Rock, Texas-based Dell and MData software from MercuryMD Inc., Durham, N.C., says Theresa Brodrick, R.N., vice president of patient services at Virtua Voorhees.

The initial pilot last spring of 10 nurses went so well hospital executives decided to do a rollout to 256 nurses in the summer, Brodrick says. "For nurses who did not have a lot of tools or technology it has given them the ability to pull up patient information at the bedside," Brodrick says.

The Voorhees facility has enterprisewide wireless access and nurses use the PDAs to pull up lab values, diagnostic reports, patient medications, and look for potential medication interaction. The software also enables nurses to do medication calculations for newborns. "It's a way for us to triple check for medication," Brodrick says.

Before introducing the bedside system, emergency department nurses, for example, would have to stop what they were doing and log on to a desktop computer an estimated 10 times a day.

Those computers are in a common area, used by a variety of clinicians and sometimes require waiting for access. Now nurses can retrieve patient data from their handheld computer no matter where they are in the hospital, reducing trips to a desktop by nearly 80%.

The PDAs have helped communicate test results and information about medicine with patients and families. Instead of having to leave the room and go to a desktop computer, nurses can access information from the room.

Efficiency has also increased with the PDAs. After nurse managers leave for the day, a night shift nursing supervisor oversees staff throughout the hospital, including the operating rooms and the emergency department. The nursing supervisor spends a lot of time walking the halls to get from one end of the hospital to the other.

With the mobile system, the supervisor can wirelessly synch to the hospital's information systems while walking to get the most recent patient data. Now the supervisor knows patient status on arrival. Communication is faster because there is no longer the need for nurses to brief the supervisor.

While the PDAs have been successful in intensive care units, Virtua West Jersey Hospital Voorhees is looking at different point-of-care technologies for other departments. "PDAs are not meant for all nurses," Brodrick says. "We're trying to take a look at all different types of devices."

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Honorable Mention: Homegrown Tracking System Works Wonders

Reducing long waits in the emergency department is a challenge for most hospitals. How they tackle the issue is different for each.

At Salt Lake City-based Intermountain Healthcare, the delivery system's information systems department created a patient tracking system for its 16 emergency departments. The system, introduced in the summer of 2004, provides nurses and supervisors with real-time emergency department operations data and alerts, says Laura Heerman Langford, R.N., director of nursing informatics.

Intermountain Healthcare is an integrated delivery system consisting of 21 acute care hospitals in Utah and Idaho with 2,449 licensed beds and 150 service sites.

The patient tracking system is primarily accessed through desktop computers, but some nurses use Internet-enabled handheld computers, Heerman Langford says. The software runs in Java and is accessed through a Web browser.

Upon entering the emergency department, patients meet with a greeter or triage nurse who enters their demographics and assessments into the clinical information system as well as the tracking system.

From then on patients' movements are tracked. "We're capturing all their intervals of care," says Wayne Watson, R.N., operations director in the intensive medicine clinical program. "We're managing the ER experience in real time and looking for bottlenecks, then dealing with them immediately."

Nursing supervisors can spot obstacles through a dashboard, which is visible on computer monitors throughout the emergency department, Watson says. This dashboard displays a collection of information that helps supervisors manage the shift and shows where the holdups may be-for example, if lab or radiology have not returned results. "The communication it enables with the department makes all the processes easier and it settles everything down," Heerman Langford says.

Supervisors also can see what nurses are doing. "There is one click to look at assignments and see which nurses might be overloaded and which ones may have some time," Heerman Langford says.

Since deploying the system, Intermountain Healthcare's emergency departments have decreased the door-to-doctor time from 46 minutes to 24 minutes. Average patient length of stay has decreased from 183 minutes to 176 minutes.

The patient tracking system also can be accessed from different Intermountain hospitals, Watson says. This can be valuable in case a patient needs to be transferred from one facility to another.

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About the Award Competition

Health Data Management developed the Nursing Information Technology Innovation Award in collaboration with the Maryland Technology Workgroup, a groundbreaking organization studying the use of technology to assist nurses in caring for patients (maryland.nursetech.com/).

The award is designed to recognize a team of nursing professionals at a U.S. health care organization (hospital, physician group practice or any other care-giving site). It honors innovation and excellence in using information technology in the field of nursing to directly improve the quality of care/patient safety and/or promote the effective use of nursing resources.

A total of 39 organizations submitted essays to be considered for the award. These essays were reviewed by a panel of judges that selected one winner and four honorable mentions, based on their total scores. Judges included Howard J. Anderson, publisher, Health Data Management, and three Maryland Technology Workgroup members:

* Susan Newbold, R.N.BC, lecturer, Vanderbilt University School of Nursing, Columbia, Md. (workgroup co-chair)

* Louella Dorsey, R.N., clinical systems analyst, Kennedy Kreiger Institute, Baltimore.

* Dana Womack, R.N., director, nursing technologies, Innovative Patterns Corp., Westminster, Md.

Another workgroup member, Brenda Cunningham, R.N., informatics nurse, Washington County Health System Inc., Hagerstown, Md., participated in conceptualizing the award.

For the very latest information on nursing-related issues, visit Health Data Management's Nursing I.T. portal, http://www.healthdatamanagement.com/ portals/nursing. This portal includes the opportunity to sign up for a free monthly e-newsletter.

For more information on related topics, visit the following channels:

• Hospitals