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Wrapping Safety Around Patients
Health Data Management Magazine, April 1, 2008
Deep vein thrombosis, the formation of blood clots, is a common risk factor for hospitalized patients, particularly those immobilized in bed or undergoing surgery.
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Six hours after admission of a patient, the program checks the pharmacy information system to see if blood-thinning drugs have been ordered. If so, the program does nothing else. If not, it checks the clinical system to see if compression stockings were ordered for the patient. If so, the program does nothing else. If not, an alert — with a hypertext link to an order sheet—is sent to the appropriate nurses’ worklists so they can ask the attending physician if any preventive measures should be taken.
Riverside Walter Reed, part of Newport News, Va.-based Riverside Health System, worked with the vendor to develop the deep vein thrombosis workflow program, which operates in sync with the Soarian rules engine. The workflow program went live in late 2005, and it now is one of the “model” workflow programs offered with the Soarian product.
Riverside Walter Reed launched the deep vein thrombosis workflow program “because we wanted to get information in front of the doctor,” recalls Charles Frazier, M.D., director of medical informatics at Riverside Health System. Since the program started, the percentage of patients who get preventive treatment has risen 30%, he adds. As the Soarian system is implemented at the delivery system’s two larger acute care hospitals, clinicians there also will adopt the patient safety tool.
Beyond Medication Safety
Eliminating errors during the medication administration process gets the lion’s share of attention in the patient safety arena. Many information technologies are marketed specifically to help prevent medication errors.
But a growing number of organizations, like Riverside Walter Reed, are applying information technologies beyond the realm of medication administration to improve patient safety.
Some are using radio frequency and infrared technologies not just to track equipment and supplies, but also to track patients to prevent wandering and identify those who need immediate help. Others are using specialized software to improve the safety of blood transfusions and to identify patients who might be developing an infection.
Some clinicians even offer a convincing argument that software designed to automate the patient consent process also serves as a patient safety tool.
The University of Miami Hospital, for instance, is rolling out the English and Spanish-language iMedConsent application from Atlanta-based Dialog Medical to standardize and document communication with patients during the informed consent process.
“It’s a tool that supports consent and provides a double-check that the patient and family are informed and that we’re really doing the right procedure on the patient,” says David Arnold, M.D., a head and neck cancer surgeon and assistant professor at the Leonard M. Miller School of Medicine.
Arnold particularly likes the Spanish version because of the region’s large Hispanic population. But he’d also like to see the vendor devise a Creole-language model to serve that sizable population in South Florida. “Anything that helps me practice better is a safety tool,” he adds.
Nursing Home Innovation
At long-term care facilities, a huge patient safety issue involves patients wandering the facility and risking a fall. One organization has discovered that specialized wireless technology can play an important role in addressing this challenge.
Sprucedale Care Center, a skilled nursing facility in Strathroy, Ontario, implemented wireless technology to track both patients and equipment.
The InSites Enterprise Visibility Platform, from Fargo, N.D.-based Intelligent InSites, has significantly improved s taff efficiency and patient safety and comfort, says Darren Micallef, administrator of the 96-bed center.
“This is a technology I believe should be in every long-term care facility,” he adds. “It’s a timesaver—the time for my staff to give to patients is crucial. If you are paying $30 an hour, you want that money to go as far as possible. You don’t want people spending time looking for things, but to emphasize the care.”
Sprucedale uses the wireless network to track patient lift equipment, walkers, wheelchairs and a scheduling book. The staffer who most used the book asked Micallef why a $3 binder was being tracked. “I said, ‘You’re the one constantly looking for this book.’”
But the real value of the network, which uses both infrared and radio frequency technology, is its support for safety, he adds. Equipment is tracked using attached tags. Patients and staff wear pendants.
Staff members, who access the network via PDAs, can locate a patient’s walker almost immediately because its location is pinpointed on a map. “If a patient really needs a walker and is attempting to walk on her own, that’s a safety risk,” Micallef says.
The iPAQ PDA from Palo Alto, Calif.-based Hewlett-Packard Co. also enables voice communication between staff members by transmitting WAV sound files via the Internet. Micallef recalls a patient who fell in the enclosed courtyard. The staff member who found the patient notified others via PDAs, staying to comfort the patient while help was coming.
Infrared technology is used for tracking, but an alarm system, which staff or patients can activate with a button on the pendant, uses radio frequency technology. When the button is pushed, the location of the person in need is sent to staff members via PDAs.
Sensors at every door also can trigger locks as an unauthorized person approaches, which prevents patient wandering. The wireless network also has helped boost staff morale because when incidents happen, they can be better investigated, Micallef says.
A patient recently complained of poor care, telling his family that he had to press his pendant button 10 times before a staff member came to assist him.
Micallef ran a report of network activity and showed the family that staff responded almost immediately to the request for help.
“That, to the staff, is huge,” he says. “Now, my staff knows that the good employees are going to be protected.”
The reporting features also can be an infection control tool. After a patient was diagnosed with influenza, Micallef ran a report that showed which other patients had been in contact with the flu victim so they could be monitored.
The report also helped identify which areas of the facility should be disinfected. “Another patient came down with the flu, and the report showed she had not attended a big event, but stayed in her room, so that saved unnecessary cleaning,” he notes.
The Sprucedale Care Center has three “home” areas of 32 beds each. The facility first tested the wireless network in one area, training staff and creating super users. It then took about six weeks to implement the technology throughout the facility."
Access Points At Issue
The biggest issue was access points,” Micallef says. “Go with an established wireless network vendor.”
Another nursing home has discovered that yet another technology can play an important role in preventing patient falls.
For more than two decades, Clement Manor in Greenfield, Wis., has used sensor pads in beds and chairs to immediately know if a patient has fallen out.
But the skilled nursing home and assisted living facility received new benefits when it installed a newer system in early 2007. Clement Manor serves 168 residents in its skilled nursing unit.
It also offers 72 assisted living apartments and operates an adult care day for 40 individuals, many of them with dementia.
Sensing Trouble
Fall management systems use sensor pads that ound an alarm if an individual no longer is lying or sitting on the pad. Nurses during registration ask a series of questions to determine if a patient is at increased risk for falling.
Clement Manor’s previous system had two types of alarms, and nurses had to figure out which pads worked with which alarm, says Judy Cottonaro, materials management agent.
Now with the Sensatec Fall Management System from Brookfield, Wis.-based RF Technologies Inc., any pad is compatible with the alarm system. The pads have a wire that plugs into a jack on an alarm box.
The box plugs into an electrical outlet for power and a wire on the box plugs into a phone jack to connect to the nurse call system. The boxes also have a nine-volt battery for back-up power and use in a wheelchair.
Clement Manor also has replaced its wander management system with RF Technologies’ Code Alert Wander product. The new system has eliminated false alarms, which were a problem with the previous technology, Cottonaro says.
The wander prevention system uses wireless radio frequency technology that instantly locks certain doors should a patient wander.
For hospitals, blood transfusions pose great potential risks to patient safety. That’s why St. Luke’s Episcopal Health System in Houston recently implemented a blood transfusion verification information system throughout 670-bed St. Luke’s Hospital. Last year, the hospital trained 900 nurses and other clinicians to use the system.
As the hospital neared completion of the system, a powerful financial incentive also emerged.
Medicare Takes A Stand
The Medicare program announced that it will not cover the associated treatment for a patient who receives incompatible blood. “If a facility could not justify the development cost for the transfusion system based on patient safety alone, they now have this financial justification,” says Kathy Brient, laboratory information systems manager.
The hospital is using the CareFusion transfusion system from Dublin, Ohio-based Cardinal Health Inc., combined with labeling software from Lincolnshire, Ill.-based Digi-Trax Corp., thermal bar code printers from Vernon Hills, Ill.-based Zebra Technologies Corp., and blood bank software from Wyndgate Technologies, El Dorado Hills, Calif.
Together, the applications automate the documentation of blood administration while verifying patient information and preventing incompatible transfusions, Brient says.
The hospital uses PDA-based bar code scanners to verify patient identification, blood product unit number and product code before transfusion.
But an optional module to CareFusion, called Rapid Infusion, streamlines the process for critical patients by decreasing the documentation that is required and allowing vital signs to be documented elsewhere in the patient record.
That’s important during emergency care, when the priority is to get needed blood, plasma and platelets administered to the patient, Brient says. “Making sure the blood products are compatible with the patient is more important than documentation of vital signs on the transfusion record.” Vital signs, for instance, already are collected elsewhere, such as on the ventilator information system.
St. Luke’s uses the Rapid Infusion feature in the operating room to verify patient identification and ensure blood products are given to the correct patient.
Rapid Mode
Only the anesthesiologist and nurse anesthetists do the transfusion verification documentation. The rapid mode also is used in cardiovascular recovery and during dialysis in cases when large, fast volumes of infusion are required.
This year, the hospital will implement another software product to analyze the utilization of blood products as a cost saving and patient safety feature. “Every unit of blood you transfuse has the potential to transmit blood borne disease, even if you test it, label it correctly and ensure it goes to the correct patient,” Brient notes.
The software, from Old Bridge, N.J.-based Hemo Concep s Inc., compares a facility’s blood utilization with peer organizations.
This will help standardize transfusion treatments and reduce unnecessary blood transfusions. But it also has the potential to reduce complications, such as transfusion-related acute lung injury, which can happen when a substance in plasma causes adverse pulmonary reactions, Brient says.
In addition to managing the risks involved in blood transfusions, many hospitals are looking for ways to use technology to prevent infections.
Last summer, Memorial Regional Hospital in Hollywood, Fla., implemented decision support software to help identify patients possibly developing an infection. The hospital already is seeing positive results.
“I can definitely say there are cost savings and better safety; you can see it in our drug budget,” says John Connors, R.Ph, operations and systems manager in the hospital’s pharmacy. That budget shows fewer antibiotics and other drugs being used to combat infection, he explains.
The hospital is using the Infection Control Assistant software of Salt Lake City-based TheraDoc Inc., which collects and analyzes patient data from multiple information systems. Data that indicates a possible problem triggers alerts to the appropriate clinicians caring for a patient.
Getting A Second Look
Memorial Regional also is using the vendor’s Clinical Alerts Assistant application to look for other possible emerging complications and to be a “second look” for medication management.
If collected data, for instance, indicates a patient’s renal function has decreased, medications can build up in the patient and become toxic, necessitating dosage adjustments, Connors says.
The software also can provide alerts of platelet problems that can lead to internal bleeding. " Both applications are highly customizable, enabling a hospital to specifically target certain conditions for intensive monitoring, Connors notes. “There are a lot of ways to get things done and it depends on your personal preferences because you can customize a lot.”"
Note to vendors: What your clients want
Health care executives have wish lists of the information technology functionality that would be helpful in improving patient safety.
Charles Frazier, M.D., director of medical informatics at Riverside Health System in Newport News, Va., believes automated medication reconciliation is a wonderful tool that isn’t fully ready for prime time. “I still think we have a ways to go with medication reconciliation,” he contends. “That’s still a tough thing to do well.”
It’s tough because information systems vendors have yet to integrate their products with disparate systems to ensure all of a patient’s medications are tracked, Frazier says. “Vendors tend to look at their own systems and say, ‘OK, we have a medication reconciliation tool.’ But that doesn’t really get to all of it.”
If a home health patient is admitted to the hospital, there’s no better list of what medications they are on than the list on the home health information system, he adds.
“But vendors aren’t linked to it. We need to be able to look across different platforms and silos of information.”
David Arnold, M.D., a head and neck cancer surgeon at the University of Miami Hospital, uses a Tablet PC to access data and images from the hospital’s electronic health records, radiology and picture archiving and communication systems." "
What he really wants, however, is a mobile device, “kind of a big iPhone,” that is a little smaller than a Tablet PC and would fit in his lab coat. “If I could get that, it would be a huge step toward ultimate efficiency and safety,” he adds. “They go hand-in-hand.”
Web site eases safety collaboration
A password-protected Web site is helping members of the Connecticut Hospital Association share ideas and best practices to improve the quality and safety of care.
The association last November launched the site — starting with the issue of treating pressure ulcers — for its 30 hospital and long-term care facility members. In February, the members also started discussing how to combat multiple drug-resistant organisms, such as staph infections.
“We use shared experiences to try to find ways to implement well-vetted, evidence-based medicine,” says Brian Fillipo, M.D., vice president of quality and patient safety at the association.
The Web site quickens communication among members and also lists references and resources, Fillipo adds. Members post on the site their own experiences and tools, such as visual or auditory cues, check lists, and metrics for others to use.
For example, playing music on patient floors every two hours can remind nurses to turn patients to prevent pressure ulcers. To fight infection, a stop sign on walls or doors can remind staff leaving a patient’s room to wash their hands.
A list serv on the site enables members to post questions and answers.
After the site went live last fall, members soon learned they needed a better way to update and track documents that were posted for comment and additions. “We had multiple versions of documents,” recalls Jane Deane Clark, a senior consultant at the Connecticut Hospital Association.
To fix that problem, a spreadsheet loaded on the server now enables uniform updating of a single document. Further, data collected in a single database enables members to compare their organization’s performance on specific metrics of care with other organizations.
Association members will add a new topic every two months to the Web site. For more information, send an e-mail to fillipo@chime.org."
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