To Cart or Not to Cart
Health Data Management Magazine, July 1, 2009
As hospitals strive to provide doctors and nurses with better access to clinical information systems at the point of care, they're considering whether to use mobile computer carts or some other hardware option, such as hand-held computers or wall-mounted PCs.
Some are concluding that carts are a good option because they can store medications and supplies in addition to computers. Others, however, are rejecting carts because of high maintenance requirements and poor nurse acceptance. And many are finding that carts work well in some areas, but not in others (see sidebar, page 34).
Shands at the University of Florida, a 660-bed facility in Gainesville, initially considered small notebook or tablet computers, but also had a history of equipment disappearing, recalls Veronica Carr, R.N., a practicing nurse and information services coordinator for nursing and patient services. "It wasn't so much that we feared the devices were being stolen; staff just had trouble keeping track of them," she adds. "We'd find equipment like transport monitors in the bottom of laundry bins."
Having computing devices in patient rooms was a necessity to support real-time clinical documentation and point-of-care access to patient data. As a safety measure, for instance, nurses had to look up a patient's latest vital signs before administering medications. So carts with bolted-down laptops became the initial solution.
Likewise, two-hospital Christiana Care Health System concluded that computer carts were the answer to how best to support bedside, bar coded electronic medication administration to close the medication loop and improve charge capturing.
The carts were a single source to hold an all-in-one computer and monitor, scanner, medications and medical supplies, says Carolyn Zsoldos, R.N., clinical support specialist at the Wilmington, Del.-based delivery system.
Some organizations, however, have rejected carts in favor of other hardware options at the point of care. For example, three Hospital Corp. of American facilities in Independence and Lee's Summit, Mo., were heavy cart users. But when they closed in 2007, the two new HCA hospitals that replaced them opted for wall-mounted computers, with a small number of carts as back-ups.
"We understood the limitations of carts and nurses' dissatisfaction with having an extra piece of equipment to tote around," says Shannan Pfeiffer, director of information technology and services at Centerpoint Medical Center in Independence and Lee's Summit Medical Center.
Troubled Start
Some hospitals that have adopted carts have had to fine-tune their strategies. For example, the first attempt to use computerized carts at Shands at the University of Florida was problematic. The biggest initial problem was poor wireless connectivity, recalls Carr, the information systems coordinator.
Because laptops mounted on the carts were losing their connection to the wireless network, nurses would "look at that cart and that cart was evil," she says.
The effort also was hampered because the information services department did not "have a vision" for carts, Carr says. I.T. staff wanted nurses to use carts to carry laptops plugged into the wall. They did not understand that nurses wanted bigger screens, a separate power supply, and electronic rather than manual positioning of the keyboard. They also needed outlets in the right places for recharging.
Carr also had to service the carts herself because the I.T. department would not and the maintenance department wanted to know why I.T. wasn't servicing them. "So, I had no one who wanted to own the carts."
In early 2008, Carr along with several I.T. staff members went to cart vendor exhibits at the Healthcare Information Management and Systems Society's Annual Conference and Exhibition in Orlando. They discovered that many cart vendors were recommending that hospitals use carts to carry personal computers with large screens and powerful batteries, rather than laptops, Carr says. "It was a strategic change in their thought processes," she says.
Since last fall, the hospital has been replacing existing carts that break down with new carts from Rubbermaid Medical Solutions, Huntersville, N.C. These carts use an all-in-one PC and large monitor. I.T. maintains the computers and carts.
When a new cancer tower opens in November, it will use new carts and computers from Rubbermaid. Additional computers and carts from the vendor will be brought over from a sister hospital that is closing to support patients coming from that facility.
Picking a Brand
Several factors distinguished Rubbermaid from other vendors as Shands chose its replacement cart vendor, Carr says. The company has a good selection of carts for different needs, she says. Many components for the carts are interchangeable, and the vendor permits the warranted parts to be stored onsite so I.T. staff can quickly swap out broken ones, she notes.
The computer screens from a third-party vendor are larger than those sold with other carts, she says, and the small footprint of the cart makes them easy to move in and out of rooms. Rubbermaid also let Shands test carts for a couple of months before it signed a contract, then let the hospital initially purchase a limited number. "Other vendors would give us a week to test, which is not long enough to really understand how they would be in routine, heavy use," Carr says.
Despite the rocky start with computer carts, Carr is sold on the technology. She advises hospitals not using carts to consider them for several reasons: "Carts make computers available right now, no matter where you are. Stationary computers at the bedside don't work unless you have a lot of money and can use biometric authentication technology. Doctors and nurses don't want to sign in and out at every bed."
Further, carts help avoid the cost of installing additional wiring in older hospitals, she adds.
Still, there's a simple enhancement to carts that would make a world of difference in clinician acceptance, Carr believes. The vendor that figures out how to add an attached chair "will corner the market," she adds. "Nurses want to sit and chart. The average nurse is 46 years old. They don't want to stand all day and chart. They want to bunch up charts until they can sit down."
Alternative Choice
Two-hospital Cristiana Care Health System's core reason for adopting carts-350 of them and growing-was to support a bedside medication management system that went live in most units during 2008.
But the original plan at Wilmington Hospital was to have locked medication cabinets outside the rooms because nurses thought carts would be too bulky. However, nurses testing these cabinets quickly found them to be unusable, recalls Zsoldos, the clinical support specialist. "It took 48 hours for the nurses to tell us to take the cabinets out."
By using carts at both hospitals, nurses didn't have to leave the patient's room to get the medications after verifying the "five rights" of medication administration because everything they needed was on the cart.
With an all-in-one computer/monitor from Winchester, Va.-based Datalux on the cart, along with medications, supplies and the bar code scanner, nurses also were spending more time in the room instead of running in and out.
One benefit of uninterrupted patient time with the nurse became clear during a test of the carts from Columbus, Ohio-based Artromick International. After placing carts in the joint replacement unit to support an electronic medication administration initiative, the unit had a period of three months without sustaining a patient fall.
Patients perceived that nurses were spending more time in the room, Zsoldos says. So, they wouldn't try to get up and go to the rest room on their own.
Still, patient and nurse satisfaction dropped during the first month or so of doing electronic medication administration. "It takes a good six weeks until nurses really rely on the technology," Zsoldos says.
And the carts themselves played a role in initial nurse dissatisfaction. "We had to reassure nurses that they don't have to take the cart in the room every time for medication administration," she adds. "If a patient only has one medication, there's no point to lugging the whole thing in there. Just take the medication and handheld scanner. Once the nurses realized that it's another tool to use and not a mandate, they really got into it."
Christiana Care's cart vendor selection came down to two finalists. The nurses liked Artromick because of its all-in-one computer/monitor and its narrow but deep design, Zsoldos says.
They also viewed the other vendor's carts as "having a lot of unnecessary stuff," such as visible wires that could fray or get something caught in them," she notes. Nurses did not like the rotating arm on the other carts. They feared the elbow would be an infection risk or they would catch their clothes on it.
The selected carts "just had nothing sticking out to catch you or your patients," Zsoldos says. Asked what she doesn't like about the carts, the practicing nurse answers, "I'll never find a cart that has enough drawers for me to squirrel things away."
Zsoldos advises other hospitals to avoid using carts for other purposes, such as to carry medications and supplies, without using them to also carry computers.
"If you're going to invest in carts, you have to have a computer on them," she contends. "Everyone wants the computer at the same time. Computerized carts give nurses their own mobile workstation and they have gotten very territorial. If they see someone at their cart, they say, 'This is my cart, what are you doing with my cart?'"
A Different Direction
Unlike Shands and Christiana, two new hospitals in Missouri rejected carts in favor of wall-mounted computers because of concerns about the durability of carts.
Pfeiffer, the hospitals' director of information technology and services, remembers when three hospitals in Missouri owned by Nashville, Tenn.-based Hospital Corp. of America used hundreds of computerized carts that didn't hold up well. Because of that experience, two new hospitals that replaced the older facilities opened two years ago with hundreds of wall-mounted computers in all nursing units, ancillary departments and public areas such as hallways.
"As a company, we deployed carts extensively for four years and saw that wear and tear on the carts and laptops was fairly significant," recalls Pfeiffer, who directs I.T. at 221-bed Centerpoint Medical Center and 64-bed Lee's Summit Medical Center.
At the old hospitals, information technology staff members were not trained in the maintenance of hardware such as carts. Among other problems, hydraulics that move the laptop up or down would fail and the retractable power cords would fray.
"It became an issue of typical maintenance that computer folks didn't deal with," Pfeiffer says. So, she arranged for the plant operations unit to maintain the carts.
For the new hospitals, HCA opted for computer cabinets from Houston-based Proximity Systems, holding downsized PCs from Dell Inc., Round Rock, Texas. "We thought a stationary device is better in the long run," she adds.
While laptops on carts had to be replaced every two or three years, the hospitals expect to replace the PCs every four or five years. But the cabinets are expensive, as was cart maintenance, so the overall cost is close to being the same, Pfieiffer says.
The hospitals have one back-up computer cart in each unit in case a mounted PC in a patient's room fails. "That was something we learned very quickly that we needed," Pfeiffer says.
Carts also are the computing tool of choice for respiratory therapists as they treat patients throughout the Centerpoint and Lee's Summit hospitals. These clinicians have lots of equipment, and the carts have lots of places to store all their stuff. Instead of being the extra piece of equipment that nurses hated, the carts have become a caddy for the therapists.
"Carts are not a thing of the past," Pfeiffer contends. "They are a matter of personal preference. But from an equipment perspective, it's been far easier to service PCs in rooms instead of laptops on carts."
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