Providing healthcare is a study in coordinated, constant movement. Humans, machines and information have to be synchronized so they show up in the right place, at the right time, and perform the clinical functions necessary to keep treatment flowing in a time-intensive environment.

Enormous resources have been poured into electronic health records and other software tools to ensure the information gets to the point of care. But getting humans-both patients and caregivers-and equipment to the right place at the right time continues to frustrate efforts to provide the optimal workflow.

Real-time location systems (RTLS) provide the ability to pinpoint a position precisely for tracking equipment, monitoring hand-washing stations, tracking staff and patients, and monitoring the temperatures inside refrigeration units via sensors.

By doing so, RTLS is offering new levels of visibility into how people and assets behave. But that visibility doesn't always show behavior in the best light. RTLS leaders are finding they often have to manage the message of real-time location systems and sometimes walk a fine line between collecting data and being intrusive before the technology can be used effectively.

No limits

Real-time location systems comprise wireless receivers, transmitters and sensors that pinpoint the location of passive or active tags. RTLS networks typically combine different technologies, such as radio frequency, infrared sensors and ultrasound, to pinpoint location.

"RTLS is really just a measuring tool, but once you have it deployed the sky's the limit on what you can measure," says Todd Frantz, a senior technologist at Adventist Health System, a 45-hospital organization based in Altamonte Springs, Fla., that operates facilities in 10 states and has developed RTLS networks with technology from Stanley Healthcare Solutions in Waltham, Mass. "That's when you get into the really tricky part of using RTLS. You can tag equipment and people and see what happened in terms of location, but what you really need to understand is why they did what they did."

Most organizations initially use RTLS for asset tracking and other functions-like monitoring refrigerator units-that have quantifiable returns on investment before they move into the more complex realm of tracking humans, where ROI is harder to measure and attain.

Mark Rheault, founder and CEO of consulting firm Infinite Leap, who is serving on contract as director of the office of enterprise visibility at Wake Forest Baptist Medical Center in Winston-Salem, N.C., says the ROI from those quantifiable returns can be enormous. Wake Forest Baptist has gone big with its RTLS infrastructure, which uses hardware from CenTrak in Newton, Pa., and operational software from Fargo, N.D.-based Intelligent InSites. (Rheault is also one of the founders of Intelligent InSites.)

More than 5,000 infrared sensors and 800 receivers are deployed across 4 million square feet of Wake Forest Baptist facilities. The health system has tagged 13,000 pieces of medical equipment and has sensors in 800 refrigerated units to monitor temperatures every five minutes in each unit. In addition, Wake Forest Baptist has issued 2,600 staff badges, and plans to dramatically ramp up that effort this year to approximately 8,000 staff badges and 2,000 patient tags as it rolls out a personalized wait management initiative for patients and staff-driven clinical quality efforts.

By locating and increasing utilization of the 240 types of known equipment it tracks, Wake Forest Baptist figures it has generated $8 million in total value to date through better asset management, automated temperature monitoring, enhanced staff productivity and eliminating the need for several purchases. By bumping up utilization by 30 percent and putting many pieces that had been hidden away back into use, it has avoided spending $2 million a year for new equipment.

With regard to monitoring refrigeration units, Rheault's analysis found that there are hundreds of alerts about malfunctions and rising temperatures occurring each month, and about 20 percent of the alerts from the RTLS tags would have resulted in lost product. Most of these alerts wouldn't have been caught through the previous, manual monitoring process, which required nurses and other staff to walk to the refrigerator at regular intervals and record the temperature from the thermometer. "Those alerts that we wouldn't have had in the past save us nearly $1 million in drug costs, which is the amount we would have had to pay to replace lost product," Rheault says.

Constructive intelligence

So RTLS is a very powerful tool, but like any tool, its effectiveness hinges on how it's used. Therein lies the challenge. Kevin Capatch, director of supply chain technology and process engineering at Geisinger Health System in Danville, Pa., says that leaders have to ensure the intelligence gleaned from knowing the exact location of humans and equipment at any given point in time is used in a constructive way.

"A lot of practices in healthcare are really invisible today-you have an idea they're going on, but with very granular location systems you can in fact know what's going on," he says. "That's a very fine line between increasing intelligence and being perceived as intrusive. Be it equipment or personnel tracking, you have to be consistent with your message that it's about improving operations and not penalizing people."

Geisinger has used equipment tracking as the foundation for its plans for broader RTLS use. But even when tracking machines, the human factor comes into play.

Capatch says the industry adage about 30 percent of medical equipment being in the wind proved true at Geisinger. When the health system rolled out its tagging initiative, it located around 70 percent of its known assets with an RTLS system that uses infrared sensors and other hardware components from CenTrak, combined with management software from Pittsburgh-based TeleTracking Technologies. The effort to find the 30 percent of unaccounted assets required Capatch to confront the seemingly intractable issues faced by all supply chain and bioengineering departments: hunting, hiding and hoarding.

"There's no getting around the fact that some departments and staff have raised this to an art form in virtually every hospital in the country," he says. "In their defense, sometimes it's been necessary to hide and hoard equipment for their patients, and by this point it's basically an instinct to tuck pumps and wheelchairs and other equipment into closets or in unused corridors and all kinds of places you'd never think to look. But that makes our jobs that much harder, because the return on investment on RTLS here is understanding what equipment you have on hand, increasing the utilization of that equipment and saving money on future capital expenditures or leasing contracts."

Humor is an effective tool in change management, Capatch adds. "We encourage people to chuckle when they realize the futility of the practice of equipment branding as they look at the equipment that says property of the ED while standing in the nursing unit two buildings away." Once tagged, the pool increases and the need for branding is eliminated because you now have visibility to the entire pool, not just your stash.

Geisinger opted not to take a punitive approach to the three Hs. Instead, Capatch says, when "misplaced" equipment is found, either his team or the clinical engineering team tag it and bring it into the RTLS fold while thanking the department for its "donation" to the enterprise equipment pool. The health system has a vetting process to determine the necessary level of equipment deemed mission-critical on each floor, and has more than 90 percent of that equipment tagged and tracked constantly by the RTLS network. That has helped alleviate chronic shortages of available feed pumps and other equipment, he says.

Understanding the why

While it's frustrating to deal with hunting, hiding and hoarding, it's critical that leaders understand the "why" behind it, adds Frantz from Adventist Health. "Nurses didn't go to nursing school because they wanted to be equipment managers," he says. "If you have a little bit of hoarding going on, you're dealing with human nature. If you have a lot of hoarding, you're dealing with a management problem, because you either haven't allocated resources correctly or you haven't otherwise convinced people there's no need to hoard."

While the human factor plays a big role in the successes and failures of equipment tracking, in terms of visibility, the rubber really meets the road for RTLS when organizations begin to use it for human tracking. Frantz, who has worked on numerous RTLS initiatives across Adventist's sprawling enterprise, says the same principles apply for humans as machines.

"You have to determine what information is important to your organization-so often when you start down this path you come to the realization that you were measuring an outcome when you should have been measuring the cause," he says.

For example, an initiative to measure the time it takes nurses to move from one assigned patient to the next might determine that nurses are taking too long between treatments. But a better measure would be the distance the nurses walked going from one patient to the next. "You might find some odd behavior, like nurses went to faraway medication cabinets or a more remote nursing station. And then you'd have to ask why they'd do such a thing, and there's typically a very logical answer-you didn't have a cabinet stocked with the right drugs or you didn't have the right set-up in a nursing station," Frantz says.

"Bottom line," he adds, "don't try to measure how long someone is in the bathroom. Try to develop measurements that can be used constructively. Yes, people will be reluctant at first to be tracked, but if you work with them to use tracking data to make their work hours more efficient-like stocking a medication cabinet properly-then you'll have their full support."

At Wake Forest, RTLS will track staff to support initiatives to provide patients with personalized wait management as well as set targets for maximizing the value of time patients spend in its facilities, says Rheault, the director of the office of enterprise visibility.

"Patients today know they have options, and their decisions on where to get healthcare services is often based on the convenience of treatment and experience once they're at your facilities," he says. "We understand that better than most: One of our biggest competitors is a few miles down the road, so we're pushing wait time management and service quality as competitive advantages. That makes staff more supportive of the system-caregivers know we're in a competitive market and want to improve our service levels as much as anyone."

Initiatives slated to roll out this year include providing tags to patients to ensure the best throughput for them through their appointments, as well as measuring the amount of time patients spend with clinicians during their visit to the facility.

Under the personalized wait time management initiative, if a patient needs to go to the lab as well as get an X-ray, office staff will be able to check wait times being projected by the RTLS system via time-stamps and other data. They can then tell patients to go to the lab first because wait time there is shorter, for example, and then go to the radiology department.

Another example: When patients register, they can track their personalized wait times on large-screen monitors. If it's a 30-minute wait, patients can leave the area and will be sent a text message 10 minutes before they see a care provider. "The real critical aspect of this is that we can manage expectations," Rheault says. "There's nothing more frustrating than sitting around in a reception area with no idea how long you'll be there and no options but to sit and wait. And the system also lets us pinpoint how to shorten those wait times, as well as set targets for how much of the total time a patient is in our facilities is spent with a caregiver. We are setting targets along those lines, such as 70 percent of their time in the facility should be spent with providers."

How RTLS Improves Safety at Senior Facility

Light of Hearts Villa is a senior living facility in Bedford, Ohio, that lacks the technological bells and whistles of an inpatient facility. But it has deployed a straightforward use of a real-time location system that has paid off big in terms of resident safety.

The potential for falls is a concern at Light of Hearts, as it is at most facilities treating the elderly. The safety system here and at most other senior living communities has traditionally been pull cords deployed in patient apartments and common areas. When a patient falls or has another urgent problem, he or she pulls the cord and an alarm-or in Executive Director Betty Hickle's words, "an extremely loud, obnoxious noise"-is tripped, which gets the attention of everyone around.

To improve its response to falls-and to lower noise levels-Light of Hearts contracted with Stanley Healthcare Solutions to implement an RTLS that tied into its existing Wi-Fi network to send alerts when a fall occurs. The facility, which has 90 apartments, has issued wireless tags to all residents; the tags can be worn on a lanyard or kept in a pocket.

When a button is pushed on the tag, an alert, including the resident's initials and location, is sent immediately via text message to all the nurses and nurse aides on duty. The alert also pops up on the computer screen of the director of wellness and the assistant director, in the form of a map that shows the location of the resident on a layout of the facility.

When a staff member arrives on the scene, the alert is de-activated, automatically creating a timestamp between the alert firing and the response.

Each day, directors get a report from Stanley Healthcare that lists how many alerts were fired and what the response time was, which has helped establish a benchmark for response. If an alert isn't answered within a few minutes, the system escalates it by sending alerts to additional staff, all the way up to Hickle.

This has brought a new level of accountability, she says. More than 50 percent of the alerts are answered within five minutes, a vast improvement over the pull cord system, which required staff to follow the sound of the alarm across the multi-level facility and around the grounds surrounding the complex to pinpoint where the noise was coming from.

It has also brought a new layer of communication between staff and residents. Not all alerts are for falls, Hickle says: In many cases, a resident might be in an apartment or common area and suddenly feel dizzy or otherwise unwell. While there are still pull cords available, residents aren't necessarily in condition to walk over and pull one.

Hickle says the RTLS system has brought more peace and quiet to the facility in addition to helping residents get fast assistance. It's also comforting for residents' families to know their loved ones have that extra layer of safety, she notes.

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