Scanning the Horizon

Sept. 1, 2007

A health system upgrades its bar coding and patient auto-identification for improving patient care enterprisewide.

To support patient safety, hospitals need a reliable and efficient way to identify patients. That means systemwide bar code format standards, durable wristbands and dependable printers.

A health system upgrades its bar coding and patient auto-identification for improving patient care enterprisewide.

 To support patient safety, hospitals need a reliable and efficient way to identify patients. That means systemwide bar code format standards, durable wristbands and dependable printers.

  As one of the largest nonprofit healthcare systems in New Jersey, Atlantic Health has 1,585 licensed beds at its three acute care centers and another 130-bed rehabilitation facility. Serving northern and central New Jersey, Atlantic admits approximately 1,500 patients a day. Atlantic’s high levels of patient satisfaction and innovative use of information technologies notwithstanding, the organization found itself struggling with a fragmented patient identification system in 2005.

 While Atlantic did use bar code technology throughout the organization, we had not standardized one symbology or bar code format systemwide. In addition, our patient wristbands were not suitable for the rigors of a hospital environment. As a result, clinical information systems could not read administrative bar codes and vice versa. For example, a lab technician could not scan a wristband to verify a patient’s identity. Thus, bar coding at the point of care for applications like specimen collection and medication administration was off the table. Until patients were readily identifiable, nurses would continue to use a manual process based on paper charts and sticky notes.

Finding a Solution

 Even if various applications could read the bar code symbols, wristband durability posed a secondary challenge. Using a standard office laser printer, staff members were generating adhesive-backed paper labels and then applying them to the wristband. Unfortunately, the labels often fell off the wristbands or they degraded in quality to the point where they were damaged or unusable. As a result, caregivers were using patient identifiers from alternate sources, which often led to errors. In fact, staff found that at one location, as many as 15 percent of glucometer test results were being attributed to the wrong patient largely due to these problems. This high failure rate posed a serious risk and required that staff spend too much time reprinting labels for wristbands.

 As a part of our ongoing commitment to patient safety and quality healthcare, Atlantic realized we had to overcome these obstacles. Two primary drivers for the upgrade were the immediate needs to standardize the symbology and improve materials used for wristbands systemwide. The health system also wanted to prepare for our first major patient-identification-related initiative for patient safety— our implementation of McKesson’ s Horizon Admin-Rx solution for bedside medication administration. Reliable, efficient patient identification would also improve the accuracy of charge capture for treatments and medications.

 With manual processes, the task of crediting a patient’s account for medications that were not administered is complicated and often leads to time-consuming rebilling. Bar code systems at the point of care make it possible to charge upon administration only, rather than from the pharmacy. This kind of automated charge capture is good for patient satisfaction and overall efficiency.

 In November 2005, representatives from the nursing, laboratory, finance, registration, purchasing, risk management and information services departments began the selection process. The group first defined its criteria for the project, with the following among the priorities: A compact, standard symbology that could support future application requirements (e.g., phlebotomy, blood bank, radiology); Durable, comfortable and tamperproof wristbands available in adult, pediatric and infant sizes; Scalability, to accommodate all possible patient types throughout Atlantic Health; Practicality, efficiency and cost-effectiveness; Compliance with The Joint Commission and other patient safety and privacy guidelines; and, the ability to print on-demand.

 Evaluating the Options

 The team acknowledged that to achieve these objectives, the organization might be required to make substantial changes to its registration process and wristband production workflow. The committee evaluated various print technologies based on quality, readability of the bar code symbols, cost, maintenance and waste. The thermal print solution offered the best combination of image resolution and durability and the project team further determined a preference for the direct thermal print technology. These printers do not use a ribbon, saving on consumables and avoiding the hassle of destroying ribbons in accordance with HIPAA guidelines. Additionally, the thermal printing solution featured the advantage of a small footprint, a particularly significant consideration given the premium value of desktop surface space in the hospital environment.

 Atlantic then held a ” vendor fair” at which four vendors demonstrated their printer and wristband solutions for bar coding. To test the two finalists’ bar code print solutions, the team enlisted the help of volunteers to wear the wristbands in a variety of settings, including hospital and outpatient environments (one team member’ s mother wore one in an independent living facility). By testing the products in a variety of places, Atlantic was able to evaluate how exposure to alcohol, foam, soap, blood and water affected the wristbands and ensure their durability for nearly any scenario. This was an important step because without legible, easy-to-scan bar codes on the wristbands, the entire auto-identification system breaks down. Nurses may not be able to identify a patient, resulting in the potential for safety to suffer and staff frustrations to ensue.

 Bar code systems at the point of care make it possible to charge upon administration only, rather than from the pharmacy. This kind of automated charge capture is good for patient satisfaction and overall efficiency.

Implementation

 The Atlantic team ultimately chose the H 2824-Z thermal bar-code printer and wristbands by Zebra Technologies Inc., and with supporting research data, selected Code 128, one of the most compact of the linear one-dimensional bar code symbologies. Furthermore, Code 128 was already compatible with Atlantic’ s existing glucometers, ADT software and the forthcoming medication administration system. In April 2006, Atlantic began a pilot of the Zebra bar code print solution, which interfaced directly with the organization’ s ADT software. This interface eliminated the need for middleware to print directly from the McKesson STAR application, a feature that would save Atlantic a substantial sum in licensing fees and eliminate a potential point of failure.

 Because the staff was familiar with the existing ADT application, little retraining was required. In fact, no classes were scheduled. The key workflow change was related to the reduction in the total number of printers previously used to print labels for wristbands. Because fewer reprints would be required, Atlantic placed the new thermal printers in registration areas and virtually eliminated printing from the nursing stations. Even though staff can no longer generate labels from any office printer, the process is much more streamlined and very few reprints are needed.

 Perhaps the biggest challenge with an initiative like this lies in building a culture of patient safety that’ s strong enough to support changes the clinical staff may have to make. Understandably, change is not easy in any clinical environment— nurses may prefer familiar, paper-based processes better than automation. Through a significant investment in planning, interdisciplinary involvement, and strong nursing leadership support, Atlantic has been successful in shifting the mindset such that change is welcome, particularly when it helps to drive enhancements to patient safety.

Results

 Between June and September 2006, Atlantic installed 125 Zebra wristband printers. Though the outcome of this project is difficult to quantify, it has had a tremendous impact. For example, the health system has seen improved bar code read rates working with glucometers and elsewhere in the organization. The simple fact that wristbands remain intact with readable bar codes is huge. By itself, eliminating the old failure-prone labels would have been justification enough.

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 In addition to the advantage of fewer reprints, Atlantic is now able to generate patient wristbands in a single step. The wristband process has essentially become invisible. IT staff do not receive complaints anymore, and that’ s a good thing. Another patient safety enhancement is that Atlantic is able to print patient identification ” on-demand,” one at a time. That means no more printing sheets of labels, which can easily be lost or misplaced.

 Most importantly, Atlantic has established a foundation for future, bar code-driven applications. As of early summer 2007, medication administration was just emerging from pilot phase. Atlantic is also investigating the possibility of deploying a patient location tracking application from McKesson that will allow the organization to utilize the bar coded wristbands to monitor a patient’ s movement throughout a facility. With applications like these— and the accompanying improvements in clinical workflow— Atlantic anticipates significantly fewer errors from manual transcription, more accurate clinical data readings at the bedside, more precise charge capture at the point of care, and improved efficiency throughout the organization.

SEPTEMBER 2007

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