Eight years ago, emergency department (ED) personnel at Christiana Hospital recorded the whereabouts of patients in a health information-technology system that required manual entry of all changes in a patient’s location. This non-automated system had served the ED well in the past but had become outdated and unworkable when volume reached 85,000 annual visits in 2003. As the volume surged, the hospital realized it needed an automated system to avoid significant wait times and reduce the percentage of patients who left without been seen (LWBS).
Also, not surprisingly, 20 percent of the time patient location information recorded in the non-automated system was incorrect. Although that appears low, it meant the 913-bed hospital owned by Wilmington, Del.-based Christiana Care Health System didn’t have the exact location of 50 to 60 out of the 250 to 300 people presenting daily at its ED. Sometimes patients were in transit or were moved to a different room after a diagnostic study or procedure, and the new location wasn’t immediately noted. Unaware of the change, staff would direct friends and family members to the wrong room, inconveniencing visitors.
To address these issues, increase efficiency and improve ED throughput, Christiana Hospital began looking to information technology and learned about a real-time location system (RTLS) from Awarepoint that offered immediately accessible, up-to-date patient location data.
Methodical planning
The hospital realized that the right RTLS could continuously track and locate patients and staff in addition to tracking devices and supplies, while also streamlining ED workflow. Adopting a deliberate and methodical approach, Christiana planned implementation of the system for a year. It went to great lengths to educate and seek input from every constituency that would be directly impacted or could potentially benefit from the application, which included the ED, radiology, laboratory, bed-management and patient-transport departments.
Despite excellent relations between management and the employees and physicians, ED management was concerned that some staff members might object because they would be concerned that “Big Brother” was trying to measure their personal productivity. To avoid this perception, they stressed to staff that the goals were to improve staff and patient safety, patient care and efficiency.
The ED team leading the project emphasized that it wanted to keep staff and their families safe in case they were exposed to infectious conditions, such as meningitis, or dangerous substances, such as anthrax. The staff recognized that if such an emergent situation occurred, it would be critical for Christiana to identify and quickly find every employee who was exposed and everyone with whom they had interacted.
Additionally, in the beginning, staff members’ locations were only identified when they were in patient care areas – the system wasn’t activated in nursing stations and other locations until later, after the staff requested this expanded capability. The hospital has never activated tracking in the break areas or restrooms.
In 2004, the system, which was interfaced with the laboratory, radiology system and bedside management applications, went live. In 2010, order entry was added. Wary employees became instant converts because they realized the value of knowing patients’ locations at any given time. In fact, staff considered RTLS a mission-critical system within hours of go-live, which was driven home when Christiana had to shut down its application 24 hours after roll out due to a hardware problem unrelated to RTLS. Staff immediately told managers that they needed the solution back up right away and were eager to start using it again when it was restored later the same day.
Shortly after implementation, the medical staff – unanimously and voluntarily – chose to turn on the staff location function for the doctors after they experienced how much time they saved when they were needed for a consult or needed to find a patient or another physician. Nursing and the rest of the employees soon followed suit.
Now when patients present at the ED, they are instructed to clip the tracking badges to their clothing. Registrars enter the badge number and patient’s name into the system. Currently, the badges emit infrared signals detected by sensors mounted on the ceiling of all patient care areas. The sensors then transmit the patient’s location to the tracking solution, which is easily accessible to nurses, physicians, registrars and other authorized personnel.
Not wash and wear
Since deploying the system, Christiana Hospital has found that badges sometimes become buried in the linen when patients are discharged. Although housekeeping has been trained to look for the badges, when things get busy they can be overlooked and don’t survive the wash cycle. The hospital is considering installing sensors that will sound an alarm whenever badges are detected in laundry chutes.
In a handful of cases, patients refused to return badges because they mistakenly thought their personal health information was stored in them, which surprised the facility. The hospital never insisted on return and refined its education process to address these issues. They tell patients upfront what the badge does and does not do, and they instruct staff to be aware of the location of the badges, particularly at discharge.
Another challenge Christiana faced is that the technology used in the ED requires a clear line of sight for the badges and sensors to communicate. If the badge is covered by a blanket or flipped around, the hospital momentarily loses the patient. However, the loss is brief because the facility has installed 400 sensors across the ED, meaning that the system will pick up people as soon as they start moving again and line of sight is reestablished. A technology upgrade is currently underway that will eliminate this issue by enabling sensors to detect the badges even when they are obscured or turned the wrong way.
Actionable intelligence drives improvements
The RTLS-enabled workflow efficiencies were so impressive that Christiana deployed the Awarepoint RTLS solution at its second ED at Wilmington Hospital and eventually expanded its use enterprise-wide for asset tracking.
In just the first year, RTLS was a key factor in reducing ED length of stay (LOS) by an average of 36 minutes and cutting the LWBS rate by 24 percent. As Christiana Hospital’s ED volume soared between 2004 and 2008, the health system realized it needed to expand its use of RTLS from a tracking to a continuous process-improvement tool.
A major advantage of Awarepoint’s RTLS is that it can precisely record, measure and track numerous performance metrics at pre-determined time intervals, including wait time, arrival to discharge, door to triage and door to doctor. This actionable intelligence enables users to identify and prioritize processes. It also enables users to refine or redesign processes and procedures and determine whether changes are successful.
To maximize the value of the RTLS data, in 2008 Christiana dispatched a group of employees to a six-day immersion course at the University of Tennessee on lean production system principles pioneered by Toyota Motor Corp. Since then, Christiana’s lean group has focused its attention on improving ED throughput of low-, medium- and high-acuity patients. The lean group has been able to use the RTLS data to achieve numerous benefits, including:
- Cutting overall wait times for low-acuity patients by 46 percent, even as ED volume jumped to 116,000 in 2011 from 85,000 in 2003;
- Reducing the ED LOS for low-acuity patients to approximately an hour from an average of two-and-a-half hours;
- Decreasing the overall LWBS rate by 25 percent;
- Dropping the admitted patient ED LOS by over 30 percent despite the census increase; and
- Enhancing staff safety with an automatic log of all direct and indirect patient interactions.
Like other health systems, Christiana Care is challenged by mounting costs, growing ED visits, wait times and pressure to provide high-quality, timely and efficient care, while simultaneously striving to attract patients and be recognized for the excellent care it provides. RTLS has been instrumental in helping the organization successfully address major challenges while improving workflow and staying ahead of the curve and market trends.
About the author
Linda Laskowski-Jones, M.S., R.N., ACNS-BC, CEN, is vice president of emergency and trauma services at Christiana Care Health System, which has deployed real-time location systems enterprise-wide. For more on Awarepoint solutions, click here.
How does workflow management impact the bottom line and the quality of patient care?
Jay Deady, president and CEO, Awarepoint Corporation
A hospital’s biggest revenue-generating departments – emergency, surgery, cardiovascular and oncology – can all be adversely impacted by a lack of real-time visibility of critical assets. As just one example, a facility can put a patient’s health at risk and lose revenue when it must delay surgeries because the patient, surgeon or a vital piece of equipment is not present at the scheduled procedure time.
Fortunately, the growing prevalence of advanced real-time location systems (RTLS) has proven to improve asset visibility for healthcare providers across the enterprise. In addition, as more and more of today’s RTLS provide the functionality to scale by the entity to be tracked, its purpose and scope of hospital workflow, facilities will be better able to adhere to regulatory compliance requirements, identify process inefficiencies and support the higher occupancy and acuity needs of today’s hospitals.
