Hospital Noise

Ring, Buzz, Tone, all sounded as Caregivers bustled and hustled past my seat with IV bags, food, charts, and doctors. My heart rate increased. It seems no matter how long I have worked with hospitals those noises still make me nervous. It’s kind of like taking your first airplane ride – you are not quite sure what the noises mean but you know the plane could fall from the sky at any moment. I began thinking about noise, as I waited to speak to the Nursing Director, why is it so noisy? When you are sick all you want to do is rest, yet how do you rest when an IV pump - that sounds like the worst alarm clock in the world - is going off randomly down the hallway.

Noise is measured in decibels(db) - I learned that from my early days of designing sound systems. The average bedside monitor is approximately 79db (Hospitals & Health Networks Dagmara Scalise Mayo Clinic May 2004) but what does that mean? Compare it to a heavy truck driving by – a diesel mind you – which is 80 decibels. At Mayo clinic they documented the loudest point of the day to be at a pre-intervention shift change which was at 113db – to compare a gunshot is 140db.

Is a “decibel” really the right method or measure? Do we really expect the Clinicians to be concerned with actual decibel readings? Is it practical to think that they are going to carry around a little decibel meter in their pocket and then say ohhh we are 15 decibels too loud? Impractical, Difficult, and Inefficient….

Since assessing all noise on a unit is a huge undertaking (footsteps, conversations, cell phones, chatter, beds running into walls) - What if we took the section of noise that has to do with alarms and began to create a method to quickly and efficiently assess it? Total quantity of alarms multiplied by total devices in the rooms = the Noise Issue. (that’s way too simplistic but it helps establish the initial concept)

The initial solution by hospitals (and manufactures trying to sell a product) is “send it to a wireless phone or device”. While I am onboard with the mobility revolution – I think that it’s an overused medium that manufactures and vendors use to pull at the overworked heart strings of the caregivers. The mantra “We can make your life easier – just send it to a wireless phone” conceptually is wonderful but realistically how many alarms can we actually take on our hip? (See earlier post) Don’t jump on the band wagon that mobility is always best - jump on the band wagon that efficiency – ease of use – reduced redundancy is always best.

At Sphere3 we utilize a sophisticated equation in our workflow analysis and link it back to proper categorization of alarms which decreases alarm fatigue. One of the items we look at is noise and utilizing a scoring system we help establish the most effective area to automate.

I think that it would be interesting to create a calculator that the caregivers could easily use to establish their noise level – efficiently and effectively. Anyone interested?

Check out the article posted by @BhawkesRN (Beth Hawkes) on Noise.

Single Source of Truth

The Clinical Transformation blog is about workflow – how do we positively impact the caregiver’s day by providing technology that is purposefully chosen based on process. Remember if you pick the product without knowing the workflow you want to achieve up front – then you are shopping for a book based on the picture on the cover not the content of the material.

That being said - I am totally enamored with what is occurring with device connectivity platforms and the flexibilities they offer. I am equally enamored by the marketplace shift that is occurring. Companies large and small move into a space as a disruptive technology, and it begins a ripple effect. This starts to shift our view of status quo and wonder – is there a better way?

One of the best parts of our growing start up is all of the interesting people I get to meet. Wednesday, I had the opportunity to sit down with Tom Herzog, VP of IT and Medical Device Technology – head of the MDBUS. Tom is a fascinating individual who is very intelligent and a visionary in the marketplace - I was blown away by our conversation and truly appreciated the interaction. He is someone to watch. MDBUS is Cerner’s connectivity platform that connects medical devices to the EMR. While MDBUS has several similarities to CapsuleTech (blogged about earlier) they have built tight relationships in the marketplace with companies such as Hill-Rom that allow them to garner additional information on an interactive touchscreen, and interactive integration software piece that allows a user to query systems using a handheld device.

The one items that stands out to me as their biggest challenge (this might be the elephant in the room) in the market place is the blessing and curse of the Cerner brand. Cerner is well known for innovative thinking and product development – if you have been to a smart room you would agree. The blessing of the brand is it’s trusted stability in the marketplace with a growing enterprise EMR market share documented at 13%(2006 HIMMS) which I have read other sites to be closer to 20%. This is a great base of clients who are prime candidates for “the bus”. As a relatively unknown startup – I am envious of having such a well known brand. What Mr. Patterson has done is amazing.

The curse of the Cerner brand is it’s tight tie to a specific EMR. While the product is designed to be EMR vendor agnostic - it would only be logical to utilize the product to position themselves in competitive accounts. Why would Epic invite a Cerner product into the mix? I could be way off base here but this seems counter intuitive. While it may occur – GE still utilizes Emergin (aka Phillips) Emergin as a standalone brand had the ability to be Vendor Agnostic but now linked to Phillips it is a leverage point to bring Phillips into an account.

All of that aside – the thought process used in developing MDBUS is correct – the product is really impressive. Open Source – Open Data – Single Source of Truth (as Tom would say) is important in healthcare. It offers significant abilities to decrease caregivers workload and increase safety.

I think that every hospital should be evaluating these types of systems and DOCUMENTING their validity.
What method are you using to see if this is garnering you results?
Is it going to positively affect safety, accountability, redundancy, and noise?
Is it affecting their caregiver satisfaction, patient satisfaction, and safety?

I think that Capsuletech (Brian McAlpine) and Cerner MDBUS (Tom Herzog) are fellas that you should watch – I know I am. I appreciate this interaction.

Who would’ve thought – a little gal from Kansas would be talking to such powerful industry changing people. All it took was Twitter and a choice to join the conversation – are you ready to join?

Thanks Tom – look forward to learning more.
www.cerner.com

Stay tuned – I am working on a thought provoking post about Cerner’s vision of allowing people to write apps to their Iphone and utilize the EcoSystem to share (possibly sell) that work. Probably one of the most innovative ideas I have heard in a long time – not sure I am on board with the ide, but I can’t wait to experience it myself.

The 5 I's of Fall Mitigation

Our Goal is to reduce falls in the patient rooms – whether or not you hire Sphere3. I believe in the power of the conversation for the overall improvement of healthcare. I encourage you to read what is written and add to it. We have had a great team working to develop this framework but I believe in the power of collaboration.

Collaboration outside of healthcare can also be powerful. As many hospitals have discovered, manufacturing may have some ideas that could answer some of the questions. What are other industries that may compliment process improvement for healthcare?


The First "I": Introduce

The basic premise of the first “I” is to describe how the patient is introduced to the unit. This is not a, “hello my name is Joe, what’s yours?” It is how do they get there and once they are there how do people know? Not that we are recommending a camp like cheering section to greet them in a tunnel but how are the caregivers on the unit provided with information that a new patient has arrived. What’s the “on-boarding” process? One consideration for this process will be, is it important for everyone to know a new patient has arrived?

There is considerable time savings opportunities (and cost savings as well) prior to arrival on the unit. There are several areas to consider including how are you tracking the time from entry to bed and all the steps in between? How is the transporter contacted and how are they tracked? How does the hand-off work?

What are your thoughts on Introduce – Transport – Notification?

Our team works with your hospital to customize a strategy to respond to the above questions. Our Fall Mitigation Analysis software program allows us to document, analyze, and provide innovative recommendations for improvement. Your information is assessed against best practices for optimal results.

Patient Association

Sphere3 has a goal and focus to increase caregiver satisfaction by utilizing technology to automate workflow. The key is we don’t want to make life MORE complex by adding unnecessary technology nor do we want the hospital to spend additional dollars if existing technologies can be leveraged to increase functionality.

I had an interesting conversation with Brian McAlpine of Capsuletech (www.capusletech.com) about patient association. Capsule is highly focused on the documentation, and the ease of delivery of information.

I encourage you all to join in the conversation to increase the overall knowledge in the industry. This is my perspective - which is meant to be very elementary in it's approach.

Caregivers are challenged to manage information – whether it’s an alert to their wireless, a piece of data that needs to be documented, or request that is made or received. Adding technology to “make things better” will sometimes add steps as it requires several steps to interact with the new technology.

Traditionally, in alert automation software, the information is linked to a room number. The association to a patient is generally made by the integration to the admitting system (sometimes this is done manually) – so connection is only made by linkage to room number. The key is that the alerting device must be “tethered” (aka plugged in) to the patient room to be linked to the room number and sent to the appropriate caregiver, or the hospital must purchase additional software packages which in turn increases the number of "adapters" that must be purchased for integration software. Adding to the difficulty, new devices are wireless and can float to any room so a nurse must interact with the piece of equipment to identify it's location.

So, the question becomes will it become more necessary for alert automation to associate with the Patient as opposed to simply the room? Potentially, it could be easier to associate to the patient. This could increase the flexibility for integrating that information to medical record for multiple devices such as mobile telemetry, vents, pumps, etc. It will also blow away the current assignment process for integration software, nurse call, and other vendors. (Yes, I recognize there will be disagreement on this one.)

The Nurse Call information is the most popular item to automate directly to wireless mainly because of its highly visible patient satisfaction and caregiver satisfaction influences. The telemetry is a close second, while the loss of the waveform has been challenging to most sites, it’s still very necessary to have that alert at the “hip”. While it’s not highly critical to associate the patients name or identifier to a wireless device for nurse call, documenting the interaction can be critical if an issue arises.

Most of the companies focused on alert automation do not consider the charting piece because it’s “out of their scope” but hospitals will at some point (if not already) be tasked to correlate that information. If you read Brian McAlpines Blog you will read more about patient association, devices and documentation.

Products such as Capsuletech offer a vendor neutral integration point in the patient room. Their product can collect data from devices and correlate it with patient information, all of which can be confirmed at the bedside either manually or automatically.

Clinical Transformation

I love the new Bing.com commercial. The daughter asks the parents a simple question and they begin to rattle off information containing the word within the request. Notice that they never get her the right information to answer her question.

The internet has made us more connected, and more informed than ever before. We are masters and weeding quickly through information, and scanning documents to find the nugget that we need, but how do we know we are getting the right information? How do we assess the nugget is not just information containing the word but not really providing the answer? Apply that thought process to the speed at which information travels to our clinicians. How do we make sure the right nugget of information gets to their hands at the right moment? How do we delineate critical vs clutter?Stay Tuned for the next post as we continue the discussion.

Clinical Transformation is an evaluation of the information, process, people, and technology. It provides a solution for how these items interact. It’s focused on the distinct goal to increase value. It does not simply use the processes to monetarily create value but also by value through improving quality of care delivery. Removing the Clutter from the caregiver and providing them with the right Data, at the right time, and in the right format. Patients need access to caregivers and vice versa. Caregivers need access to patient’s information.

ECRI Institute (www.ecri.org ) pointed out in their paper about the Top 10 Technologies for the “C-Suite” to watch in 2009, that Alarm Automation Tools will be an important hospital tool. However, they encourage hospitals to consider the following questions:

« Which patients are assigned to which nurses at any given time?
« Which devices are assigned to which patients at any given time?
« What data will be transmitted?
« Which patients’ alarms should be sent to which nurses?
« Which alarm escalation model will be employed?

We add this question, once you start automating your alarms how is your response to the need categorized? Do you have a response plan based on the categorization or on the specific alarm?

Sphere3 offers a number of solutions to how to effectively categorize alerts to have more effective alarm response.

Alarm Overload

Alarm OVERLOAD
If your hospital is considering using the wireless device to receive clinical alarms direct to caregivers to “make them more efficient” consider this:

• Automating the Nurse Call System on average can send 5 alarms (not considering escalation which could double this potential) per patient
• Automating the Telemetry on average can send 15+ alarms per patient
• Automating the Vents and Pumps without Data (ie through a contact closure – not the full information available) can provide 2 alarms per patient
• Automating the Bed Exit Alarm is a single alarm per patient
  

Automating the additional Bed Alarms can send up to 28 alerts per patientThis does not include things like Bed Management, Lab Results, Orders, Automated Process Stations, etc. The question is balance. If you were to automate all of these alarms you could be sending over 51 alarms to your caregivers per patient. In a 1:4 Ratio situation that’s over 200 alarms! Planning and preparing for these are crucial. Categorizing alarms and keeping response procedures simple can improve the process of automation. At Sphere3 we specialize in evaluating the current situation and providing best practices solutions. Understanding the information that is being processed, the systems that are sending the data, and the caregivers workflow is our specialty. Many providers will encourage automation as a decision point for their product, but understanding the full scope of the integration is the key.

Contact us for more information

Sphere3

I just enjoyed the X3 Summit in San Fransico. The learning and collaboration was great, and I look forward to engaging more with my new colleagues. From now on when you read the blog we will work in groups of 3 - this will keep the blogs concise and the information structured in a optimal learning paradigm - the power of 3.

Social Media
Having the conversation - is intimidating to say the least. Presenting your learning in a manner which readers can engage and interact with the findings puts the presenter in danger of "being wrong". I would object - that the conversation should not be able being wrong, especially when we are looking at healthcare. It must be about finding the best solution to our ever growing need. Having the conversation is about engagin new ideas, challenging the thinking of the norm, and establishing whether status quo is most effective or needs to be adjusted. In a world of Twitter, Facebook, and Blogs our thoughts are moved freely our abilities to assess are only limited by our abilities to tolerate the conversation. Long-Term -- Healthcare can be improved by these conversations but we must be prepared to move thoughts and words into action.

ROI
Many of the hospital learners were discussing ways to justify purchases based on a Return On Investment analysis and several good points were made. I must admit my view point was challenged as well. When assessesing ROI projections from vendors understanding their starting point is crucial. Each vendor has the ability to mold the ROI to their benefit based on small feature sets that differentiate their product. Establishing your goals associated with a return is crucial. It may be beneficial to engage a firm or team with outside perspective to help establish the correct principles.

You also need to assess - if we are reducing work in a process what is the person going to do with the additional time and how is that improving the overall picture. If you simply add technology to save time - you have to decide prior to implementation what the new found time will be used for - if not you won't see any global productivity changes.

Technology Infrastructure
I was enlightened to the world of "Healthcare IT Consultants" during this visit. It's a broad term that can be interperted in several ways. Some are focused on the low voltage aspects, while others are focused on the technology, and others are foucsed on the transition. While my initial perspective was - you don't need them just evaluate the products you are presented with associated with your needs. At the end of the conference - I am convinced that a technologist is needed during a construction process. As a former vendor, who didn't appreciate the consultant, I now see that they are extremely valuable in decreasing the hospitals overall costs associated with purchasing and making sure that the workflow dictates the technology - not the other way around.