Brian R. Jacobs, VP, Chief Medical Information Officer & CIO, Children's National Medical Center
Effective communication across the healthcare organizations between nurses, physicians and ancillary healthcare providers is essential for high quality care delivery, education as well as employee and patient engagement. Failure to communicate effectively has been associated with 80 percentof serious medical errors in the hospital setting. In addition, biomedical devices such as cardiopulmonary monitors, ventilators, and IV infusion pumps communicate to clinicians via alarms. Furthermore, patients frequently communicate with healthcare providers via bed call systems. The volume of communication with enhanced technology over the last decade has increased dramatically, and can occupy a significant portion of the data for most health care workers. According to a recent study by the Poneman Institute, clinicians waste more than 45 minutes daily due to the use of outdated communication technologies. The cost of this waste is estimated to exceed $5.1 billion annually in the United States. Deficiencies in communications increase patient length of stay, discharge time and reduce time available for patient care.
Alarms and alerts from biomedical devices across a typical hospital environment today communicate with clinicians in a variety of non-specific (audio only) and specific (detailed data) ways. Alarms and alerts can be pervasive and have been the subject of extensive study related to the issues of over-alerting and alert fatigue. Alarm fatigue is a multifaceted issue related to high false alarm rates, lack of standardization, poor positive predictive value and a great number of alarming devices in healthcare organizations today. Our own alert fatigue data from Children’s National suggests a 38 percentfalse alarm rate related to cardiopulmonary monitors.
In 2013, in addressing alarm-related harm, ECRI suggested that reduction will result from implementation of alarm systems that integrate with phones, nurse-call systems and other devices. The organization further noted that protocols should be established to guide caregivers in tailoring alarm limits to individual patients to ensure that the appropriate staff are notified of clinically significant alarms.
“Experience at healthcare organizations indicates that integrative smart phone technology is often rapidly adopted”
With the increasing need for clinician to clinician, device to clinician and patient to clinician communication, integrative strategies to bring these technologies together will have great importance. Recently, Children’s National Health System implemented such an integrative strategy throughout its inpatient operation. The integrated approach consisted of a platform which combined smart phone voice and secure texting technology with cardiopulmonary monitor and nurse call system alerting, real-time access to patient vital signs and clinician contact information and patient assignments on the phone, and integration with unit-based patient location boards (Figures 1-4).
Experience at healthcare organizations indicates that integrative smart phone technology is often rapidly adopted. At Children’s National, within one-month of implementation, approximately 3,500 unique monthly users were receiving and sending 37,000 audio calls, 22,000 secure text messages and receiving 25,000 monitor and nurse call alarms each week. Qualitatively, clinicians are increasingly reliant on this new technology in support of efficient and effective secure communication in facilitating high quality and safe care delivery to children.
There are many aspects associated with these integrative technologies that require attention to achieve optimal performance and value. These important factors include robust process redesign, performance monitoring, enduser communication, analytic reporting, attention to over-alerting, and physician-specific issues. Integrative technology platforms centralize an organization’s communications infrastructure. Therefore an impact with one infrastructure component can impact important data flow across the entire system. The smart phones are costly and subject to loss, theft and damage if not properly managed. The integrated functionality is very much dependent on staffto patient and staff to device assignments occurring in a prompt and complete manner at each change of shift. Data flow from cardiopulmonary monitors to middleware to the internet hosting environment and to the smart phone requires proactive monitoring to ensure that there are no barriers to data flow and effective communication. Utilization and performance reports should be produced on a regular basis to ensure a complete understanding of improvement opportunities. Policies concerning text retention and monitoring should be well documented and communicated. Clinicians must be engaged to determine the types of alarms and alerts to be sent to the smart phones, the impact on workflow interruption and failsafe alarm management. Special issues of concerns to physicians include having the correct technology to allow call forwarding from one physician to the next during oncall cycles. In addition, the platform should support rolebased communication which permits the assignment of a phone to a shared role rather than for each clinician. In addition to covering the above, organizational policies and procedures should cover device ownership, accountability, battery charging protocols, ownership of troubleshooting, security and privacy, appropriate use of texting and other issues.