January 16, 2012

HIT Keeps in Touch With Patient Care
By Maura Keller
For The Record
Vol. 24 No. 1 P. 20

Touch screen monitors to better manage trauma care and an automated risk assessment tool that can help prevent blood clots serve as examples of HIT’s vast potential.

Few words captivate the HIT sector more than “change.” Anyone with even a casual understanding of HIT recognizes that change is constantly afoot, and it’s vital for healthcare organizations to keep pace. Those that do have embraced technological innovations to stay ahead of the game and improve patient care.

Monitoring What Works
During the past 10 years, technology has dramatically changed how the healthcare industry does business. Technology advancements have driven hospitals and healthcare organizations to reinvent themselves and their internal processes.

Take Christiana Care Health System in Wilmington, Delaware, which recently installed large touch screen monitors to better manage its emergency department’s (ED) trauma rooms.

Here’s how it works: Prior to a trauma patient’s arrival, a call is received on the ED’s medic phone from “prehospital” providers. Based on that information, the unit clerk initiates the trauma page system and enters the prehospital report into an electronic sign-in system that activates a 22-inch split-screen display located outside each trauma bay. The touch screen features the medic report on one side and the trauma responder sign-in on the other. At the top of the sign-in screen, the type of activation—whether it’s trauma code, trauma alert, pediatric code, or pediatric alert—is listed.

“The trauma practitioner responders view the prehospital details on the screens outside of the trauma bays and then proceed to the sign-in process,” says Joan Pirrung, MSN, RN, APRN, BC, the trauma program and neuro critical care nurse manager at Christiana Hospital, which, along with Wilmington Hospital, is overseen by Christiana Care Health System. “The portion of the touch screen dedicated to signing in displays a model of a patient with place markers surrounding the patient. Each place marker represents a defined role for a specific provider.”

As the trauma practitioner responders arrive at a trauma bay, they choose a role by touching a place marker on the screen. A name badge scan allows the provider’s name and photo to be displayed at the appropriate place marker.

Both the sign-in and medic report screens also populate a 42-inch screen displayed in the trauma bay. Any changes to prehospital provider reports called in to the unit clerk prior to patient arrival can be changed on the medic report. All changes in patient status are displayed in red.

Raising Standards
Christiana Hospital turned to touch screen monitors to help it meet objectives for streamlined care. “The goals identified for this project have been ongoing issues for several years,” Pirrung says. “Less sophisticated measures were attempted to meet the original goals but due to advancement in technology and a commitment from our internal IT department, we were able to utilize modern technology to work toward meeting our goals with an electronic system.”

The project’s original goals included the following:

• The electronic sign-in process must be quick and simplistic.

• Prehospital information must be visible and legible.

• Implementation must improve communication among team members.

• Care provider names must be visible to everyone and must assist with the documentation of the responding resuscitation team, identification of the resuscitation team, and role delineation.

• The implementation must aid in reducing the number of nonparticipating personnel in the trauma bay and reducing noise levels.

To help obtain buy-in from C-level executives, the IT department opted to create the software on its own. ”The vice president of the trauma program understood the need to improve the communication and documentation of responding providers during trauma resuscitations. Therefore, this process did not need to be presented to any higher level executives,” Pirrung says.

Karen Gifford, Christiana Care Health System’s IT director, says the organization had already made it a priority to improve ED patient flow through the Acute Care Redesign initiative. “The value that would be achieved in improved communication, documentation of responding providers during trauma resuscitations, and more efficient operations of the trauma events themselves more than offset the costs of the effort,” she says. “IT had identified that they could create the software on their own. Besides salary time, the only additional costs were for the computer screens, badge scanners, monitors, and hard drives, which were already allocated in the capital budget, so it was an easy win.”

While it was important to have buy-in from C-level executives, it was also imperative to gain approval from hospital staff. As it turns out, all it took was some learning on the job.

“We decided to do hands-on education after e-mailing the staff about the process,” Pirrung says. “Once staff started to use the system and noted the improved communication, reduction in noise level, crowd control, and role delineation, they saw the usefulness of the process and started monitoring each other.”

Workflow Improvement
While patient care was not directly affected—trauma resuscitation continues to be efficient and effective—the sign-in process for trauma care providers is quicker, and prepatient and postpatient arrival communication has been enhanced.

“Since the medic report is displayed outside and inside the room, the chief does not have to repeat the medic report over and over as each trauma responder arrives. In turn, there has been a reduction in noise,” Pirrung says.

Additionally, a nurse recorder can accurately document responders’ names and roles by utilizing the trauma bay monitor, which displays all provider names and their roles. This is a key component because documentation of trauma responders is a requirement to be certified as a level 1 trauma center by the American College of Surgeons.

Continuing Education
When introducing a procedure or process, communication is vital to ensuring consistent use and facilitation of the new technology.

One of the biggest hurdles facing Christiana Care’s monitor implementation was getting unit clerks to activate the screens. “If the unit clerk doesn’t activate the screen, the sign-in process will not work,” Pirrung says. “We continue to educate the unit clerks on the importance of activating the system.”

According to Pirrung, spreading the word about the new system was simple. “All staff were made aware of the process through e-mail with screen shots and explanations on how to sign in,” she notes. IT staff educated unit clerks regarding the inputting of medic reports and how to activate the screens. Throughout the go-live period, those who created the software and trauma program staff responded to trauma activations and assisted responders in using the system.

Still, there’s more to be done, says Pirrung. “Ongoing education to the unit clerks and clinical staff continues as this is a new process,” she notes. “As with most new processes, it will take time for everyone to consistently follow the process.”

To further help the project’s chances of succeeding, Christiana Care’s multidisciplinary workgroup (IT, trauma program clinicians, ED clinicians, physicians, clerks, and trauma physicians) took the time to gain a detailed understanding of the trauma resuscitation process and the trauma program’s goals.

“The multidisciplinary team met throughout the year to review, edit, and provide feedback on the project as it was being built by internal IT developers,” Pirrung says. “The goal of this project was to develop an electronic communication tool to disseminate prehospital information, provider identification, role identification, accuracy of documentation of team members, and crowd/noise control for trauma resuscitations. The quality of the care provided to the patient remains at a high level; improved communication has enhanced that outcome.”

Prevention Technology at Its Best
Like Christiana Care, Texas Health Resources is also embracing HIT to improve patient diagnosis and care. Recently, the organization integrated an automatic risk assessment tool with its EHR to cut down on blood clots.

According to Chief Medical Information Officer Ferdinand Velasco, MD, blood clots, or venous thromboembolism (VTE), are among the most common preventable causes of hospital deaths. Texas Health’s clinical quality project to prevent hospital-acquired blood clots throughout its facilities focuses on early identification of at-risk patients and appropriate and timely intervention strategies conforming to national guidelines and evidence-based practices.

The initiative began in 2008 when VTE prophylaxis evidence and measures were embedded into EHR computerized physician order entry sets. In March 2010, best practice alerts were established.

 “The project uses the EHR to help assess each patient’s risk of developing potentially deadly clots,” Velasco says. Using a risk assessment calculator, a clinician receives advice on preventive therapies such as blood-thinning medications and mechanical compression devices that wrap around the feet and legs to promote blood flow.

“VTE prophylaxis has become increasingly visible as a national healthcare quality issue,” Velasco says. “Given the extent of variances as well as the opportunity for improvement, Texas Health’s Chief Quality Officers Council endorsed formation of a multidisciplinary VTE performance improvement committee and appointed a well-respected hospital chief quality officer as chair.”

Texas Health’s work with blood clot prevention aligns with its participation in the federal Partnership for Patients initiative. Sponsored by the Centers for Medicare & Medicaid Services, the initiative seeks to eliminate preventable hospital injuries and complications. VTE prevention is one of the hospital-acquired conditions designated as a focus area by Partnership for Patients.

A key aspect of Texas Health’s VTE reduction initiative is a system of checks and balances. If preventive therapy is not ordered within a timely fashion after a patient’s arrival, an alert appears in the EHR reminding the provider to order VTE prophylaxis and suggesting use of the VTE risk assessment calculator.

Hurdles to Clear
For the initiative to succeed, hospital staff needed to embrace its concepts and tools.

According to Velasco, the project team was forced to address several challenges when implementing the VTE reduction initiative. Among those were the following:

Challenge: Weaning staff from the numerous paper-based risk assessment tools and order sets throughout the hospital system

Solution: Strong leadership from the project’s multidisciplinary performance committee, hospital chief quality officers, physician champions, and nursing leaders. “Ultimately, we agreed upon a standard risk assessment methodology across all our hospitals,” Velasco says. Local VTE reduction initiative champions also worked to promote the project at their hospitals.

Challenge: Converting paper-based VTE protocol to an electronic VTE protocol integrated within the EHR

Solution: Achieved consensus to convert a modified Caprini VTE risk assessment tool (which is used to assess the likelihood that a patient will develop dangerous clots) into an electronic format that would work within the EHR framework.

Challenge: Educating busy caregivers

Solution: To help educate clinicians, Texas Health sponsored a live continuing medical education presentation by a nationally renowned expert, followed by e-learning modules. In addition to those learning opportunities, the organization provided technical instruction through tip sheets and online demonstration videos.

Challenge: User adoption

Solution: Chief quality officers were engaged to answer questions regarding clinical issues while IT staff handled technical concerns.

HIT Leads to Quality Gains
“The primary key for our success is our strong belief in the use of the electronic health record to help advance quality and patient safety,” Velasco says. “We began implementation of the EHR throughout our integrated delivery network in 2006 and now have more than 4.7 million electronic patient records. Our early adoption of the EHR led Texas Health to become one of the first health systems nationally to demonstrate achievement of stage 1 meaningful use requirements and receive federal Medicare and state Medicaid incentive payments.”

The results of the electronic VTE protocol speak for themselves. Since the quality improvement program’s inception, Texas Health has seen more than a 20% reduction in postoperative pulmonary embolism/deep vein thrombosis. In addition, it’s made clinical staff more aware of the harm that the condition can cause.

“We’ve seen an increased utilization of VTE prophylaxis using standardized VTE risk assessment tools and evidence-based order sets. Prior to this implementation, VTE prophylaxis could be overlooked,” Velasco says. “Now clinicians either use the order set or document the reason it wasn’t used.”

Integrating the VTE risk assessment application with the EHR increases the technology’s value and illustrates Texas Health’s ability to improve quality, which increases its chances of qualifying for federal incentives. Workflow has also received a boost.

“There are improved efficiencies,” Velasco says. “Time is saved as 25% of the VTE risk assessment is autopopulated with patient data and calculations are made electronically. Clinicians no longer manually complete paper assessments and manually compute scores. It is done automatically.”

Finally, Texas Health has enjoyed the benefits of collaborative information sharing and a standardization of best practices. “Since VTE risk assessment results are stored back into the EHR, this information is accessible by any other clinician who is treating the patient,” Velasco says. “Rather than clinicians using a variety of VTE risk assessments, now our clinicians are using a standardized, evidence-based VTE risk assessment tool.”

— Maura Keller is a Minneapolis-based writer and editor.