Clinical Workflow Improvements with Technology Upgrade

Report
St Mary’s Hospital for Children
Bency Mathew RN
Director of Clinical Informatics
Steve Massinello
Director of Clinical Systems
Clinical Systems Integration
Clinical Workflow Improvements with
Technology Upgrade
St Mary’s Healthcare System for Children
- St. Mary’s is a not for profit pediatric healthcare system
- Began serving children in 1870 with a 15 bed hospital in NYC
- In 1951 a 97 bed Inpatient post acute pediatric hospital was
constructed
- Serves 4000 kids per day between inpatient, homecare and
daycare programs
- We service medically fragile children with complex needs
- Meditech 6.0 site
Challenges
• Outdated technology limitations caused delay in
communication to clinicians. This lead to a delay in
patient care.
• Increased downtime in previous alert notification
system caused interruption in patient care.
Systems Implemented
and Integrated
•HP wireless
•Rauland Responder 5 Nurse Call System
•Masimo Patient Monitoring System
•Vocera VOIP Communication
•ShoreTel Phones
•Connexall Middleware
Vocera VoIP P2P Communication
• Vocera makes communication possible anywhere at anytime in the hospital.
Vocera badges communicate P2P via our wifi network. Nurses, RTs and CNAs must
log in and out during their shift to be able to receive calls and alerts. They are also
assigned to patient rooms.
Vocera badges hang around your neck and can receive Vocera to Vocera
communication, phone calls from inside or outside the hospital, alerts via Connexall
from Masimo devices, the Nurse Call System, ventilators and Meditech lab results.
The badges act as hands free phones or walkie talkies that can receive voice
commands.
Vocera uses a web based system to assign Nurses and RTs to rooms and units, if
they are not assigned correctly, they do not get alerts.
Rauland Responder 5 Nurse Call System
Responder 5 Nurse Call System sends urgent and non-urgent alerts to our
clinical staff.
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Wall panels are equipped with a Code Blue button, a staff assist button, a house keeping
button and a 30 min staff reminder button, which we are currently using.
Wall panels are located in each patient room on each unit. In addition, there are AUX jacks
via a separate wall panel that we monitor ventilator equipment. There is also a patient
call/TV remote that plugs into the wall.
Additional wall panels are located on the ground floor in our rehab areas.
Pull strings are located in bathrooms and showers on each floor.
Each alert sends text to voice alerts to Vocera badges for our clinicians, who respond to
provide patient care.
Configuration managed by our IT dept, no direct user access defined.
Masimo Patient Monitoring System
The Masimo patient monitoring system allows St Mary’s to keep a close
watch on our patients by monitoring their vital signs closely.
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Device: Masimo Rad 87connects wirelessly to HP Access points.
There are Rad 87s in every patient room in the hospital.
The Rad 87 is mobile and has an internal battery so it allows the device to follow the patient
around to monitor vital signs when they are out of their room.
The vital signs are communicated back to Masimo’s servers and viewable on the Patient
Safety Net Workstations, placed on each floor.
Critical vital sign levels are communicated via text and text to voice alerts directly to the
clinician’s Vocera badge worn around their neck at all times they are caring for patients.
Masimo – View Station Monitor
Vocera VoIP P2P Communication
Vocera makes communication possible anywhere at anytime in the hospital.
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Vocera badges communicate P2P via our wifi network. Nurses, RTs and CNAs must log in
and out during their shift to be able to receive calls and alerts. They are also assigned to
patient rooms.
Vocera badges hang around your neck and can receive Vocera to Vocera communication,
phone calls from inside or outside the hospital, alerts via Connexall from Masimo devices,
the Nurse Call System, ventilators and Meditech lab results.
The badges act as hands free phones or walkie talkies that can receive voice commands.
Vocera uses a web based system to assign Nurses and RTs to rooms and units, if they are
not assigned correctly, they do not get alerts.
Vocera – Staff Assignment
The charge nurse on each unit is responsible for entering Primary Nurses,
Nurse Buddies, CNAs, Charge Nurses and Respiratory Therapists into Vocera’s
web-based assignment interface.
Vocera Call Flow Path
ShoreTel IP Phone System
ShoreTel is an IP phone system that St Mary’s uses in the hospital and at other
locations.
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Internal and external hospital communication with all the standard features.
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Users are able to call Vocera badges from inside or outside the hospital.
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ShoreTel connects to our overhead PA system and by dialing 5555 emergency
announcements are made, like Code Blue, Code Red, etc.
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ShoreTel integrates with Connexall to communicate with Nurse Call and Vocera.
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ShoreTel will receive Nurse call Code Blue alerts and announce them over the PA System
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Configuration managed by our IT dept, no direct user access defined.
Connexall Middleware
Connexall is the “middleware” that makes our integration possible and runs
seamlessly behind the scenes.
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Connexall integrates with our vital clinical technology to help us maximize our quality of care
by giving us a direct link to our patients.
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Connexall integrates with Vocera, Rauland Nurse Call System, Masimo and our LTV
Ventilators.
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Configuration managed by our IT dept, no direct user access defined.
Integration Workbook
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The systems integration workbook was used as a guide to help St Mary’s define the
escalation path of alerts
Level system used to set alarm path in Connexall
For example the pulse oximetry alarm path
Level 1-Primary Nurse – no response for 75sec or Escalation
Level 2- Nurse Buddy – no response for 75sec or Escalation
Level 3- Charge Nurse\Respiratory Therapist – no response for 75 or Escalation
OT- Loops to Charge Nurse/RT until answered
Previous System and Workflow for Pulseox Monitoring
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Web based central monitoring system integrated with Masimo.
One PC and monitor display at each nursing station
Post-sentinal event, the system was upgraded to use pagers to send alerts to
assigned nurses.
In addition, a new position was created, (6 FTE) Monitor technicians were
assigned to watch the displays around the clock.
The responsibilities of this position included calling the nursing station of the
unit from where the alert initiated from, if no response, and condition not
corrected they were instructed to page a code blue overhead.
They documented each alert as it happened, info collected: unit, name, time,
date, alert type, duration, staff.
Case Study #1Ineffective Workflow
Patient had a sudden drop in oxygen level. The alert reached the Primary nurse and
there was no response. The alert auto escalated to look for level 2 which is the nurse
buddy and there was no response. The alert then auto escalated to level 3, the charge
nurse and Respiratory therapist on duty assigned. Respiratory therapist acknowledged
the message.
New alarm of Low Heart Rate reached the primary RN and she acknowledged the
message and went to patient bedside. Staff Assist from nurse call system was initiated
at 6:05am instead of Code Blue.
Case Study #1 Alerts
First Alerts was Low SP02 levels
REPORT INTERPRETATION FOR CODE BLUE (S.H.)
Report ran from Connexall from 0500-0700 from Rm NUR 220A
5:58:31- Initial SPO2 LOW=79
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Level 1-Reached Primary RN’s Vocera badge at 5:58:32 – No response
Level 2- Attempted Nurse buddy’s badge at 5:59:45 – No Badge available (possible not in
assignment)
• Level 3- Reached Charge RN’s Vocera badge at 6:01:03 (No response) and reached RT ‘s badge at
6:01:03
RT acknowledged message at 6:01:24
Case Study #1 Alerts Cont’d
2nd Alert was low perfusion
6:02:00- HR=37 with low perfusion
• Level 1- Reached Primary RN’s 6:02:01. RN Acknowledged at 6:02:09
Staff Assist button from Nurse call initiated at 6:05:37
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Level 1- Primary RN’s Vocera badge at 6:05:39. RN escalated to Level 2
Level 2- No badge avail. Possible not in assignment
Level 3- Charge Nurse received on badge 6:06:55. Charge Nurse call back into the room
immediately.
Level 3 OT- Staff assist over time after 5 min reached RN Supervisor . Due to staff assist not
being cancelled at bedside.
Case Study #2 Effective Workflow
System integration functioned as desired for the clinical workflow as it supported the
staff in attending to critical alerts in a timely manner.
Nurse received a high heart rate alarm on her Vocera badge and she entered to room
at 12.05pm to check patient. The patient was positioned and heart rate returned to
normal. At 12.35pm, the patients oxygen level dropped suddenly to 59%. This is
critically low and the alert reached the badge 12.35pm. She rushed to the room and
instructed the Unit Clerk to page CODE BLUE overhead. Clinical team responded for
medical intervention.
Play video
Case Study #2Report
REPORT INTERPRETATION FOR CODE BLUE (J.A)
Report ran from Connexall from 12:05 PM through 1:00 PM for RM NUR 204P
12:05:40p- Initial PR HIGH=163 (Normal Range 120-160)
• Level 1- Reached primary RN’s (M.K) Vocera badge at 12:06:59 PM. User acknowledged
message at 12:07:08 PM.
12:35:08p- Initial SPO2 LOW=59 (Normal Range 93-100)
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Level 1-Reached Primary RN’s (M.K) Vocera badge at 12:35:41 PM – Looked at badge and
responded immediately. Called for help and instructed Unit Coordinator to page
overhead “CODE BLUE” to get more medical support at 12:36:42 PM.
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Case Study #2- Connexall Report
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Case Study #2- Vocera Report
Case Study #2- ShoreTel Report
The ShoreTel call report, let us piece together when the code was called over the PA system.
We used this report to determine when the Code Blue was called and match it to the account of the event.
Masimo – Trend Analysis Report
Captured the severe dip in SPo2 levels consistent with the Connexall report
Additional Connexall Integration
– Code Blue to Vocera Badges, ShoreTel Speaker
Phones and Overhead
– Lab Results to Vocera Badges
– Fire Alarm System
Down systems email alerts (Server crash, network
down)
Meditech EMR Lab Alerts
Meditech is St Marys’ inpatient electronic medical record.
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Medical providers enter Lab and Microbiology orders in OM, which cross over to the Lab
Module, an HL7 message is sent to the Vendor Lab. The results are sent back to Meditech
which then files into the EMR.
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Core lab will identify Critical lab results and send the message back to Meditech and
Connexall simultaneously. Connexall will take this message and send it to the Vocera
badge of the Ordering provider and the Attending physician for that patient.
Overhead Paging System
Code Blue Alerts will be announced over the paging system
1. Code Blue button pressed in patient room or in other areas of the hospital
2. Alert goes to Vocera badge
3. Instead of a manual call to the paging system, Connexall accesses the paging system and
makes the announcement via a text to speech engine, announcing the floor, and room.
Thank you

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