Professional Documents
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Issue Brief
by 2012.1 Adding new physical capacity is often There are a moderate number of RTLS vendors.
out of the question. In some urban areas, the They differentiate themselves by the underlying
estimated cost of adding physical capacity can technology they use (e.g., radio frequencies,
exceed $1 million per bed. For a facility with an infrared light, ultrasound), although at the user
average length of stay of five days, each additional level they are roughly equivalent. There are only a
bed accommodates only about 70 extra admissions few vendors of integrated software-based patient
annually.2 flow solutions, and they are fragmented. Few large
clinical vendors offer inpatient tracking solutions,
Rather than increasing physical capacity to meet which tend to be very similar in features and
growing patient volumes, hospitals can increase functionality.
their service capacity by improving their ability
to move patients through the treatment system, The benefits of implementing patient flow
a measure known as “throughput.” New patient solutions are fairly well documented. They include
tracking technologies help caregivers work more increased throughput, decreased average length
efficiently by providing them with real-time of stay, improved recording of treatment costs
information on patients and updates about labs, (charge capture), fewer ambulance diversions,
orders, and other notifications that are crucial and higher patient satisfaction ratings. Some
to their workflow. Patient tracking technologies industry analysts have characterized the net gains
provide information to improve the “flow” of generated by patient tracking systems as moderate,
patients in the emergency department (ED), the particularly for RTLS-based ones, which can entail
inpatient setting, and by increasing the number a significant upfront investment in hardware (e.g.,
of acute care transfers coming into the facility.3 sensors, tags, and devices on the network).
Use of technology to improve patient flow in the
inpatient and outpatient surgical environment is The success rate for patient flow technologies is
uncommon. unknown, but implementations are considered
relatively straightforward, low-risk, and highly
Inpatient tracking systems are technology-based customizable to fit the needs of organizations.
solutions used to improve patient flow in hospitals.
Some solutions provide information about patients Regardless of the technology chosen, it is crucial
through the use of real-time location systems that hospitals also carefully review key processes
(RTLS), while others use a combination of existing and workflows. Good change management A pril 2011
practices dictate that this should always be done, but This issue brief examines the technologies and techniques
patient flow is an especially sensitive area. The review that are helping hospitals improve their patient
may include process redesign, workflow optimization, the throughput in this demanding environment. The analysis
application of Lean Manufacturing principles, predictive also touches on industry adoption, implementation
modeling, or the use of simulation tools. decision factors, and benefits. The brief ends with a series
of short case summaries showing real-world use of these
The solutions on the market today are automated and technologies.
passive, so they require little additional attention from
staff. RTLS-based systems track location automatically. Technologies for Improving Patient Flow
Integrated software-based systems pull data primarily This examination organizes patient tracking technologies
from existing clinical information sources. The important into two categories: (1) those that use real-time location
thing for hospitals to recognize is that low patient systems (RTLS), and (2) those that use existing event-
throughput can be caused by many factors, and that they driven data. The two approaches are complementary, not
should understand the underlying processes and measure mutually exclusive. In addition, for either approach to
what they want to manage. succeed, it needs to be implemented as part of a broader
effort to review processes and optimize workflows.
Best practices for improving patient flow with technology Figure 1 (page 3) shows how these approaches interrelate.
include:
Tracking assets
Tracking staff
Data entered by upstream
partner (e.g., transfer center)
Process optimization
primarily in cost, infrastructure requirements, and Patient tracking systems communicate with the hospital’s
precision.4 They are roughly equally suitable for patient information systems, including the bed management
flow initiatives. system, through the automated exchange of messages
using the HL7 standard. This provides data to decision
The practice of using of RTLS to track patients is makers, which enables them to make informed decisions
relatively new and not widespread. Systems that track about patient admissions and placements. Bed managers
patients this way record patient locations, times, can see which units have available beds and what the
characteristics (e.g., fall risk, selected diagnoses), and expected wait times are for dirty rooms to be cleaned.
status (e.g., waiting for x-ray, ready to be discharged).
Real-time information is typically overlaid onto a drawing The ability to track patients means that any patient can
of the floor plan of a given unit. Physicians, nurses, other be located in the facility at any time. This saves staff the
caregivers, and members of environmental services staff time they normally spend looking for patients who may
can refer to this “electronic whiteboard” for the latest have been brought to another department for a test or
status, location, and indicators for each patient. imaging, or who may be walking about to see visitors or
In hospitals today, RTLS is more commonly used to track Patient Tracking Using Event-Driven Data
equipment and staff than to track patients. However, Another approach to improving patient flow is to track
the former also improves flow by speeding the ability to patients by deducing their location through changes in
locate key equipment used to move or discharge patients, their last-known status. Some tracking systems require
such as wheelchairs and portable IV pumps, and by staff to make manual entries to record that a patient has
more quickly alerting nurses and environmental services moved from one room to another. Other systems import
personnel to needs that arise.6 Studies have shown that event-based data automatically from hospital information
nurses spend up to 48 percent of their time managing systems (e.g., ADT, lab, radiology, PACS, and CPOE). If
supplies, tracking down equipment, doing paperwork, a patient’s record shows that an x-ray has just been taken,
directing other staff, and handling admissions and that patient can most likely be found in the radiology
discharges.7 RTLS helps recover a portion of that lost department.
time.
The ability to accept data and messages in standardized
Albert Einstein Medical Center (AEMC) in Philadelphia formats such as HL7, Observational Report/Unsolicited
is an example of a facility that uses RTLS to locate (ORU), and General Order Message (ORM) is a universal
patients, employees, and medical devices. AEMC uses capability across vendors in this space. (HL7 is the main
ultrasound tags from a hardware RTLS vendor coupled message format; ORU and ORM are generally used only
with tracking software from a patient tracking vendor to communicate orders and allergies.) Almost all systems
to monitor people and assets across its campus. Every allow users to make manual updates and for data to be
patient who comes into the ED receives a tag, as does all imported. Vendors have designed their systems to work
equipment essential to patient transfers. The nursing units with as little duplicate data entry as possible.
and ED display the real-time information on electronic
“scoreboards.”8 Whereas EMRs are designed to drill down into the
records of a single patient, tracking systems emphasize
Another benefit of implementing real-time tracking is visibility and provide a broad, quick, dashboard-like
detailed reporting. Doctors can receive automatically snapshot of what is going on with all the patients at a
generated reports showing the number of patients treated given time on a given floor.
by the physician, the time it took to treat those patients,
how often each person was visited, the length of time Hospitals can use color, highlighting, and icons to convey
before each was discharged or moved out of the ED, and different information. They can also set timers to trigger
more.9 This level of detail is difficult to obtain through events such as discharge and configure the system to
any other means. email, text message, or page staff.
UCSD will use the results of their studies to determine ◾◾ Automatically generated interaction reports and
whether to continue, and perhaps expand, their use of
increased accountability;
the tracking systems.
◾◾ Improved performance with accreditation agencies
and quality measures;
If considering an RTLS-based patient tracking solution, Best Practices for Implementing Patient
the main implementation decisions will involve the Tracking
technical details of the transceivers, network devices, To implement patient flow technologies successfully,
and tags.39 Some transceivers plug directly into standard organizations first need to view patient flow as a system-
electrical outlets and communicate wirelessly with wide phenomenon requiring system-wide attention.
devices housed in existing network equipment closets. By Consider using a cross-functional, multidisciplinary team
contrast, infrared RTLS systems require a transmitter to to analyze key processes and identify opportunities for
be installed in the ceiling of each room for which coverage improvement. Once traditional process improvement
is desired. All RTLS patient tracking systems also involve methods have removed broken processes, then technology
the issuing and managing of physical tags, whether worn solutions can be introduced that will help caregivers
around the neck, integrated into a wristband, or attached move patients through the facility safely, effectively, and
to the patient chart and moved around with the patient. efficiently.
1. R
TLS-Based Tracking for Patients, Staff,
Now the location of patients, staff, and equipment are
and Equipment
tracked in real time. When patients arrive at the ED,
Christiana Hospital (Newark, DE)
they receive a small badge that clips to their clothing. As
Context and Objectives patients move from one room or department to the next,
Christiana Hospital is a 913-bed facility in Newark, clinicians view the updates on a map of the building. Key
Delaware, and home to the only Level I Trauma Center information such as patient acuity levels and isolation
on the East Coast corridor between Baltimore and codes are always visible to any caregiver who looks at the
Philadelphia. In 2003, the hospital started to see large display.
increases in the number of patients it served. The effects
of rising demand were felt in the ED and the inpatient The high level of integration between the systems helps
units. Patients were increasingly becoming difficult to Christiana to optimize patient flow from the time that
keep track of. Family members were occasionally told the patients enter the ED through the time they are placed in
wrong floor or room number. Physicians working with an inpatient bed. Information is updated automatically as
old information could not find their patients. Transport bed assignments are made.
services would arrive with a gurney or a wheelchair and
not be able to find the right patient. Results
Christiana’s ability to manage patient flow improved
At the time, Christiana had a basic tracking system that noticeably. The hospital has experienced reductions
relied on manual input, but it was not very accurate. in patient visit length, reductions in patients leaving
Caregivers tried to deduce patient location based on without being seen, and improvements in patient
patient status recorded in charts (e.g., last caregiver and staff satisfaction. In the 12-month period after
seen), but records often lagged patient movement. Data implementation, the average time to be treated and
fields that were not updated automatically tended to be released was reduced by 14 minutes, and average time to
unreliable, as manual updating took a back seat to direct be treated and admitted was reduced by 36 minutes.
patient care.
Post-implementation data show that during the first flu
An audit revealed that the patient locations contained in season after implementation, patient turnaround time
the patient tracking system were accurate just 80 percent in the ED decreased 5 percent despite an increase in
of the time. The rest of the time, clinicians needed to volume of over 7 percent. The number of patients who
make multiple phone calls or walk the hallways to locate left the ED without being treated fell by 24 percent, and
admitted patients. With this in mind, the hospital set out patient satisfaction rose. ED availability also improved:
to find a solution that would bring more automation to The number of hours that the hospital was diverting
their patient tracking process.
Derek Berz
Assistant Administrator
Providence Holy Cross Medical Center
Mission Hills, CA
Kay Buchwald
Clinical Systems Manager
St. Vincent’s Hospital
Birmingham, AL
Leslee Gross
Director of Transfer Center
Baptist Health South Florida
Doral, FL
Tom Hamelin
Senior Vice President of Business Process Improvement,
Awarepoint
(Former Associate Administrator, UCSD)
San Diego, CA
Linda Jones
Vice President of Emergency, Trauma, and Aeromedical
Services
Christiana Care
Newark, DE
Scott Williams
Vice President of Operations
Mercy Hospital
Toledo, OH
Diane York
ED Health Care Program Analyst
Santa Clara Valley Medical Center
Santa Clara, CA
Co n t a c t I n for m a t i o n V e n d or C a t e g ory
6. Swedberg, Claire. “Trident Health System Boosts Patient 2 1. HIMSS Analytics. RFID Patient Tracking Market Share
Throughput, Asset Utilization.” RFID Journal. April 21, Report (Custom Report by Product). July 2010.
2010 (www.rfidjournal.com).
2 2. Runyon, Barry et al. Hype Cycle for Healthcare Provider
7. Institute for Healthcare Improvement. Transforming Care at Technologies and Standards, 2009. Gartner. July 28, 2009
the Bedside. Cambridge, MA: 2004 (www.ihi.org). (www.gartner.com/DisplayDocument?id=1098412).
8. Bacheldor, Beth. “Philly Hospital Uses RTLS to Track 2 3. Agency for Healthcare Research and Quality. Patients
Patient Flow, Care, and Training.” RFID Journal. May 29, Admitted to Hospitals on a Weekend Wait for Major
2009 (www.rfidjournal.com/article/view/4934). Procedures. March 4, 2010 (www.ahrq.gov).
3 1. Ibid.