Midstate Medical Supercharges Legacy Nursecall

Posted by: Kenny Schiff on June 25, 2012

Last spring Gary Blumberg at Midstate Medical Center (Meriden, CT) called to ask if there was a way to tweak their nursecall/Vocera workflow to accommodate staff members taking breaks or leaving the nursing unit. While I enjoy giving rapid fire sage wisdom to my customers, the answer was not as simple as having users pressing the DND button on their Vocera communication badge.

If you know anything about the way nursing units work, you will understand why what seemed like a relatively simple request turned into deeper discussions about nursecall workflow in general…

So if someone went to lunch, who should receive patient notifications? and what would happen if they were tied up with another patient. And how would that be different at night? or on weekends? And what if the nursecall was urgent? or trivial?

Turns out that in spite of Rauland’s Responder IV nursecall meeting their general needs, process wise no one at Midstate had really good handle on the rhyme or reason of its setup. And until Gary joined Midstate full time in 2011, there was no one with wherewithal or responsibility to cook up how calls could flow from patient to caregiver more smoothly and in a more meaningful way. Even something as simple as the significance of the colors that corridor lamps flashed outside patient rooms was a mystery to most clinical staff. No real knock on Midstate here, this is par for the course at most customers we visit with.

How Did they Handle the Break Issue?
I’m excited to share the details about how we worked with Midstate to solve the “what to do about breaks” workflow problem, but also how Midstate used this as an opportunity to provide a streamlined nursecall escalation process (with key failsafes built in), and to provide ongoing reporting on types of patient requests (and the amount of time it takes to close these).

Best part of this story is that Midstate has been able to leverage existing technologies without significant capital expenditure. No forklift platform upgrade required.

By shifting the call processing intelligence from their legacy nursecall to their Connexall workflow engine, Midstate is extending the useful life of an existing legacy nursecall platform. All this while improving patient response times and adding a layer of reporting and accountability that had not previously existed. Nothing really revolutionary here. Together we built something very smart and practical that didn’t requiring massive process re-engineering, without it costing a ridiculous amount of money.

Some Background
Midstate had been using Globestar’s Connexall alarm notification middleware to connect Responder IV with Vocera since March of 2007 (their initial launch was the first Connexall/Vocera integration anywhere). Prior to Vocera/Connexall, Midstate had used in-house pocket pagers (beepers) for receiving nursecall notifications with the workflow managed and orchestrated by their existing Rauland system. Before and after, the system was simple, easy to manage, and reliable.

Given the significant change management involved with their initial Vocera implementation as a whole, when Vocera badges were introduced the desire was to simply replace the beepers with badges workflow wise. A patient pushing their call bell would receive attention from the caregiver covering their room. Midstate kept everything flat, with no escalation involved, or differentiation of alarms. To keep things familiar, the assignment process was kept in the Rauland system. And even though they had the capability of calling back into rooms from Vocera badges, that functionality was never widely advertised.

CIO Jen Comerford always knew that they could do a lot more with what they had, she was just looking for the right opportunity and timing.  That opportunity came in 2012.

Good Bones Already in Place, But Still Room for Improvement
The building blocks of Midstate Rauland Responder IV System were originally put in place when the hospital established its new campus in 1998. In 2003, and then again 2010 it made the most sense for the hospital to add on to their Responder platform as new inpatient units and additional services were added. While an upgrade to a newer platform could potentially add some useful new features, changing out a nursecall (or “Call Bell” to the rank and file) system is not trivial, especially for a community hospital like Midstate.

Workflow wise, during most nursing shifts Midstate has operated using Triage/Dispatch model. A Clinical Information Associate (CIA) answers most nurse calls and then uses the Rauland console to dispatch a specific caregiver by choosing from a preselected list of “Service Requests” alerts that are then dispatched to caregivers covering the room that originated the request. For example, if the patient tells the CIA that they need pain medication, an alert is triggered to the RN covering that patient. If the patient needs help getting to the bathroom, the request is sent to the proper Clinical Care Associate (CCA). This methodology worked well for them with beepers and carried over with them to Vocera.

What had become clear over time was that there were incidences where a request had become forgotten or the covering staff member was not available or not properly assigned. This inevitably automatically triggered nurse call overtime alarms which needed to be silenced in the room by a staff member. As we looked at this, we determined that Midstate struggled with four major problems:

  • Excessive response times, sometimes for basic request like bathroom assistance, or worse for more critical needs like pain medication
  • Difficult to manage and awkward staff assignment process
  • Unnecessary alarm noise from patient or service requests that have not been responded to (and the nursecall system upgrades to “Overtime”)
  • Lack of data supporting where the bottlenecks or process disruptions were

With increased attention on life safety (e.g. fall prevention) and patient satisfaction scores due to adoption of HCAHPS driven surveys, the need to tighten up and perform better is on everyone’s mind. It was clear that Midstate had most of the components already in place to fix this.

Nursecall Integration Reinvented
As we looked at solving the problem technology wise, we knew that no one single component system would provide the solution. Rather the solution would be the sum of the parts (Rauland + Connexall + Vocera). We’d leverage what each system did well.

The first decision was to move the call processing that delivers alerts to nursing staff’s Vocera badges out of Rauland and place it in Connexall’s workflow engine. This gave Midstate enormous flexibility in tailoring escalation timing, alarm differentiation and ongoing nursecall reporting. Connexall’s hierarchical callpoint framework could catalog every type of nursecall alarm and give it specific behaviors. Connexall would keep track of every nursecall, its type, its originating location, and what happened all the way through cancellation. And because Connexall had visibility to the entire process end to end, it would be the backbone of the reporting engine.

Given its simplicity, ease of deployment, and the lack of additional costs required to deploy it, Vocera’s Connect Console application made the most sense for the staff assignment process. By placing the assignment process in Vocera, users would reap the benefits of Rauland and Connexall’s technologies without having to directly interact with any of the complexities behind it. Nurses and CCAs would continue to use Vocera badges as they always have, but we’d introduce some enhancements to the way alarms were displayed and could be interacted with. Midstate would also start introducing new Vocera B3000 devices into the mix which are better built for alarm integration (improved front-facing display and front-side alarm interaction buttons).

Vocera Connect Console

Workflow Modifications
Nursing determined that we would continue to the Triage/Dispatch model during times that a unit was staffed with a CIA. During those shifts, all nurse calls would go to the console with the CIA being the first responder. The original alerts would also go to a caregiver team (RN + CCA). If the alarm was not canceled within 90 seconds, then it would be escalated to a backup. Any staff member could “cancel” the call (and stop further escalation), by either talking to the patient (from the console or badge), or by going into the room and pressing the cancel button. During shifts where there was no CIA, the caregiver team would become the first responder without any modification to the system.

New Workflow for Patient Initiated Nurse Calls

If a CIA was in place to triage calls (day shift), then a “Service Request” would be sent to the appropriate caregiver. If the staff member was unavailable or tied up with another patient, the request could be escalated from the Vocera badge with a simple voice command or button press.

New Service Request Workflow

Behind the scenes we worked to synchronize the alert process so that any member of the workflow canceling the alarm would stop further escalation, but also remove the alert from all others who may have received it. We also created a mechanism that allows any member of the workflow to be bypassed if they are not available (e.g., on break, or at lunch).

Data = Knowledge
To get our new framework ready for production, we did extensive testing and validation. With most of the kinks worked out, Midstate trained all CIAs (in staff assignment), RN/CCAs in alarm integration and general nursecall. All RNs, CCAs, and CIAs are required to test out of the class to ensure consistent understanding of the nursecall response process. You can see the  excellent training video that Gary created to support the rollout here.

On April 3rd we launched to Midstate’s Pavilion 3E (an inpatient med-surge unit). Perhaps the most significant outcome of the initial rollout was the dialog between nursing management and staff regarding procedure. The new system immediately forced a discussion regarding operating issues that had previously not been discussed or adequately defined.

The good news is that the initial results are encouraging. The new framework has led to an immediate reduction in response times by 30 seconds.

Preliminary Results

Here’s a sample snapshot of data for a full day/night on 4/25/2012

Nursecall Distribution Chart

Update (6/26/2012): With 3E operating smoothly, the rest of the nursing units have progressively been rolled out. June 25, 2012 the final 2 nursing units and the Emergency Department went live to complete the project’s launch.

Some Final Thoughts
While it is way too early to claim complete victory, there are a few fundamental outcomes we can be certain of that will lead to improved patient care and safety at Midstate.

  1. Defined and Documented Workflow—All nursecalls have a defined destination that includes multiple backup layers and failsafe escalation to a responsible managerial member of the team. Even if responsible caregivers are somehow not available, the system will properly distribute calls to the proper backup entities.
  2. Improved Understanding of Patient Response Process—Nurescall workflow has been clearly defined and communicated to the entire clinical staff through a well designed and executed training program that will now be built into orientation and ongoing staff development.
  3. Ongoing Performance Data is Easily Available—Nursecall performance data is available to management via a push mechanism. It is easy for managers to compare results from week-to-week, day-to-day, shift-to-shift. Additionally, should there be a patient/family complaint, or an incident, it is easy to drill down into the data to review actions based on room location and time. The reporting process doesn’t require IT or other support services to execute.
  4. New Workflow Didn’t Require Complex Operational Changes—Assigning caregivers (and backups) to room/patients is an easy process that gives immediate visibility to who is assigned where. Users now have more meaningful alerts on their devices and the ability to easily escalate or rollover calls to team members

and last, but not least

  1. A process for handling breaks
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