“The patient in Cubicle A is fasting.”
“Remember to phone the ward back.”
“The patient on the third trolley in the back corridor needs to be taken down to X-ray.”
“The bloods on John Smith are overdue.”
In the hectic environment of emergency departments all over the country, critical patient information is handwritten on whiteboards and post-it notes, stored in the harried heads of overworked nurses and doctors, and passed on verbally between members of the emergency team. Incredibly, such practices are still the norm in this digital era.
There are only three digital hospitals in Ireland – the private Galway Clinic, St James’s Hospital in Dublin and Cork University Maternity Hospital (CUMH). And Ireland is one of the last first-world countries not to have a national electronic health record (EHR).
Air traffic control
At St James’s, the emergency department is bringing technology to the next level. It may be the largest and one of the busiest in the country, but thanks in part to new technology, patient flow has become more visible and easier for staff to manage.
Dr Geraldine McMahon, consultant at St James’s emergency department, is delighted with the new system .
“As a consultant in the department, I have a very clear visibility of the clinical picture in the ED on a day-to-day basis, as do all the other members of the team, including doctors, nurses, healthcare assistants and catering assistants. This high level of visibility allows us to make decisions more efficiently. One of the new system’s capabilities is to act like an air traffic control system enabling the management and clinical teams to optimise patient flow in a much more dynamic way.”
The new system is called LaminOS-ED and was developed in a partnership between a small Irish health informatics company called Centuri Analytics and the interdisciplinary accident-and-emergency staff and management team at St James’s.
Centuri Analytics founder and chief executive Stephen Brennan explains: “I had been advising hospital CEOs about the opportunities for using digital technology, and I couldn’t understand why there was plenty of technology supporting patient diagnostics, but so little technology in hospitals to help manage the actual journey of the patient as they make their way through the hospital system.
“No other service or business could operate like this. Take Amazon as an example. They could not co-ordinate the purchase of all their products and then manage the fulfilment, including transport and delivery, without digital technology. But with the right support technology they are able to provide a high level of service to millions of diverse customers with a relatively small staff.”
The Centuri team worked alongside the emergency department multidisciplinary team – doctors, nurses, healthcare assistants (HCAs), catering staff, physiotherapists, social workers and allied professionals – as well as the hospital’s administration, finance and operations departments, week after week, tweaking and adapting the technology solution based on the input of staff.
The result is software that reflects the actual day-to-day management support needs of the hospital team. Complex patient flows are modelled by gathering critical patient information from emergency department staff and combining it with data from the hospital’s existing Patient Information System (PAS) and Electronic Patient Records (EPR).
All of this information, including the patient’s name, exact location, age, complaint, doctor, arrival time and length of stay, is clearly visible on huge touch screens in the department that is used by all staff. The screens also show the status of blood tests sent to the labs, and orders for radiology, and so on.
As patients move from one area to another, the information follows by dragging their name and dropping it into the relevant area on the screen.
Neil O’Carroll, Centuri User Interface Developer, says it was vital that the system was easy to use as electronic projects fail largely due to lack of engagement with users.
“Most people are familiar and comfortable with smartphones and touch-screen devices and this is a very simple design with no training required. People no longer have to rely on their memory or a handwritten note for information or dive into menus for individual patients on an electronic system. By looking at the screen, they can see clearly where each patient is, what tests have been ordered and whether their results are in.”
Before the introduction of the new patient flow system, doctors had to log in every half hour or so and search for each patient individually to determine where they were and what their status was, for instance if their bloods were back or their X-ray had been done. Now, Dr Brennan says, they can just look at the screen and make immediate decisions.
“Instead of a lot of phone calls and handwritten notes being exchanged when a patient moves from one area of the hospital to another, a staff member can now just drag and drop using the touchscreen and all the relevant notes are available for the next step in the patient flow. We can also begin to predict and co-ordinate different actions in the hospital. For example, the diagnostic units can see incoming patients in advance, nurses can configure resources where they are needed and doctors can configure their teams.”
The intuitive system is colour coded so if a patient is waiting longer than the target time set by the hospital’s KPI (key performance indicator), they are coded red for overdue. If a cubicle has been used by a patient who is an infection risk, the system prompts staff to make sure the cubicle has been cleaned before moving another patient in.
Dr Brennan adds: “The software allows us to interpret targets in real time. It allows the whole hospital team to use patient flow as a shared objective and manage it in a consistent and relevant way. It facilitates real-time intervention to manage targets before it’s too late to do anything about it. We are making patient-centric information available in real time when the patient is in the ED so something can be done to prevent or minimise KPI breaches.”
Day and night, there is a constant move of patients through three different locations within the emergency department at St James’s and a constant flow of information being gathered and shared.
“The HCAs no longer get regular calls on the tannoy system to bring a patient to X-ray, or have to go running around the X-ray department writing on different boards. Everybody, can clearly see the name of each patient, and which division of the radiology department they need to go to, which makes their work a lot more efficient.”
Safety and efficiency
Dr McMahon says the new technology has been a huge step forward in improving the safety of clinical processes and the efficiency of handovers.
“We run consultant-led clinical handovers at intervals throughout the day where we regroup on every patient in the department. We had a process in place before, but now we have a lot more information readily available. Nursing handover is also much more efficient because the information required for safe and efficient handover is now readily available.”
While the long-term benefits of the new system have not yet been analysed in detail, Dr McMahon says that having such high visibility of critical patient information has led to positive behavioural changes in staff. There has been a 12 per cent reduction in unanswered phone calls and this, she believes, is because staff know that they can go to the screen and quickly find the information the person on the other end of the phone is looking for.
“We have the tools now to properly deal with a very important part of the patient experience which is communication – when you have the information, you can communicate,” she says.
Dr McMahon has also seen benefits in decision-making when people arrive in A&E and later around admission and discharge.
Another positive has been the improved morale of the team, says Dr McMahon. She says that the director of finance, Simon Moores and the hospital’s management team have all been very supportive of this new innovation.
“Obviously emergency overcrowding is very high on the public agenda. Finding a solution is complex, it’s an international issue,” she says. “ There are a number of critical components. Capacity is a big issue in an aging population and we need innovation in models of care and innovation that allow us to optimise our existing resources. Most innovation in ED has an impact across the hospital site.”
Dr McMahon says Dr Brennan and his team integrated the system seamlessly into the clinical world, pointing out that “translating what’s in a clinician’s head can be a challenge for an IT person”. She believes the system is an essential tool for emergency departments across the country: “A no brainer.”
Although still a small company, Centuri’s hospital-specific technology has been gaining attention and there is potential for the software to be applied more widely, in areas such as bed management, scheduling and discharge. The Emergency Task Force has been in to observe the system at St James’s as well as representatives from other hospitals .
“This has been a remarkable journey for us,” says Dr Brennan. “New technology is not high on the agenda of clinical teams, but the ED team at St James’s have been so excited and supportive about this project all along the way. The new system has made their job easier: they can now concentrate on fixing patients rather than worrying about where they are. At the end of the day, all they want to do is help make patients better,” he says.