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RFID-initiated workflow control to facilitate patient safety and utilization efficiency in operation theater
c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 1 0 4 ( 2 0 1 1 ) 435–442
journal homepage: www.intl.elsevierhealth.com/journals/cmpb
RFID-initiated workflow control to facilitate patient safety and utilization efficiency in operation theater Charles C.H. Liu a,b , Chia-Huang Chang c , Mu-Chun Su d , Hsueh-Ting Chu a , Sheng-Hui Hung e , Jau-Min Wong b , Pa-Chun Wang c,e,f,∗ a
Information Technology Department, Cathay General Hospital, Taipei, Taiwan Institute of Biomedical Engineering, National Taiwan University Hospital, Taipei, Taiwan c Outcomes Research Unit, Cathay Medical Research Institute, Taipei, Taiwan d Department of Computer Science and Information Engineering, National Central University, Taoyuan, Taiwan e Quality Management Center, Cathay General Hospital, Taipei, Taiwan f School of Medicine, Fu Jen Catholic University, Taipei, Taiwan b
a r t i c l e
i n f o
a b s t r a c t
Article history:
Objective: To control the workflow for surgical patients, we in-cooperate radio-frequency
Received 4 December 2009
identification (RFID) technology to develop a Patient Advancement Monitoring System
Received in revised form
(PAMS) in operation theater.
16 August 2010
Methods: The web-based PAMS is designed to monitor the whole workflow for the handling
Accepted 27 August 2010
of surgical patients. The system integrates multiple data entry ports Across the multi-
Keywords:
digital assistance (PDA), ultra-mobile personal computer (UMPC), or traditional keyboard
functional surgical teams. Data are entered into the system through RFID, bar code, palm Active RFID
at designated checkpoints. Active radio-frequency identification (RFID) tag can initiate data
Workflow control
demonstration on the computer screens upon a patient’s arrival at any particular checkpoint
Web-based database
along the advancement pathway.
Patient safety
Results: The PAMS can manage the progress of operations, patient localization, identity
Efficiency
verification, and peri-operative care. The workflow monitoring provides caregivers’ instant information sharing to enhance management efficiency. Conclusion: RFID-initiate surgical workflow control is valuable to meet the safety, quality, efficiency requirements in operation theater. © 2010 Elsevier Ireland Ltd. All rights reserved.
1.
Background
According to the report of National Patient Safety Foundation, over half of the medical errors might stem from peri-operative care; surgery-related errors are the second most frequent cause to error-related death [1]. Drug administration error, wrong patient, incorrect surgery, and wrong surgical
site are the most frequent peri-operative procedures causing human injury [2–4]. Peri-operative setting would include “preoperative assessment”, “management of associated medical conditions” “preparation for surgery”, “choice of anesthesia”, “monitoring of sedated patient”, and “care of sedated or resuscitated patient”, in which every step is crucial to patient safety and is vulnerable to errors owing to the complex nature of care processes. Therefore, workflow control for surgical patients
∗ Corresponding author at: Quality Management Center, Cathay General Hospital, 280 Sec. 4, Jen-Ai Rd., 106 Taipei, Taiwan. Tel.: +886 2 27082121x3364; fax: +886 2 66362836. E-mail addresses: [email protected], [email protected] (P.-C. Wang). 0169-2607/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.cmpb.2010.08.017
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Fig. 1 – Patient advancement monitoring workflow.
is important to operation theater utilization efficiency and is critical to patient safety [2–10]. To handle the complex processes, the evolving radiofrequency identification (RFID) technology can be applied to improve peri-operative management with its unique capabilities of identification, locating, and tracking [11–13]. RFID, with its unique properties, has been wildly applied into many industries [14,15]. When used in the healthcare industry, the technology is valuable to help healthcare providers in meeting Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) patient safety goals – in which correct patient identification ranks as top priority [16,17]. Furthermore, patient tracking with instant information sharing from electronic health records (EHR) systems are both auxiliary to quality and safety management. Chang et al. surveyed the status of RFID applications in medical safety in Taiwan by questionnaires [18]. The RFID applications were discussed on operational structure benefits, users’ structure benefits, and organizational and environmental benefits. The authors concluded that the benefits of data integration are the most significant, and the facilitation of medical safety is still in evaluation and developmental stage, compared to the mature applications such as inventory, asset, and personnel tracking. RFID application in peri-operative setting was discussed only recently [18,19]. Nagy et al. reviewed the applications in surgical settings in three domains – workflow tracking of assets and staffs (productivity), medication and inventory supply chain (cost control), and patient tracking (safety). The
additional benefits of RFID lie on the interfaces among the three domains, such as the patient identification between the asset and patient domains, or the stock supply between the inventory and patient domains [19]. To improve management competency and to enhance patient safety, we address the issue of data integration by tracking the whole surgical workflow in the peri-operative settings in using radio-frequency identification (RFID) technologies to develop a Patient Advancement Monitoring System (PAMS). The project is constructed simultaneously with the implementation of our electronic medical record systems related to operative theater, including etransformation of many medical, nursing, aesthetical, and surgical paper forms, and concurrently with a bar code-based inventory management system of our operating instrument. The staffs of our Surgical and Anesthesia Departments view the PAMS project as the e-platform of a continuous quality improvement of the whole operative team. So the project increased in scope due to ever-growing user demands after implementation of the initial integration scheme.
2.
Methods
The pilot study was conducted from August 2007 to July 2008 in the Cathay General Hospital, a near-800 beds medical center located at downtown Taipei in Taiwan providing comprehensive acute care services, including major cardiac
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Fig. 2 – RFID wristed tag and reader.
and neurological surgeries; 14 operation rooms (OR) support 25,000 surgeries annually. The prototype of PAMS was formulated based on the existent peri-operative environments in the research hospital. The OR, surgical, emergency room (ER), anesthesia, and nursing staffs and managers were consulted to understand their demands on data collection and management. Active RFID was chosen for the additional benefits over the bar code identification system. When the patients were advanced into each station, the RFID readers on the ceilings identified the entry automatically, without the need of alignment of traditional wrist bar code tags for scanning. Subsequent patient identification and data entry could be confirmed according to the workflow based on the basic location information of the patients in the current station. Prior to the implementation, system analysis of the workflow for surgical patient was detailed through more than 30 group meetings and interviews. There are around 20 checkpoints identified to serve as data entry ports from ward to OR. The workflows would start from ER, surgical ward, or OR front desk (ambulatory surgery) to end at the recovery room (Fig. 1). Surgical patient would start to wear active RFID wristband tag (SYTAG245-TM-B01) at starting points. RFID readers (SYRD245-1N) are placed on the ceilings of various checkpoints to calculate and analyze signals emitted from active RFID tags (frequency 2.4 GHz with transmission range up to 80 m) (Fig. 2). In this study, the RFID readers were placed in distances larger than 15 m from each others, due to demographical distances between the ward stations, the OR front desk, and the operating rooms. The problem of interference was only encountered in the initial period between the readers of the two nursing stations of the adjacent floors, which was soon resolved after change of the direction of the antenna. PAMS system is developed on a J2EE-based (Java 2 Platform, Enterprise Edition) application and constructed on Apache WebSphere platform using Microsoft SQL, Java, JSP (Java Server Pages), and Java Script. The web-based PAMS SQL database is designed to link with hospital information system (HIS). Operation schedule, care process, patient identification information, and anesthesia data are entered into the database at various checkpoints along the patient advancement pathway. The data ports, including RFID, bar code, PDA, and UMPC are chosen, considering the convenience of field employees at designated checkpoints (Fig. 3). Middleware can support 1–256
different regions, update its position in 1 s to show information in the control interface, and can support up to 256 labels with accuracy within 2 m. For patient identification, the alert prompt of the arrival of a new patient at the checkpoint needs to be confirmed by the staffs. Then the detailed information of the patient was automatically loaded, and was displayed to support working flow at the current station. All OR team members (surgeons, residents, nurses, anesthesia team members, ancillary support members) were required to performed “sign-in”, “time-out”, and “sign-out” as recommended by the WHO Surgical Checklist [20]. Anesthesia team was in charge of “sign-in”, and OR circulating nurses, “sign-out”. The information based on the WHO checklist was shared to each other, avoiding duplicated work, on the webbased system. The staffs just browse along the lists, and “sign” in the respective button on their web pages. The data were entered into the PAMS for audit. The PAMS inventory management system was developed independently with the existing inventory system in the hospital information system. PAMS managed the specialized operative instruments owned by the operative theater. Bar code labeling was chosen for its cost-effectiveness and efficiency in the logistic management. The staffs scanned the bar codes manually, and the inventory was recorded into their specific operation records. The instrument packages are tagged with bar codes after sterilization, as so the logistic records can be loaded into the PAMS. During the implementation process, we conducted user satisfaction survey by evaluating the convenience, efficiency, use-friendliness, and feasibility of the PAMS. Inventory management data were also retrieved from the system for analysis.
3.
Results
The benefits of RFID integrated workflow management could be addressed in the fields of patient tracking, inventory management, and quality monitoring.
3.1.
Patient tracking in PAMS workflow
Patient’s location can be tracked and displayed on the PAMS automatically. Nursing staff checked and verified whether
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Fig. 3 – Data flow and information sharing in the PAMS.
surgical patient ID and records correctly registered in the PAMS system. RFID tag is also used to initiate data demonstration on the computer screens upon a patient’s arrival at particular checkpoint along the advancement pathway (Figs. 4 and 5). Ward nursing staffs can complete pre-operation evaluation in the PAMS, then send message to OR and dispatch center through the system when patients are ready for escort. Messages from different wards will pull together on dispatch center’s message board. A flash light alert system is built to notify the incoming new escort request messages. Through the operation of this system, dispatch center can manage their escort teams to reduce considerable daily phone-answering workloads (7–800 escort requests phones per day).
When surgical patient arrives in the OR waiting area, the receptionist can use the PAMS to verify patient’s identification, to check the medicine and medical records accompanied with patients. The PAMS would allow data sharing and cross-checking (patient ID, operation site marks, laboratory data, and other relevant materials) at this point for nursing, surgical and anesthesia teams. The patient identity verification completion rates increased from 75% at baseline to 100% after implementation. While the surgery is in progress, circulating nurses can complete their record stepby-step from operation site mark check, timing the antibiotics prophylaxis, to the identification of major operation processes. The delay rates of first operation have also decreased from 4% to 1% and the average time of delay has reduced
Fig. 4 – Patient identification and localization display.
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Fig. 5 – Nursing pre-operation evaluation sheet.
from 25 to 10 min. Anesthesia team can re-evaluate ASA classification and fill out quality assurance form for every operation (Fig. 6). The ASA classification verification rates increased from 53.2% at baseline to 86.9% after implementation. Frozen section report can also be displayed in the PAMS system. At the end of operation when patient is in the recovery room, the PAMS also provides excellent communication platform between recovery room and ward staffs, hence can greatly improve the completeness of handover process.
3.2.
Inventory management
The PAMS also supports logistic management and infection control. Since all sterilized instruments packages are labeled with bard code to register into the PAMS, the stock management of instruments becomes more efficient. The central supply room can track the instrument usage should there is any in-hospital infection outbreak. Through the data flow integration, the surgical patients can be matched to all the instruments and inventories usage in the workflow of a particular surgical day.
Fig. 6 – Operation-site marks, OR checklist.
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Surgical instruments packages are classified into “instrument in use”, “in stock”, “used”, and “overdue” in the PAMS. Those statuses are shown when the instrument package bar codes are scanned at due points: “used” – back to instrument room, “in stock” – when sterilization and repacking are completed in the instrument room, and “in use” – when the instrument package is opened in the operation room. Overdue and near-overdue instruments are marked and displayed in the PAMS with different color to remind instrument managers. The instrument loss rates have reduced from 0.146% at baseline to 0.089% after implementation.
3.3.
Quality monitoring
The PAMS currently monitors 101 quality indicators, including guideline compliance (in conducting WHO recommended “sign-in”, “time-out”, and “sign-out”), timing for antibiotics prophylaxis, intra-operative mortality, re-operation, OR turnaround time, etc. to provide team leaders management information on a monthly or quarterly basis (Fig. 7). The data are collected and integrated real-time and on-site through the multiple data entry ports along the whole patient care process. For example, time data can be easily captured by RFID, and re-operations can be identified and recorded by indicator algorithm embedded in the system. The automation of data integration significantly reduces the time and manpower devoted to the quality data collection. The appropriate antibiotics prophylaxis rates have maintained around 81.4–100% for six major surgical entities (cardiac bypass surgery, abdominal hysterectomy, vaginal hysterectomy, total knee/hip replacement, and appendectomy). The data integration and workflow control also facilitate quality improvement campaign for different surgical subspecialties to develop customized standard operation procedures (SOPs) in solving their specific domain problems. The OR average turn-around time has reduced from 16 to 9.4 min. The physician “time-out” execution rates have increased from 43% to 70%; similarly with “sign-in” and “sign-out” execution rates. The establishment of PAMS also has positive effect on organizational culture through benchmark learning across the surgical teams.
3.4.
Post-implementation user survey
The survey collected opinions after implementation of the PAMS from 174 staffs (240 questionnaires were sent totally). There are 56 surgeons and physicians (32.2%), 41 anesthesia and recovery room nurses (29.3%), 26 operative room and instrument room nurses (14.9%), 30 staffs of the emergency departments (17.2%). The main age groups are between 30 and 39 years old, 39.7% (n = 69), and 27.0% (n = 47) and 24.1% (n = 42) for the 20s and 40s groups respectively. 40.2% (n = 70) worked longer than 10 years, and 22.2% (n = 39) between 1 and 3 years, 17.2% (n = 30) between 4 and 7 years, and 13.2% (n = 23) between 6 and 10 years. The post-implementation user survey shows satisfaction rates between the aims and the usability of the system. 91.3% agreed that the system is conducive to improving patient identification and promoting operation safety, but only 72.2% for efficiency improvement, 78.3% for user friendliness, and overall satisfaction is 80%.
Table 1 – Average time to complete for the main forms. Items
Mean (STD) in minutes
Average time to complete the form in your checkpoint Average time to complete the operation summary Average time to complete the “time-out” sheet Average time to complete the pathology examination requests Overall satisfaction
7.48 (4.71)
7.48–12.25
4.59 (3.85)
1.00–20.00
2.69 (2.55)
0.50–10.00
3.87 (3.50)
0.50–20.00
68.83 (12.04)
45.00–90.00
Interval
The satisfaction rate on the “data entry” is 68.8%. The average time to complete the e-forms is listed in Table 1. The main source of user complaints lies in the additional time expense for completion of the e-forms to the original paper forms. Excessive efforts of computer operations and instructions about the basic skills of coping with the web-based interface are still required, despite continuous improvements, including more clear data input areas for respective departments (Fig. 5), and graphical input assistance of the body sites (Fig. 6), in the 1-year period of pilot study.
4.
Discussion
Patient safety has becoming the center of public concerns since the release of Institute of Medicine report “To Err is Human” [21]. The Harvard Medical Practice Study, using retrospective medical record review, also revealed that adverse events occurred in health care industry was under-estimated [22]. Researches proved that medical errors were not only harmful to patients but also can incur additional healthcare expenses and resources consumption [22–24]. To improve patient safety, the JCAHO of the United States started to instituted “National Patient Safety Goals” since 2002 with aim to prevent medical errors from happening [25]. Next to medication error, surgery-related error is the second most frequent type of medical errors that causes most of the error-related deaths. Surgical errors would result in severe and irreversible harm to patients [21,26]. As so patient safety and utilization efficiency are the key objectives of OR management [3,5–10]. Studies revealed that the more OR efficiency was achieved, the less cost and workload was spent [5,6]. Other studies dedicated to efficiency improvement, such as implementation of 6-sigma and technique-induced information would improve patient flow, decrease OR holds, and reduce patient waiting time [7–10]. The RFID-initiated PAMS is designed to enhance patient safety and improve quality monitoring. Additionally, managers are able to execute real-time, on-line management decisions to further improve operation theater utilization efficiency. Correct patient identity verification has long been ranked as the top priority of the patient safety goal [19]. With RFID wristed tag, patient ID and electronic medical record can be identified and validated to improve the accuracy of patient identity verification and to ensure the completeness of handover procedures. The PAMS improves the effectiveness
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Fig. 7 – Display of quality indicators.
of communication among caregivers. The wireless network deployment provides cross-functional medical staffs a communication platform to eliminate the possibility of wrong site, wrong patient, or wrong procedure surgery. The introduction of a wireless information system, with a real-time visual display of ongoing OR activities, resulting in an increased performance of OR activities. The RFID-initiated PAMS provides caregivers’ instant, wireless information sharing with minimized data entry work loading. The data captured by the PAMS can be analyzed to monitor surgical quality from risk prevention and outcome improvement perspectives. To meet the requirements of inter-organization or interdepartment integration, Klischewski and Wetzel proposed that the “service flow” or “work flow” architectures must meet the requirement of flexibility, inter-operability, and customer orientation [27,28]; the need is especially true for the inter-departmental needs in a modern hospital [29]. With the continuous efforts to enhance HIS functions, we believe that the PAMS can be further upgraded to meet the future demands from processes re-engineering in the hospital. The potential benefits of RFID to the healthcare management have been discussed in several researches [19,30,31]. However, one concern is the possible infringement to patient privacy through wireless networks [32]. Based on the design of RFID-initiated PAMS, patient’s record is not stored in the RFID tag. The RFID tag is used as a medium for initiating patient record database in the PAMS and therefore patient’s privacy is protected. The other concern is the electromagnetic interference (EMI) to medical devices. Many studies support that wireless area networks and Bluetooth systems do not interference with medical devices [33–35]. Our experiences with the RFID tag (frequency 2.4 GHz) used in the PAMS have not shown problems with EMI since the system’s initiation. The interference between RFID receivers was not tested fully in this implementation, since only one data port was set-up in each ward station, and the distance between the three data ports in the reception desks of the operating room and of the Anesthesiology Department were larger than 7 m. During the hardware set-up, we encountered the problem of duplicated tag detection by the two ward stations of two adjacent floors. But this interference problem was soon eliminated by adjustment of the direction of the antennae on the receivers.
The user satisfaction was poor on the data entry of e-forms, which had been revised and updated more than three versions in the year of pilot studies. The usability problem was complicated by the concurrent reformatting of the original paper-based forms of nearly all OR and anesthesiology work sheets. Various user needs of different departments and of different operation types always came after announcement and preliminary testing of every stages of implementation. The majority of those proposals were related to the remodeling of traditional work flows, and should only be resolved in more general way. In the pilot study, one common work sheet replaced one paper form due to the limitation of resources. OR-PAMS continues to be integrated in our daily work, concurrent with the e-transformation of many traditional processes. After the pilot study, customized forms for specific operations were under construction, including the shorter forms for selected ophthalmological stereotype surgery, and a more delicated form for the open cardiac operation. A version customized to the cardiac catheterization procedure was also implemented from the scheduling, patient identification, to the procedure notes. Usability and the satisfaction should be re-evaluated after the integration between systems and maturation of remodeling of the traditional work flows.
5.
Conclusion
The wireless information system, with a real-time visual display of ongoing OR activities, resulting in the improvement in OR utilization efficiency with less human efforts in data entry. The application of RFID plays an active role in patient’s advancement monitoring information. The PAMS also provide an on-line, cross-functional communication platform to integrate and facilitate workflow monitoring in peri-operative care. We conclude that the RFID-initiate PAMS is a valuable management tool to meet the safety, quality, efficiency requirements in a high service volume operation theater.
Acknowledgements This study was supported by the joint research fund (Project number: 96 CGH-NCU A3) of the Cathay General Hospital and the National Central University of Taiwan.
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journal homepage: www.intl.elsevierhealth.com/journals/cmpb
RFID-initiated workflow control to facilitate patient safety and utilization efficiency in operation theater Charles C.H. Liu a,b , Chia-Huang Chang c , Mu-Chun Su d , Hsueh-Ting Chu a , Sheng-Hui Hung e , Jau-Min Wong b , Pa-Chun Wang c,e,f,∗ a
Information Technology Department, Cathay General Hospital, Taipei, Taiwan Institute of Biomedical Engineering, National Taiwan University Hospital, Taipei, Taiwan c Outcomes Research Unit, Cathay Medical Research Institute, Taipei, Taiwan d Department of Computer Science and Information Engineering, National Central University, Taoyuan, Taiwan e Quality Management Center, Cathay General Hospital, Taipei, Taiwan f School of Medicine, Fu Jen Catholic University, Taipei, Taiwan b
a r t i c l e
i n f o
a b s t r a c t
Article history:
Objective: To control the workflow for surgical patients, we in-cooperate radio-frequency
Received 4 December 2009
identification (RFID) technology to develop a Patient Advancement Monitoring System
Received in revised form
(PAMS) in operation theater.
16 August 2010
Methods: The web-based PAMS is designed to monitor the whole workflow for the handling
Accepted 27 August 2010
of surgical patients. The system integrates multiple data entry ports Across the multi-
Keywords:
digital assistance (PDA), ultra-mobile personal computer (UMPC), or traditional keyboard
functional surgical teams. Data are entered into the system through RFID, bar code, palm Active RFID
at designated checkpoints. Active radio-frequency identification (RFID) tag can initiate data
Workflow control
demonstration on the computer screens upon a patient’s arrival at any particular checkpoint
Web-based database
along the advancement pathway.
Patient safety
Results: The PAMS can manage the progress of operations, patient localization, identity
Efficiency
verification, and peri-operative care. The workflow monitoring provides caregivers’ instant information sharing to enhance management efficiency. Conclusion: RFID-initiate surgical workflow control is valuable to meet the safety, quality, efficiency requirements in operation theater. © 2010 Elsevier Ireland Ltd. All rights reserved.
1.
Background
According to the report of National Patient Safety Foundation, over half of the medical errors might stem from peri-operative care; surgery-related errors are the second most frequent cause to error-related death [1]. Drug administration error, wrong patient, incorrect surgery, and wrong surgical
site are the most frequent peri-operative procedures causing human injury [2–4]. Peri-operative setting would include “preoperative assessment”, “management of associated medical conditions” “preparation for surgery”, “choice of anesthesia”, “monitoring of sedated patient”, and “care of sedated or resuscitated patient”, in which every step is crucial to patient safety and is vulnerable to errors owing to the complex nature of care processes. Therefore, workflow control for surgical patients
∗ Corresponding author at: Quality Management Center, Cathay General Hospital, 280 Sec. 4, Jen-Ai Rd., 106 Taipei, Taiwan. Tel.: +886 2 27082121x3364; fax: +886 2 66362836. E-mail addresses: [email protected], [email protected] (P.-C. Wang). 0169-2607/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.cmpb.2010.08.017
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Fig. 1 – Patient advancement monitoring workflow.
is important to operation theater utilization efficiency and is critical to patient safety [2–10]. To handle the complex processes, the evolving radiofrequency identification (RFID) technology can be applied to improve peri-operative management with its unique capabilities of identification, locating, and tracking [11–13]. RFID, with its unique properties, has been wildly applied into many industries [14,15]. When used in the healthcare industry, the technology is valuable to help healthcare providers in meeting Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) patient safety goals – in which correct patient identification ranks as top priority [16,17]. Furthermore, patient tracking with instant information sharing from electronic health records (EHR) systems are both auxiliary to quality and safety management. Chang et al. surveyed the status of RFID applications in medical safety in Taiwan by questionnaires [18]. The RFID applications were discussed on operational structure benefits, users’ structure benefits, and organizational and environmental benefits. The authors concluded that the benefits of data integration are the most significant, and the facilitation of medical safety is still in evaluation and developmental stage, compared to the mature applications such as inventory, asset, and personnel tracking. RFID application in peri-operative setting was discussed only recently [18,19]. Nagy et al. reviewed the applications in surgical settings in three domains – workflow tracking of assets and staffs (productivity), medication and inventory supply chain (cost control), and patient tracking (safety). The
additional benefits of RFID lie on the interfaces among the three domains, such as the patient identification between the asset and patient domains, or the stock supply between the inventory and patient domains [19]. To improve management competency and to enhance patient safety, we address the issue of data integration by tracking the whole surgical workflow in the peri-operative settings in using radio-frequency identification (RFID) technologies to develop a Patient Advancement Monitoring System (PAMS). The project is constructed simultaneously with the implementation of our electronic medical record systems related to operative theater, including etransformation of many medical, nursing, aesthetical, and surgical paper forms, and concurrently with a bar code-based inventory management system of our operating instrument. The staffs of our Surgical and Anesthesia Departments view the PAMS project as the e-platform of a continuous quality improvement of the whole operative team. So the project increased in scope due to ever-growing user demands after implementation of the initial integration scheme.
2.
Methods
The pilot study was conducted from August 2007 to July 2008 in the Cathay General Hospital, a near-800 beds medical center located at downtown Taipei in Taiwan providing comprehensive acute care services, including major cardiac
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Fig. 2 – RFID wristed tag and reader.
and neurological surgeries; 14 operation rooms (OR) support 25,000 surgeries annually. The prototype of PAMS was formulated based on the existent peri-operative environments in the research hospital. The OR, surgical, emergency room (ER), anesthesia, and nursing staffs and managers were consulted to understand their demands on data collection and management. Active RFID was chosen for the additional benefits over the bar code identification system. When the patients were advanced into each station, the RFID readers on the ceilings identified the entry automatically, without the need of alignment of traditional wrist bar code tags for scanning. Subsequent patient identification and data entry could be confirmed according to the workflow based on the basic location information of the patients in the current station. Prior to the implementation, system analysis of the workflow for surgical patient was detailed through more than 30 group meetings and interviews. There are around 20 checkpoints identified to serve as data entry ports from ward to OR. The workflows would start from ER, surgical ward, or OR front desk (ambulatory surgery) to end at the recovery room (Fig. 1). Surgical patient would start to wear active RFID wristband tag (SYTAG245-TM-B01) at starting points. RFID readers (SYRD245-1N) are placed on the ceilings of various checkpoints to calculate and analyze signals emitted from active RFID tags (frequency 2.4 GHz with transmission range up to 80 m) (Fig. 2). In this study, the RFID readers were placed in distances larger than 15 m from each others, due to demographical distances between the ward stations, the OR front desk, and the operating rooms. The problem of interference was only encountered in the initial period between the readers of the two nursing stations of the adjacent floors, which was soon resolved after change of the direction of the antenna. PAMS system is developed on a J2EE-based (Java 2 Platform, Enterprise Edition) application and constructed on Apache WebSphere platform using Microsoft SQL, Java, JSP (Java Server Pages), and Java Script. The web-based PAMS SQL database is designed to link with hospital information system (HIS). Operation schedule, care process, patient identification information, and anesthesia data are entered into the database at various checkpoints along the patient advancement pathway. The data ports, including RFID, bar code, PDA, and UMPC are chosen, considering the convenience of field employees at designated checkpoints (Fig. 3). Middleware can support 1–256
different regions, update its position in 1 s to show information in the control interface, and can support up to 256 labels with accuracy within 2 m. For patient identification, the alert prompt of the arrival of a new patient at the checkpoint needs to be confirmed by the staffs. Then the detailed information of the patient was automatically loaded, and was displayed to support working flow at the current station. All OR team members (surgeons, residents, nurses, anesthesia team members, ancillary support members) were required to performed “sign-in”, “time-out”, and “sign-out” as recommended by the WHO Surgical Checklist [20]. Anesthesia team was in charge of “sign-in”, and OR circulating nurses, “sign-out”. The information based on the WHO checklist was shared to each other, avoiding duplicated work, on the webbased system. The staffs just browse along the lists, and “sign” in the respective button on their web pages. The data were entered into the PAMS for audit. The PAMS inventory management system was developed independently with the existing inventory system in the hospital information system. PAMS managed the specialized operative instruments owned by the operative theater. Bar code labeling was chosen for its cost-effectiveness and efficiency in the logistic management. The staffs scanned the bar codes manually, and the inventory was recorded into their specific operation records. The instrument packages are tagged with bar codes after sterilization, as so the logistic records can be loaded into the PAMS. During the implementation process, we conducted user satisfaction survey by evaluating the convenience, efficiency, use-friendliness, and feasibility of the PAMS. Inventory management data were also retrieved from the system for analysis.
3.
Results
The benefits of RFID integrated workflow management could be addressed in the fields of patient tracking, inventory management, and quality monitoring.
3.1.
Patient tracking in PAMS workflow
Patient’s location can be tracked and displayed on the PAMS automatically. Nursing staff checked and verified whether
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Fig. 3 – Data flow and information sharing in the PAMS.
surgical patient ID and records correctly registered in the PAMS system. RFID tag is also used to initiate data demonstration on the computer screens upon a patient’s arrival at particular checkpoint along the advancement pathway (Figs. 4 and 5). Ward nursing staffs can complete pre-operation evaluation in the PAMS, then send message to OR and dispatch center through the system when patients are ready for escort. Messages from different wards will pull together on dispatch center’s message board. A flash light alert system is built to notify the incoming new escort request messages. Through the operation of this system, dispatch center can manage their escort teams to reduce considerable daily phone-answering workloads (7–800 escort requests phones per day).
When surgical patient arrives in the OR waiting area, the receptionist can use the PAMS to verify patient’s identification, to check the medicine and medical records accompanied with patients. The PAMS would allow data sharing and cross-checking (patient ID, operation site marks, laboratory data, and other relevant materials) at this point for nursing, surgical and anesthesia teams. The patient identity verification completion rates increased from 75% at baseline to 100% after implementation. While the surgery is in progress, circulating nurses can complete their record stepby-step from operation site mark check, timing the antibiotics prophylaxis, to the identification of major operation processes. The delay rates of first operation have also decreased from 4% to 1% and the average time of delay has reduced
Fig. 4 – Patient identification and localization display.
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Fig. 5 – Nursing pre-operation evaluation sheet.
from 25 to 10 min. Anesthesia team can re-evaluate ASA classification and fill out quality assurance form for every operation (Fig. 6). The ASA classification verification rates increased from 53.2% at baseline to 86.9% after implementation. Frozen section report can also be displayed in the PAMS system. At the end of operation when patient is in the recovery room, the PAMS also provides excellent communication platform between recovery room and ward staffs, hence can greatly improve the completeness of handover process.
3.2.
Inventory management
The PAMS also supports logistic management and infection control. Since all sterilized instruments packages are labeled with bard code to register into the PAMS, the stock management of instruments becomes more efficient. The central supply room can track the instrument usage should there is any in-hospital infection outbreak. Through the data flow integration, the surgical patients can be matched to all the instruments and inventories usage in the workflow of a particular surgical day.
Fig. 6 – Operation-site marks, OR checklist.
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Surgical instruments packages are classified into “instrument in use”, “in stock”, “used”, and “overdue” in the PAMS. Those statuses are shown when the instrument package bar codes are scanned at due points: “used” – back to instrument room, “in stock” – when sterilization and repacking are completed in the instrument room, and “in use” – when the instrument package is opened in the operation room. Overdue and near-overdue instruments are marked and displayed in the PAMS with different color to remind instrument managers. The instrument loss rates have reduced from 0.146% at baseline to 0.089% after implementation.
3.3.
Quality monitoring
The PAMS currently monitors 101 quality indicators, including guideline compliance (in conducting WHO recommended “sign-in”, “time-out”, and “sign-out”), timing for antibiotics prophylaxis, intra-operative mortality, re-operation, OR turnaround time, etc. to provide team leaders management information on a monthly or quarterly basis (Fig. 7). The data are collected and integrated real-time and on-site through the multiple data entry ports along the whole patient care process. For example, time data can be easily captured by RFID, and re-operations can be identified and recorded by indicator algorithm embedded in the system. The automation of data integration significantly reduces the time and manpower devoted to the quality data collection. The appropriate antibiotics prophylaxis rates have maintained around 81.4–100% for six major surgical entities (cardiac bypass surgery, abdominal hysterectomy, vaginal hysterectomy, total knee/hip replacement, and appendectomy). The data integration and workflow control also facilitate quality improvement campaign for different surgical subspecialties to develop customized standard operation procedures (SOPs) in solving their specific domain problems. The OR average turn-around time has reduced from 16 to 9.4 min. The physician “time-out” execution rates have increased from 43% to 70%; similarly with “sign-in” and “sign-out” execution rates. The establishment of PAMS also has positive effect on organizational culture through benchmark learning across the surgical teams.
3.4.
Post-implementation user survey
The survey collected opinions after implementation of the PAMS from 174 staffs (240 questionnaires were sent totally). There are 56 surgeons and physicians (32.2%), 41 anesthesia and recovery room nurses (29.3%), 26 operative room and instrument room nurses (14.9%), 30 staffs of the emergency departments (17.2%). The main age groups are between 30 and 39 years old, 39.7% (n = 69), and 27.0% (n = 47) and 24.1% (n = 42) for the 20s and 40s groups respectively. 40.2% (n = 70) worked longer than 10 years, and 22.2% (n = 39) between 1 and 3 years, 17.2% (n = 30) between 4 and 7 years, and 13.2% (n = 23) between 6 and 10 years. The post-implementation user survey shows satisfaction rates between the aims and the usability of the system. 91.3% agreed that the system is conducive to improving patient identification and promoting operation safety, but only 72.2% for efficiency improvement, 78.3% for user friendliness, and overall satisfaction is 80%.
Table 1 – Average time to complete for the main forms. Items
Mean (STD) in minutes
Average time to complete the form in your checkpoint Average time to complete the operation summary Average time to complete the “time-out” sheet Average time to complete the pathology examination requests Overall satisfaction
7.48 (4.71)
7.48–12.25
4.59 (3.85)
1.00–20.00
2.69 (2.55)
0.50–10.00
3.87 (3.50)
0.50–20.00
68.83 (12.04)
45.00–90.00
Interval
The satisfaction rate on the “data entry” is 68.8%. The average time to complete the e-forms is listed in Table 1. The main source of user complaints lies in the additional time expense for completion of the e-forms to the original paper forms. Excessive efforts of computer operations and instructions about the basic skills of coping with the web-based interface are still required, despite continuous improvements, including more clear data input areas for respective departments (Fig. 5), and graphical input assistance of the body sites (Fig. 6), in the 1-year period of pilot study.
4.
Discussion
Patient safety has becoming the center of public concerns since the release of Institute of Medicine report “To Err is Human” [21]. The Harvard Medical Practice Study, using retrospective medical record review, also revealed that adverse events occurred in health care industry was under-estimated [22]. Researches proved that medical errors were not only harmful to patients but also can incur additional healthcare expenses and resources consumption [22–24]. To improve patient safety, the JCAHO of the United States started to instituted “National Patient Safety Goals” since 2002 with aim to prevent medical errors from happening [25]. Next to medication error, surgery-related error is the second most frequent type of medical errors that causes most of the error-related deaths. Surgical errors would result in severe and irreversible harm to patients [21,26]. As so patient safety and utilization efficiency are the key objectives of OR management [3,5–10]. Studies revealed that the more OR efficiency was achieved, the less cost and workload was spent [5,6]. Other studies dedicated to efficiency improvement, such as implementation of 6-sigma and technique-induced information would improve patient flow, decrease OR holds, and reduce patient waiting time [7–10]. The RFID-initiated PAMS is designed to enhance patient safety and improve quality monitoring. Additionally, managers are able to execute real-time, on-line management decisions to further improve operation theater utilization efficiency. Correct patient identity verification has long been ranked as the top priority of the patient safety goal [19]. With RFID wristed tag, patient ID and electronic medical record can be identified and validated to improve the accuracy of patient identity verification and to ensure the completeness of handover procedures. The PAMS improves the effectiveness
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Fig. 7 – Display of quality indicators.
of communication among caregivers. The wireless network deployment provides cross-functional medical staffs a communication platform to eliminate the possibility of wrong site, wrong patient, or wrong procedure surgery. The introduction of a wireless information system, with a real-time visual display of ongoing OR activities, resulting in an increased performance of OR activities. The RFID-initiated PAMS provides caregivers’ instant, wireless information sharing with minimized data entry work loading. The data captured by the PAMS can be analyzed to monitor surgical quality from risk prevention and outcome improvement perspectives. To meet the requirements of inter-organization or interdepartment integration, Klischewski and Wetzel proposed that the “service flow” or “work flow” architectures must meet the requirement of flexibility, inter-operability, and customer orientation [27,28]; the need is especially true for the inter-departmental needs in a modern hospital [29]. With the continuous efforts to enhance HIS functions, we believe that the PAMS can be further upgraded to meet the future demands from processes re-engineering in the hospital. The potential benefits of RFID to the healthcare management have been discussed in several researches [19,30,31]. However, one concern is the possible infringement to patient privacy through wireless networks [32]. Based on the design of RFID-initiated PAMS, patient’s record is not stored in the RFID tag. The RFID tag is used as a medium for initiating patient record database in the PAMS and therefore patient’s privacy is protected. The other concern is the electromagnetic interference (EMI) to medical devices. Many studies support that wireless area networks and Bluetooth systems do not interference with medical devices [33–35]. Our experiences with the RFID tag (frequency 2.4 GHz) used in the PAMS have not shown problems with EMI since the system’s initiation. The interference between RFID receivers was not tested fully in this implementation, since only one data port was set-up in each ward station, and the distance between the three data ports in the reception desks of the operating room and of the Anesthesiology Department were larger than 7 m. During the hardware set-up, we encountered the problem of duplicated tag detection by the two ward stations of two adjacent floors. But this interference problem was soon eliminated by adjustment of the direction of the antennae on the receivers.
The user satisfaction was poor on the data entry of e-forms, which had been revised and updated more than three versions in the year of pilot studies. The usability problem was complicated by the concurrent reformatting of the original paper-based forms of nearly all OR and anesthesiology work sheets. Various user needs of different departments and of different operation types always came after announcement and preliminary testing of every stages of implementation. The majority of those proposals were related to the remodeling of traditional work flows, and should only be resolved in more general way. In the pilot study, one common work sheet replaced one paper form due to the limitation of resources. OR-PAMS continues to be integrated in our daily work, concurrent with the e-transformation of many traditional processes. After the pilot study, customized forms for specific operations were under construction, including the shorter forms for selected ophthalmological stereotype surgery, and a more delicated form for the open cardiac operation. A version customized to the cardiac catheterization procedure was also implemented from the scheduling, patient identification, to the procedure notes. Usability and the satisfaction should be re-evaluated after the integration between systems and maturation of remodeling of the traditional work flows.
5.
Conclusion
The wireless information system, with a real-time visual display of ongoing OR activities, resulting in the improvement in OR utilization efficiency with less human efforts in data entry. The application of RFID plays an active role in patient’s advancement monitoring information. The PAMS also provide an on-line, cross-functional communication platform to integrate and facilitate workflow monitoring in peri-operative care. We conclude that the RFID-initiate PAMS is a valuable management tool to meet the safety, quality, efficiency requirements in a high service volume operation theater.
Acknowledgements This study was supported by the joint research fund (Project number: 96 CGH-NCU A3) of the Cathay General Hospital and the National Central University of Taiwan.
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