Implementation of an Optimized Real Time Location System at Mount Sinai Hospital & Healthcare RTLS Best Practices
Conflict of Interest Disclosure Donna Baer, MS, MPA Dennis Minsent, MSBE, CCE, CBET Have no real or apparent conflicts of interest to report. 2012 HIMSS
Session Objectives Outline the differences in active RTLS technologies (RFID, Infrared, Zigbee, WiFi, Ultrasound) Discuss the do's and don'ts for a successful implementation Describe how Oregon Health & Science University (OHSU) improved hospital efficiency and patient care using Wi-Fi RTLS provided by AeroScout Discuss how OHSU is tracking and managing thousands of pieces of critical equipment throughout nine inpatient medical buildings
Implementing an Optimized RTLS solution at Mount Sinai Hospital Donna Baer, Director, Strategic Projects, IT DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.
The Mount Sinai Medical Center The Mount Sinai Medical Center is a 1,171 bed, tertiary and quaternary-care teaching facility acclaimed internationally for excellence in clinical care. The Medical Center extends from 98 th Street to 102 nd Street and from 5 th Avenue to east of Madison Avenue. The onsite campus has approximately 4 million square feet. The Hospital s 3,500 full-time and voluntary physicians treat approximately 60,000 Inpatients and 560,000 outpatients each year. Implementation of a real time location tracking system has enabled us to increase efficiency, advance patient safety, enhance healthcare workflow and improve patient and staff satisfaction, but the project was challenging and took time. I ll be sharing the journey we took to get to where we are today, including our research, proof of concept, RTLS decisions, challenges, and successes.
RTLS technology overview RFID technology basic premise Tags powered by a battery (active) or intermittently through a device (passive), transmit information over radio waves that are read by a reader and/or receiver located some distance away. The readers/receivers communicate the location information to a database. Application web-based software provides location data, generate alerts and when used as an enabling technology, can drive business process improvements. Passive systems: low-frequency, high-frequency or ultrahigh-frequency RFID tags can be read with: RFID Gun type scanner RFID Cabinets Portals Active systems: RFID, and hybrid RFID and Infrared Zigbee (wireless mesh network) WiFi (802.11) Ultra-wideband Ultrasound
RTLS in Healthcare What could potentially be in the scope of a hospital RFID project? Patients/Visitors/Employees Equipment Tracking (BioMedical, Ancillary, IT, Office) Inventory Control/Materials Management Staff hygiene compliance (hand-washing) Pharmaceuticals/Blood Products/Lab specimens Medical Records At Mount Sinai our initial focus was equipment tracking Over 25,000 medical devices Staff spends hours trying to locate equipment, especially the smaller, more portable devices Clinical Engineering tracks Could Not Locate as a performance indicator to be able to identify areas and equipment that are most susceptible. Examples include: infusion pumps, external pacemakers, bipap machines, PCA pumps, etc
RTLS Project Goals: Asset Tracking Promptly and easily locate equipment when needed for patient care, preventative maintenance, recalls Nursing/Medical staff: Enhance patient care by quickly locating equipment Clinical Engineering: quickly locate equipment for preventative maintenance and recalls Equipment utilization monitoring to determine optimal levels day to day clinical engineering operations long term strategic capital planning decisions for asset acquisitions Optimize staff productivity reduce amount of time spent searching for equipment Ability to obtain accurate analysis of location history Establish par levels in clean/soiled rooms for PEP (patient equipment tool) management Real time alerts Did equipment enter/exit a particular area Is equipment present/absent from a location Is there not enough/too much of a particular asset Is asset in use, not in use, broken
RTLS Project Gets Underway Establish collaborative working committees Validate infrastructure needs Evaluate potential EMI Establish project timeline and deliverables Develop policies and procedures Develop criteria for RFID tagging Research RFID marketplace, what other institutions are doing, vendor analysis
RTLS Project Expansion Hospital Optimization Project: a multifaceted approach to Facilitate Logistics and Optimize Workflow (FLOW) Results from the Models will allow us to refine work and patient flows for more efficient processes as well as to account for new initiatives. These refinements will be reflected in the actual data to which new modeling assumptions are applied.
Selecting a Hardware Vendor Literature Review RTLS hardware vendors and their technology platform Existing hospital implementations
Vendors: hardware & application review
Vendors Considered / Technology Awarepoint 802.15 GHz Zigbee wireless mesh network Sensors are plugged into electrical outlets throughout the facility. The sensors route the tags radio messages over our LAN through a bridge to an appliance. Centrak 915 MHz based on a blend of active RFID and Gen2 Infrared Devices (called Spiders) similar to smoke alarms are ceiling mounted and powered by 6 D cell batteries or an electric outlet. These devices read the tag information and communicate location to antennae's (called Stars) which send data over WIFI to the positioning server. Cisco/Aeroscout 802.11 WIFI technology Aeroscout tags transmit signals, received by access points in the ceiling, sent to Cisco s Location Appliance. Wall mounted exciters provide distinct location information. Data from location appliance is sent to Aeroscout s Mobileview engine Radianse 433 MHz RFID triangulation Wall mounted WiFi or LAN wired receivers sense radio signals from the tags and communicate to a web application.
Centrak & Awarepoint: Proof of Concept
Project Cost Considerations What, how much and when to tag We decided to conduct a 10 week physical inventory looking for/recording info on all 25,0000 assets and RFID tag approx 10,000 assets Infrastructure costs: Greater granularity=greater investment readers, transmitters, tags, servers, etc Portal, zone, room or sub-room level coverage We decided on blended granularity model. We have room level in our Inpatient areas where we were tagging patients, zone level in other Inpatient areas where we were not tagging patients (Maternal Child, Psych), and Portal level in our Outpatient departments, Research/School based areas and Physician offices Cost of application, installation, testing, training
Project Kickoff Building the infrastructure cable pulls device installation Physical Inventory RFID tagging of equipment and patients Designing and building the Database maps (CAD blueprints) unit and integration testing signoff Training develop training materials identify training rooms train staff Reconciliation
Challenges we faced Physical Inventory Device inaccuracies (bad batch of tags) Assets missed, Assets tagged incorrectly Infrastructure Issues Dead spots, broken antennas on Infrared devices Portal level coverage: Items show old scan dates in database RFID Coverage in open spaces atriums, hallways, ICUs, ED assets shown in wrong location RFID Tags falling off equipment PCA pumps, Humidifiers Dept specific requests for RFID tagging were often problematic Initial alerts did not make sense Wheelchairs stored by the entrances triggered alerts all day long Training Getting staff to show up Equipment ownership Getting beyond This is my equipment
A picture is worth a thousand words RFID coverage in tall buildings and RFID/Infrared coverage in wide open spaces can be an issue This stacking diagram shows 13 buildings, floors and connected walkways Floor plan complexity in basements can make accurate tracking challenging New RFID tagging procedures for PCA pumps worked for a short while (< 1 week!)
Redefining our Expectations Recognize that our size and complexity creates RTLS and work flow challenges Improve project deliverables through Infrastructure refinements, database tuning, Revamping processes, retraining, and continuous monitoring R Establish Clarify as source database, reconcile variations across both applications as needed Define appropriate level of granularity for each area. Where needed, enhance granularity using subzones and hallway carve outs
Granularity to the Max Mount Sinai has 50 Operating Rooms, 25 of which are housed on the 3 rd floor of Guggenheim Pavilion. IR works well in a closed room but not well in open areas. Locating equipment in hallways was a challenge until we carved out subzones using additional Infrared devices.
Working through the Challenges There were many factors that contributed to application inaccuracies
Project Successes Upgraded to the latest version of RFID tags with re-designed battery and better casing enhanced battery life improved battery housing ability to predict tag life proactively- tags were changed through on-going preventative maintenance Re-tagged all assets with new RFID tags continuously replaced tags in CE and PEP changed tags during every PM where applicable predicted next tag change prior to end of life deployed tagging teams strategically throughout facility targeted by equipment group Application Refinements through Infrastructure Tweaking enhanced granularity using sub-zones and hallway carve outs Implemented Infrastructure Monitoring Tools and Dashboards
Dashboard Displays for Proactive Management Infrastructure Monitoring Health Check low battery indicators activity levels for all hardware Accurate Equipment Utilization pumps in use/not in use Enhanced Equipment Distribution par levels by unit retrieval/redistribution of key items available equipment detail cleaning protocols Rental items at-a-glance Housekeeping/transport dashboard
Return on Investment/Benefits Enhanced ability to manage assets Assistance in preventative maintenance by spending less time searching for equipment Reduced rental costs Equipment utilization monitoring Reduction in equipment loss Reduced capital investment Labor savings Improved compliance and safety Improved staff morale Improved patient experience by enhancing the timeliness and quality of care by having equipment available more readily
Lessons Learned: Do s & Don ts Do: conduct a POC (proof of concept) with several vendors determine granularity requirements and infrastructure needs based on what you are trying to accomplish (equipment and/or patient locating) carefully negotiate the contract with use cases clearly defined establish new policies and procedures early on perform a detailed physical inventory recognize importance of tag location and mounting methods analyze your current state and collect data for a post implementation ROI reconcile the PI against your database vet with Nursing and other key dept's implement any additional needed process changes you can with system go live size the project team appropriately prepare a detailed implementation plan with dependencies
Don t: Lessons Learned: Do s and Don ts skimp on the budget and cut corners thinking it will work just as well without all that infrastructure underestimate the workload/staffing needed for the project think that training and continued education are not needed go with the least expensive solution believe what vendors tell you (timeframes, etc- you know your hospital best!) jump in and build functionality you don t need right away (alerts, par levels)
Where do we go from here? Infrastructure Refinements enhanced granularity: switch from portal to zone coverage in needed areas build coverage in needed off site locations (including warehouse) Develop alerts and notifications for the following: equipment needing preventative maintenance predefined min/max and par levels association of equipment and patient tags to know in-use status leased equipment nearing end-of-lease date, rental equipment alert based on patient discharge migrate to AgileTrac s EVS housekeeping and transport application to facilitate communication and improve workflow Integration with our Hilrom Nurse Call application Temperature Monitoring Data generated by the Centrak RTLS hardware and the AgileTrac patient workflows feed the Strategic and Predictive Models. The Strategic model will enable what-if analysis The Predictive model will tell us about our future and drive the decisions we make today
How does it all come together? Hospital Optimization Project: a multifaceted approach to Facilitate Logistics and Optimize Workflow (FLOW)
Questions? Donna Baer Director, Strategic Projects, Information Technology, Mount Sinai Hospital HIMSS "Stage 6" Recognition Places Mount Sinai in Top 4.5 Percent of U.S. Hospitals for Electronic Medical Record Adoption Mount Sinai Has 209 Physicians Named in New York Magazine s "Best Doctors" Issue The Mount Sinai Medical Center ranks 16 out of nearly 5,000 hospitals nationwide in the 2011-2012 Best Hospitals issue of U.S. News & World Report, and earns a spot on the Honor Roll.
Healthcare RTLS Best Practices Dennis Minsent, Director, Clinical Technology Services DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.
Overview OHSU Real-Time Location System (RTLS) best practices which were developed over the course of many years Tracking and managing thousands of pieces of critical equipment throughout nine inpatient medical buildings How and why it leveraged its standard Wi-Fi network to wirelessly monitor the temperature in refrigerators and freezers Positive impact on OHSU s biomed, nursing, pharmacy and patient transport staff Information about integrating AeroScout RTLS with Vocera devices, St. Croix Asset Enterprise and CareFusion Wireless Enterprise Server
Overview of OHSU Hospitals and Clinics Only Academic Medical Center in the State of Oregon 530-bed facility comprised of OHSU Hospital and Doernbecher Children s Hospital 80 adult and 20 pediatric intensive care beds 95% average daily census for acute adult beds, 83% overall Level 1 Trauma Center
OHSU Center for Health & Healing was the first medical facility in the world to receive the new construction Platinum certification (LEED NC) from the U.S. Green Building Council in 2007
RTLS Decision Process Major Facility Addition Under Construction 2004 Limited Wi-Fi 802.11 Being Currently Used Desire to Develop High Density Wireless Infrastructure Nursing Productivity Technology Needed
Nursing Productivity Needs New Nursing Units Over 300 Feet Long RTLS to locate equipment Vocera to improve communication
RTLS Architecture History 2006 2008 2010 Location Tracking One Application Server One Database Server No PHI Downtimes Acceptable Basic IT and Vendor Support Location Tracking & Temperature Tracking One Application Server One Database Server No PHI Downtimes Minimized 24x7 IT and Vendor Support Location Tracking, Temperature Tracking, & Patient Tracking Two Application Servers Two Database Servers Failover Capability Test Environment PHI stored Downtimes Unacceptable
Current Architecture Active Directory Authentication Load Balancer Test System 2 App Servers DB Cluster Utility Gateway/ Location Engine DB Cluster Utility 2 DB Servers
Security Best Practices Current Practice LDAP Integration for unique, secure, rolebased user access Future Development LDAP Polling LDAP Nested Groups Robust User Action Tracking
RTLS Rollout at OHSU 2006-2008 2008-2011 Current Clinical Equipment in Select Pilot Units Clinical Equipment Refrigeration Pilot Integrations for Alerting Patient Elopement Pilot Refrigeration Expansion Non-clinical Equipment 1,200 tags for Location 2,200 tags for Location 200 tags for Temperature 4,000 tags for Location 350 tags for Temperature
Challenges: Support for a Variety of Users Power Users Experienced with application Use advanced features Functional Users Frequent Access Perform simple routine tasks Once-In-A-Blue- Moon Users Access is usually eventrelated and urgent
Solutions: Support for a Variety of Users Resources: Power Users Functional Users One-Time Users Initial Training One-on-One Group session, e-learning Quick-Start Guide (2p) Documentation Up-to-date User Manuals Quick-Start Guide Search Help Standard Asset ID Descriptive Asset Names Validation Regularly updated inventory list for comment
Challenges: Inventory Management Many assets were tagged one-at-a-time at user request. Asset names and details were non-standard. As more assets were tagged, we expanded the organizational structure as needed. This led to bloated category lists. Tag batteries run out and tags occasionally fail or break off.
Solutions: Inventory Management Most items are now tagged during their initial incoming inspection performed by CTS MAC address is a standard field on our incoming forms
Solutions: Inventory Management We periodically review organizational structure, trying to optimize the number of asset categories and groups
Solutions: Inventory Management Using reports, CTS techs can proactively replace depleted batteries and flag assets that need new tags in our equipment management system
Integration of AeroScout with Other Systems St Croix Asset Enterprise Vocera VOIP Hospital Paging System Hospital Email System CareFusion Alaris Wireless Enterprise (Under Development)
Estimated Value Based on staff functions surveyed and direct observations, including salaries and benefits, it was estimated we were spending about $1,729 per shift trying to locate equipment over our 26 nursing units Annualized, that was about $1.26M per year of waste and lost productivity Making payback on the purchase of the system less than one year for OHSU
Future Considerations Tracking Sterilizable Surgical Trays Productivity Applications Patient Flow Equipment Flow and Processing EMR Integration
Integrations Enhance Usefulness Tracking boards in ED and OR Bed Management Systems Mobile Equipment Management Systems Patient Transportation System Integration Imagination: Just ask yourself What if
If You Can Dream It, You Can Do It! Your creativity and business needs can drive new applications for RTLS technology Vendor partnerships across the healthcare industry will drive future applications
Questions??? Dennis Minsent, MSBE, CCE, CBET Director, Clinical Technology Services