KURUZOVICH, JASON PhD; ANGST, COREY M. PhD; FARAJ, SAMER PhD; AGARWAL, RITU PhD
In healthcare verticals, the ability to communicate information clearly, accurately, and promptly is vital to providing the best care possible for patients and ensuring no pressing matters involving a patient's well-being are overlooked or left unattended. Studies conducted by the Institute of Medicine1 and the Leapfrog Group2 have highlighted how patient care can fail when caregivers have sparse or incorrect information. In an information-intensive environment such as a hospital,3 information technology offers a means of improving the quality of information flow and the flexibility of clinicians in accessing the right information immediately, reducing the likelihood of errors in patient care, while simultaneously improving a patients' overall experience. Although technologies such as electronic medical records, bar-coding, and radio frequency identification4-7 allow caregivers to make treatment decisions and ensure proper medications are being dispensed,8,9 none of these technologies address the need for instant access to human knowledge and expertise through timely communication.10
Although the means of communication in healthcare settings have evolved over the years, the need to access a colleague's knowledge, expertise, and assistance has not. Although many caregivers and physicians still lean toward using pagers, cell phones, and overhead paging to communicate with one another, these methods can pose several challenges.3 The downfalls of cellular technology in healthcare settings include the presence of dead spots in coverage and rooms where cell phone usage is prohibited. Reliance on overhead paging may not only lead to the discomfort of patients who are trying to rest,3,11,12 but there is no certain way to know if the intended party actually received the page and subsequently fulfilled the requested duty. Thus, novel approaches to communicating both within and external to the hospital are increasingly being sought. In this study, we investigate the use of a wireless communication system that is designed to alleviate some of the constraints noted that are inherent in traditional technologies.
BACKGROUND AND OVERVIEW
St Agnes Hospital is a 308-bed nonprofit hospital in Baltimore, MD. It is part of the Ascension Health system and primarily serves Baltimore and the surrounding region. St Agnes is a full-service community teaching hospital, with approximately 23,000 admissions annually, and is classified as a "General Medical and Surgical" hospital. Key services at St Agnes Hospital include the St Agnes Cancer Center, the Chest Pain Emergency Center, Cardiovascular Services, Women's Health Services, the Joint Connection, the Center for Minimally Invasive Surgery and Telemedicine, and the St Agnes Emergency Department, which includes pediatric, adult, and urgent care emergency centers. St Agnes also supports off-site facilities, including the Seton Imaging Center.
The Vocera Communications system consists of two main components (Figure 1): the Vocera system software (which controls and manages call activity and workflow) and the Vocera Communications badge, a wearable, voice-controlled communication device that operates over a wireless LAN (802.11b). The Vocera Communications system provides caregivers with the ability to communicate with one another using wireless, hands-free badges. The badge weighs less than 2 ounces and is worn around the neck or clipped to a lapel (Figure 2). The Vocera Communications badge comprehends spoken voice commands in natural language. By pressing a button, a user can connect to anyone in a designated facility or, as in the case of this implementation, to outside phones through Private Branch eXchange (PBX) integration, which is a private telephone switching system that allows telephone extensions to connect to each other within and outside a given facility.
In May 2003, St Agnes installed the Vocera Communications system as part of an effort to reinforce and upgrade the wireless infrastructure deployed in the late 1990s. The Vocera installation at St Agnes features the Vocera Messaging Interface (VMI), which enables connectivity between other systems (such as landline telephone system and/or nurse call systems) and the Vocera system, via the Vocera server. It performs three primary functions: nurse call integration (NCI), clinician-to-clinician(s) communications, and clinician-to-external communications as described later.
Nurse Call Integration Vocera Communications System
Of the three functions identified, the primary one of interest in this study was the NCI system. Using the Vocera system as a conduit, St Agnes integrated the existing nurse call system in a manner that allowed bedside calls from patients to be routed to the primary caregiver through Vocera badges. Primary caregivers could then read or play messages and either speak a command or respond to the call through the patient's pillow speaker via the PBX/nurse call system. Communication between the caregiver and the patient is achieved through the VMI, which is used to connect patient monitoring systems, scheduling software, bed management applications, and other systems to the Vocera Communications system. Thus, the Vocera system at St Agnes performs these tasks when contacting the nurse using Vocera NCI:
* Calls from the patient go directly to the primary care provider's Vocera badge.
* Requests are delivered as text messages and can be played out loud through the Badge.
* Caregivers can call the patient's bedside speaker directly from the Vocera badge.
* Requests, if not acknowledged or responded to, can be escalated as defined by the hospital.
* Audio tones announce the importance of the call.
* Existing lights above the door indicating the type of request using different colors continue to function.
Since its inception at St Agnes, this NCI feature has been deployed in a number of the hospital's units, as outlined in Table 1.
Clinician-to-Clinician Communication System
In addition to communicating with patients through Vocera NCI, the Vocera Communications badges allow caregivers to communicate directly with one another, referenced here as clinician-to-clinician communication. This method of communication follows the workflow shown in Figure 1. A clinician or staff member with a badge presses the button on the front of the badge and asks Vocera to connect him or her to a desired party simply by stating the person's name. Provided the desired party also is wearing a badge, the message is delivered as a synchronous call or left as a voice mail. Calls also may be made by saying the desired party's function or task (ie, charge nurse, transport, and phlebotomist), broadcast to an entire group, or initiated through instant conferencing to other caregivers wearing the badge.
Clinician-to-External Communication System
Although beyond the scope of this study, the Vocera system does allow, and St. Agnes is using, a feature that allows staff members or clinicians to use the badge to call a recipient who is using a cellular or landline telephone within or outside the hospital. The call is routed through the PBX, following the process outlined in Figure 1.
Electronic communication technology has been identified as having an important role in the operations and efficiency of organizations.13-16 Recently, there has been an increased focus on understanding how the characteristics of a technology artifact influence the nature of outcomes it produces for an organization.17,18 By examining the specific technology aspects that improve service levels in a healthcare context, it may enable one to design better technologies and systems.
One particular technology aspect that has been acknowledged as important is the level of integration within a system or across a set of systems.19 The concept of integration has been highlighted in diverse research domains, including strategy, operations, and information systems.19-25 In addition, integration has been identified as playing a key role in healthcare management.26 The specific meaning of integration in the context of communication systems parallels that in other fields and refers to the degree to which the systems and subsystems are able to connect seamlessly to one another despite differing interfaces or contexts.
In this study, we believe that the NCI benefits the operations of the organization through improved integration of the communication systems. Similar to the benefits of integration detailed in other contexts, integration of subsystems relating to communication technology is expected to improve performance through enhanced coupling and information flow. To the extent that the Vocera system can better integrate communications between the patient and other healthcare providers when using NCI, we can expect to observe a performance benefit to the organization.
In this study, our broad goal was to assess the effect that the Vocera system had on performance. We operationalized this goal in the form of two research questions: (1) how does the use of the Vocera NCI affect nurse response time? and (2) how does clinician-to-clinician communication change as a result of the use of the badges? To accurately assess these impacts, we needed to understand exactly how the system was being used. We also required a better understanding of how non-Vocera units were operated. Therefore, we were granted access to two "general medical" units within the hospital-6 North (6N) and 6 South (6S). Unit 6N implemented the Vocera NCI on June 21, 2004, and thus had roughly 1 year of experience with the system. Unit 6S went live with Vocera NCI on July 19, 2005, approximately 3 weeks after we began observing the unit. A senior faculty member trained in ethnographic methods spent 2 days (approximately 12 hours) on each of these units within the hospital observing the workflow of nursing units that had implemented the Vocera system and those that had not. From his experience, he developed a detailed form that was used to assess response time and other characteristics of the work process, such as the type of request made, the location of the nurse, the way in which the nurse responded, and unusual circumstances. This form was subsequently used by student observers as described later.
When observing activity pertaining to Vocera NCI, the primary objective was to assess whether patient requests were fulfilled in a shorter amount of time when NCI was utilized. To measure the time required to respond to patient requests, student researchers trained in observational methods were stationed at nursing stations on different units of the hospital. For unit 6S, researchers observed usage both before and after the implementation of the Vocera NCI system. In the other unit, researchers observed only the postimplementation behavior. In both cases, instances in which the Vocera technology could have been used but was not were logged.
From a central point on the floor, researchers observed when patients initiated a call to the nurse (using either the original nurse call system or the Vocera NCI) because a light illuminated on the entrance to the patient's room and an electronic signal buzzed at a central location. For each episode, the researchers positioned themselves within view of the patient's door and used a stopwatch to measure the length of time between initiation of the call and response to the patient by a member of the nursing staff. The total amount of time, including the time to walk to a telephone for non-Vocera use, was included in the analysis. After the patient's request was met, the researchers asked the nurse about the nature of the request and noted any unusual circumstances.
All statistical analyses and the calculation of descriptives, including means and standard deviations, were performed using SPSS version 11.0 (SPSS Inc, Chicago, IL). Statistical analyses between Vocera and non-Vocera observations are compared using planned, independent sample t tests to determine statistically significant differences in outcomes. For all analyses, an a priori two-tailed level of significance was set at the.05 level.
To address the second research question related to the clinician-to-clinician communication context, we utilized qualitative methods involving detailed observation, note taking, and interviews. Specifically, we used five different researchers and solicited open-ended comments from them about their observations regarding the use of the Vocera system. We also conducted informal interviews with Vocera users, and finally we directly observed and coded responses from users about attitudes toward the Vocera system.
The field study began June 28, 2005, and was completed August 19, 2005. Over the course of the study, more than 120 person-hours of direct observation were completed. After gathering data on Vocera NCI and non-Vocera use, the researchers coded and categorized the data according to a previously determined coding scheme on the basis of the activity performed by the caregiver. From the data collected in both pre-Vocera and post-Vocera NCI implementation, we generated the flowcharts shown in Figures 3 and 4. These charts provided a basis for our statistical analysis.
Vocera Nurse Call Integration Results
After the data were coded, planned comparisons were conducted. Before splitting the data by observation, we compared across all "events." An event is defined as a request made by a patient through the nurse call system-either with or without the Vocera NCI. The results revealed statistically significant evidence that Vocera NCI reduced overall mean time for attending to patients' requests. From the 539 unique events recorded, Vocera NCI improved response time by 51% (mean time reduced from 127 seconds to 62 seconds and standard deviation from 177 seconds to 128 seconds; P < .001). This significant difference was also observed when controlling for the type of request and unit (see Figure 5 for results).
Data compiled from the observations and interviews suggested there was an average of approximately 10 patient requests per hour over a 24-hour period. Given this figure, the reduction in overall mean response time yields time savings of approximately 1572 hours over the course of a year. Economically speaking, the facility stands to save approximately $37,000 per unit per year or.78 full time equivalents (FTEs) per unit.a
We had the unique opportunity to get access to the data collected by Breslin and colleagues27 from their 2003 study and combine their financial results with ours. Their study focused on clinician-to-clinician and clinician-to-external features, whereas our study focused on the Vocera NCI. When combining the financial results from the clinician-to-clinician study27 with the Vocera NCI study we conducted, a total savings of 5137 hours per unit per year, or approximately 2.5 FTEs per unit, is realized from implementation of the Vocera features. This equates to monetary savings of just less than $120,000 per unit per year. The results of this comparison are summarized in Table 2.
In addition to these empirical results, we also report qualitative findings. A prominent finding showed nurses using Vocera in a number of ways besides communication for work-related issues. For example, nurses were observed organizing meetings and conducting conversations through the Vocera badges when face-to-face communication was not convenient. This confirms prior research related to the adoption of new information technologies that suggests users often think of new ways to use technologies, ways originally not intended or conceived by the designers.28
Our examination of event sequences from the flowcharts suggested that a primary source of delay stemmed from the unit secretary (US) function. Before implementation of Vocera NCI, the US fielded the majority of patient requests and would physically find the appropriate nurse (APN), call the APN using the Vocera badge, or page the APN using the intercom or wearable pager. Locating an APN for a patient was time-consuming, sometimes taking up to 2 minutes or more. The same issues arose if an available nurse (AVN), instead of the US, picked up the call. In this case, the AVN attempted to locate an APN, which not only took time but also pulled the AVN from his or her role of directly caring for patients.
We also found that in some cases the APN walked directly into the patient's room, rather than attempting to resolve the problem without meeting face-to-face. Finally, although not quantified, researchers witnessed potential quality-of-care issues associated with the non-NCI situation in that the US forgot to tell a nurse about a patient's request.
Our results suggest that the Vocera NCI provides nurses with additional flexibility in responding to patients, as demonstrated in Figure 5. Specifically we found significant time savings when an information exchange between the nurse and the patient was required, such as when the patient requested food or drink. Information requests yielded the greatest time savings as compared with all other requests. However, tasks that take an extended period of time, such as taking a patient to the bathroom, did not result in the same magnitude of time savings. In other situations that required a physical presence in the room, such as equipment alerts, we found that nurses only responded by entering the room and did not use the badges.
A final benefit of the Vocera NCI, in addition to the time savings reported, is that it provided nurses with the capability of talking directly to patients and/or listening to messages from patients while completing other tasks. This enabled nurses to better understand patients' needs and prioritize their responses to those needs accordingly.
Non-Nurse Call Integration Vocera Communications System
The research revealed instances when the Vocera badge was not used although it was expected. Several nurses used other means of communication, such as shouting down the hall to communicate with a colleague. However, in these cases, the method of communication utilized was likely the most expedient means for the situation. Patient needs also dictated usage of clinician-to-clinician use of Vocera because in some instances, the patient's request called for a more personal means of handling the circumstance (ie, a patient might feel more at ease knowing a caregiver is with him or her and is there to help).
It should be noted that although the Vocera system was widely diffused across the units observed, some caregivers hesitated to fully adopt the technology. For example, clinician-to-external communication was observed on only a few occasions. Instead, landline telephones and cellular phones were the more popular choice when attempting to reach someone outside of the facility. Interviews revealed that the function of clinician-to-external communication was not as popular because users wanted to keep the nature of the call private. Clinician-to-external communication may evolve and become more commonplace but currently is not being used to its fullest extent.
The observed events in this study both statistically and qualitatively demonstrated that the load on the US healthcare staff could be significantly reduced by use of integrated communication systems. This provides a substantial improvement in communication for nurses: in most hospitals, overhead paging, personal pagers, and personal cellular telephones are the primary communication vehicles and the caregiver is mobile and thus not assigned to a specific desk phone or voice mail box or without consistent communication means.
This study revealed strong, statistically significant evidence that the Vocera NCI reduced overall time for completing a patient request and altered the workflow of the nurses in a positive way such that reductions of up to 51% in response time were realized. Observational data for both NCI and non-NCI show that Vocera is being used in various, creative ways, which were not initially envisioned. Similar to the manner in which cell phone use has permeated society for personal and business uses, research indicates that continued use of Vocera (personal or otherwise) will increase a user's creativity in exploring new features and capabilities, ultimately resulting in increased usage for business-related functions. Our findings suggest that new uses will continue to emerge as the system becomes even more integral to the overall workflow at St Agnes Hospital.
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1We use an average salary of $48,000, which assumes several different job roles ranging from Registered Nurse to Nurse Secretary. A total work year of 2000 hours was used to determine the Full Time Equivalent. Cited Here...
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