AS THE HEALTHCARE INDUSTRY increasingly relies on sophisticated clinical software and equipment, healthcare systems face the challenge of integrating technology with skilled and compassionate clinical services. Effectively providing technology-based and patient-centered care is a difficult balancing act that can lead to rising costs and a decrease in quality of care and patient satisfaction.
Presbyterian Healthcare Services based in Albuquerque, N.M., has created an impressive example of implementing technologic advancements that contribute to an exceptional patient experience. This article describes the implementation and success of Presbyterian's centralized nurse call system.
Texting for help
Presbyterian is a not-for-profit integrated healthcare system with eight hospitals statewide, a growing medical group, and New Mexico's largest health plan. The system has recently garnered substantial national attention for implementing treatment methods that use state-of-the-art technology to enhance patient-centered care.
Presbyterian's most recent innovation is a centralized nurse call system that's significantly changed the way patients and nurses interact and communicate. The hospital's traditional nurse call system has been augmented with a software upgrade that routes all calls initiated from a nurse call button on the patient's pillow speaker to a centralized call center. A nurse call operator answers each call, listens to the patient's request, and sends a text message to the wireless phone of the patient's nurse or unlicensed assistive personnel (UAP), indicating the patient's request.
Patient calls are addressed in this manner for 13 units and about 450 beds, making Presbyterian one of the only hospitals in the nation operating a centralized nurse call system of this scale. Each nurse and UAP has one of the hospital's shared wireless phones, which he or she picks up at shift change. Nurse call operators, who are nonclinical operators with training as dispatchers, answer 1,300 to 1,500 calls a day.
Out with the old, in with the new
The centralized approach restructures Presbyterian's original nurse call process, which was an inefficient care model that required nurses and UAPs to answer calls by entering a patient's room to determine the patient's needs. The unnecessary interruptions and extra steps in this model added to nurses' already-demanding workflow.
Presbyterian's innovative step away from this traditional nurse call system toward a more efficient centralized system is supported by a recent study examining the need to identify inefficiencies within current care delivery procedures.1
Centralizing Presbyterian's nurse call operations has significantly improved patient care and satisfaction, as well as nursing workflow. One of the most significant enhancements is the speed at which patients hear a warm and compassionate voice. After pressing the call button, operators greet patients within 12 seconds on average. Another benefit is that nursing staff can prioritize multiple calls. Each text message includes detailed information about a patient request, which takes the mystery out of what the patient needs. For example, a bathroom call can be prioritized over a request for the lights to be adjusted.
Additionally, advance notification of the patient's needs lets staff respond with the necessary items in hand, such as requested medication. Reducing travel time and interruptions lets nurses spend more time giving patients personalized, one-on-one attention.
The centralized approach also prevents nurses from being interrupted or distracted by accidental patient calls because nurse call operators can cancel these immediately. The impact of this feature is significant because about 10% of patient calls at Presbyterian fall into this category. One study examined these interruptions and found that accidentally pushing the call button was the fifth highest ranked reason for call button use.2
Thanks to this new system, nursing units are experiencing improved workflow as a result of the division of call assignments to the appropriate staff member—either the nurse or UAP. Each staff member receives fewer notifications under the centralized system, meaning that nurses have more time to spend on other vital responsibilities. A recent study analyzing how nursing staff members view patient-initiated call buttons sheds more light on this subject: 44% of nursing staff felt that call button notifications interrupted their workflow while attending to other aspects of their jobs.3
By maximizing the efficiency of staff performance while reducing wasted time and effort, this innovation is aligned with Presbyterian's initiative to improve two Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores: patient satisfaction in the areas of nurse communication and staff responsiveness. (See Patient complaints about call button and nurse responsiveness.) Dramatic improvements have been observed in a relatively short time, with an increase of about 7% in patients answering “always” for the HCAHPS survey question related to call button response. (See Percent of patients who received immediate call button help.) Performance optimization is also relevant to Centers for Medicare and Medicaid Services value-based purchasing, which focuses on outcomes that directly correlate with patient satisfaction and improved quality of care.
Another outcome of the enhanced nurse call system is a quieter environment. The nurse call console at the nursing stations on each unit used to ring more often because it was the default notification if calls weren't answered in a timely fashion—a more common occurrence with the original system. Although this observation has yet to be quantified in relation to patient satisfaction, staff members frequently comment on how quiet the nursing units are now.
Besides streamlining routine medical care, the new system has averted many critical incidents involving patients. When the program was first implemented, an operator received a patient call. After she greeted the patient, the only sound she heard on the other end of the line was the patient gasping for air. Following the triage protocol, she sent a STAT message for all staff to respond to the patient's room immediately. Within seconds, a nurse found the patient unresponsive, apneic, and pulseless and began CPR. The patient was immediately transferred to the ICU, where she recovered and was discharged home within a week. Had the operator not answered the call and sent the text message, the nurse wouldn't have been aware of this critical situation in which every second counted. When the nurse call operator sends a STAT message, it's sent from within the nurse call computer application and is received only on the nurses' wireless phones. The responding nurse determines what type of response is needed; for example, the rapid response team or the code team. (The rapid response team is notified by a group notification to their pagers or hospital wireless phones; codes are announced overhead.)
Optimizing nurse call operators
The implementation of the centralized nurse call system has included several learning cycles to refine various operational elements. The initial testing process was piloted on three medical-surgical units for 3 months. During that time, procedural issues were identified and addressed, such as the need to provide a description to patients at admission about how the nurse call process works and the need for nurse call operators to compose shorter, more specific messages.
The current learning cycle involves the development of improved methods for tracking overall call performance with more reliable statistics. The goal in enhancing data collection is to enable Presbyterian's nurse managers to better analyze the daily patterns of call button use, including the average response time, specific to individual units.
The information services department is also developing custom reports that provide the percentage of called-in patient requests by type. This information should let hospital staff anticipate and proactively address patient needs during hourly rounding, leading to a decrease in the use of call buttons. One study found that implementing hourly rounding reduces call button use by 37.8%.4
The definitive success of the centralized nurse call system at Presbyterian's main hospital has triggered plans for its implementation throughout Presbyterian's hospital network. The system has been fully integrated into its newest hospital, Presbyterian Rust Medical Center, which opened in October 2011. The nurse call team is also excited about the future opportunity to answer patient calls remotely—that is, installing the system in other Presbyterian hospitals and routing the calls to operators in the main hospital. Some of the benefits include more efficiency and reduced labor costs because a nurse call operator isn't needed at each facility. Rather, operators at one facility can answer calls for all facilities. Also, processes can be more effectively hard-wired and monitored at an enterprise-wide central nurse call location, where staff and managers are subject matter experts. This enhancement is currently in the development stages.
The centralized nurse call system, an innovation that's set a new standard for call button response procedures, is now a key tool in strengthening Presbyterian's patient-centered care model. Based on its success, this system may set a standard for other healthcare organizations nationwide.