July / August 2012
The RTLS Patient Safety Improvement Opportunity
The goals of any healthcare technology should be to improve healthcare quality and patient safety, contain or reduce healthcare costs, mitigate risk exposures, and enhance revenues. Relatively few technologies score high in meeting all of those objectives, but real-time location systems (RTLS) clearly do.
RTLS is a wireless technology that permits hospitals to track the location and status of moveable medical equipment, patients, and staff. Through the attachment of battery-powered tags to equipment and persons of interest and strategic deployment of sensors throughout a facility, RTLS essentially functions like an indoor global positioning satellite system. The tags also have the capability to interact with each other. In addition, most RTLS solutions include applications that enable institutions to monitor, analyze, and manage workflow in discrete locations such as the operating room (OR) and emergency department, and to monitor both temperature and hand hygiene.
Among the foregoing goals, improving patient safety gets my top vote. Despite the healthcare industry's intense efforts to make care safer over the past two decades, there remains a substantial amount of low-hanging patient safety improvement fruit. We need look no further than the November 2010 reports in the New England Journal of Medicine (Landrigan et al., 2010) and from the U.S. Department of Health and Human Services Inspector General (2010) for clear evidence that serious problems persist. While some progress has been made, the net gain in patient safety improvement since the Institute of Medicine report To Err Is Human was issued in 1999 (published in 2000) has been zero, or perhaps worse.
Thus, one can hardly question the need to devote more attention to patient safety. RTLS is an ideal vehicle for hospitals to realize that objective, especially as they seek ways to address the challenges posed by the emerging public policy emphasis on outcomes. How does RTLS help improve patient safety? With apologies to Elizabeth Barrett Browning, let us count the ways:
Responding to equipment recalls. When the need for an equipment recall is determined by the Food and Drug Administration or by a manufacturer, it is vital that the equipment be immediately identifiable and retrievable. Failing that, patients may be at serious risk. This capacity to facilitate immediate equipment retrieval is a trademark RTLS capability. Sometimes the need for an immediate recall is identified internally. For example, a particular infusion pump was identified as the root cause of a patient death at a major medical center. The ability to retrieve this pump just as it was about to be used again for another patient—with potentially disastrous consequences—was made possible only by the institution's functioning RTLS.
- Avoiding use of dirty pumps. The use of infusion pumps has become a fundamental element of in-patient care, but the sheer volume of this equipment makes it difficult for hospital staff to keep track of where individual pumps have been and where they are going. Recent baseline studies in hospitals about to install an RTLS have found that up to 20% of pumps used in patient care are being moved from one patient to the next without any intervening cleaning process. This is clearly a patient safety hazard. The use of RTLS provides a definitive capability to track the status of each infusion pump in the hospital, assure a continuing supply of clean pumps in each patient care area, and eliminate the obvious risk exposures for vulnerable patients.
- Reducing patient falls. Patient falls and resulting injuries among the elderly remain one of the most nagging and serious patient safety problems in hospitals. One-third of these occurrences happen when individuals leave their beds—usually while trying to go to the bathroom unaided. The frequency of those falls is greatest at night and during weekend shifts when staffing levels are lowest (The Joint Commission, 2000). The ability of patient RTLS tags to identify and alert caregivers to unexpected patient movement at the bed level offers an important opportunity to prevent or mitigate patient falls, or at least trigger immediate medical attention for the patient who has already fallen.
- Preventing pressure ulcers. More than 2.5 million hospitalized patients develop pressure ulcers each year (Lyder, 2003), and almost 60,000 of them die because of pressure ulcer complications (Reddy & Rochen, 2006). Pressure ulcers may develop when a partially or totally immobilized patient lies in bed in the same position for hours at a time, thereby cutting off the blood supply to the skin and underlying tissue. The single most important preventive measure is to regularly reposition the patient with limited mobility according to a schedule based on the patient's needs and pressure ulcer risks. RTLS software can help to prevent pressure ulcers by generating automated, patient-specific alerts to responsible nurses that are timed to the patient's repositioning schedule.
- Monitoring "timeouts" before surgery. One of the most perplexing patient safety issues is the unwillingness of some surgeons to participate in timeouts before the actual commencement of a surgical procedure. The principal purpose of a timeout is to prevent wrong-site, wrong-procedure, or wrong-patient surgeries that continue to occur with significant frequency despite the long-standing efforts of The Joint Commission and the World Health Organization. The typical timeout involves confirmation of the identity of the patient; the procedure to be performed; the planned surgical site with particular attention to laterality (right versus left side of the body); the intended patient positioning on the operating table; and the expected use of implants or special equipment (if applicable). RTLS software configured to OR workflow lends itself especially well to solving this health professional behavioral problem by virtue of its ability not only to codify, monitor, and drive existing workflow steps, but also its potential to introduce mandatory new process steps (i.e., like those involved in a timeout) whose intent is to improve surgical safety.
- Creating audit trails. One of the understated advantages of RTLS is its ability to create audit trails. Assuming that patient and caregiver tags remain attached, it is possible to create trails of staff and patient movements and interactions. The epidemiologic importance of this capability often is not appreciated. For example, if a patient admitted to the hospital is later found to have tuberculosis or another serious contagious disease, it would become imperative to quickly identify all of the caregivers who had come into contact with that patient prior to this discovery, as well as the patients with whom these clinicians had subsequently been in contact. The automatic RTLS audit trail could turn a nightmarish contagion scenario into a straight-forward problem-solving exercise.
- Monitoring hand hygiene compliance. The failure of caregivers to wash or clean their hands before and after patient contact is believed to account for a preponderance of the 2 million healthcare-acquired infections that the CDC estimates occur each year. Approximately 90,000 of these infections result in death. Despite concerted attention to this problem by the Joint Commission, World Health Organization, and Institute for Healthcare Improvement, among others, observed handwashing rates in most hospitals are regularly below 50% (Boyce, 2011). To date, various hand-washing monitoring techniques have proven to be ineffective, inaccurate, or excessively expensive. However, with recent technology improvements, RTLS now offers an objective and effective means of monitoring and recording hospital staff handwashing behaviors. In hospitals where staff and patients are wearing tags, and sensors have been attached to soap and alcohol dispensers, handwashing rates have reached and exceeded 80%.
To be sure, RTLS is not a sweeping patient safety panacea. However, it can unquestionably be part of the solution for hospitals seeking to make lasting, systemic patient safety improvements. The maturity and proven effectiveness of RTLS offers providers a significant opportunity to improve patient safety. We need only realize that the improvement opportunity has arrived, and that it is time to act.
Dennis O'Leary is president emeritus of The Joint Commission and currently serves as chief strategy officer of Awarepoint Corporation, the leading provider of real-time location system solutions for healthcare.