Caption: A nurse at Gottlieb Memorial Hospital, in Melrose Park, Illinois,
engages a wireless, voice-activated communication device while caring for a patient.
Photo courtesy of Vocera Communications

By Robert Thomas, MA, RN, and
Valerie Shahriari, JD, RN

Although physicians pledge to "first do no harm," in practice, adverse events in hospitals are common and frequently preventable. In fact, Bartlett et al. (2008) found that up to 50% of adverse events in hospitals are preventable. More revealing, the article found that the majority of adverse events are related to communications.

This finding is not surprising; The Joint Commission has consistently cited improved communication among caregivers as one of its top patient safety goals. Why? The Joint Commission (2002) found that breakdowns in communication accounted for more than 80% of sentinel events in hospitals. As a result, in National Patient Safety Goal 2, The Joint Commission identifies three specific areas to address: standardizing approaches to communications, improving the timeliness of reporting critical results, and verifying the correctness of shared information.

Solutions are available today. Identifying the challenges and aligning the right technology to the communication problems can improve workflow and reduce unnecessary miscommunication of critical patient information.

A Broken System
Communication patterns in hospitals are often complex and convoluted. In the perioperative unit alone, daily communication occurs consistently between anesthesiologists, service charge nurses, departmental coordinators and directors, laboratory techs, desk secretaries, transporters, patient waiting room volunteers, transplant teams, schedulers, pharmacists, and housekeepers. Because healthcare is provided by cross-functional teams of caregivers, there are constant opportunities for patient care to suffer due to poor communication among team members.

Worse than the complex nature of hospital communications is its fragmentation — using a combination of pagers, overhead pages, cell phones, nurse call systems, and landlines provides opportunities for information to become lost or muddled. A note delivered to the wrong nurse, an overhead page unheard by a physician, and an urgent cell phone call missed in an area of poor reception are just a few of the situations that occur every day in hospitals, contributing to medical errors and inadequate medical care.

In addition to being fragmented and inaccurate, traditional communications methods are inefficient in the hospital setting and can distract clinicians from patient care. Rather than being at the patient's bedside, clinicians find themselves waiting on hold on the telephone, searching for staff and resources in the facility, walking to and from the nurses' station to place and receive calls, and waiting for telephone calls and pages to be returned. These administrative tasks can consume hours of clinicians' time that would be better spent caring for patients.

The fundamental problem with traditional communication practices is that they are incompatible with hospital workflow. While hospital workers are mobile, nearly all of the information they need to perform their duties is retrieved from stationary devices — computers, landlines, nurses' stations, and centralized alarm monitors. When clinicians need to access information, they must interrupt their workflow to locate and access the stationery device. Adding another layer to the problem, the people and resources they need to locate are mobile. While at least the placement of devices is constant, the location of mobile staff and resources is unpredictable — finding them can be frustrating, distracting, and time-consuming for clinicians without an effective communications method.

Another constant distraction in most hospitals is overhead pages. Overhead pages interrupt caregivers from their work and disrupt patients. In addition, urgent overhead pages may be missed when caregivers are with a patient or in a part of the hospital where the pages are not easily heard. Alternatively, clinicians may become accustomed to the constant noise in hospitals and block it out, leading to missed pages.

In the mission-critical hospital environment, a lapse or delay in communication can result in a range of adverse outcomes from mild to fatal. However, even outcomes that appear to be of small consequence, such as slow patient throughput, have a snowball effect in the operating room (OR) or emergency room (ER). Slow patient throughput translates into delays for critical patients waiting for beds and surgeons to become available. A difference of minutes and even seconds in receiving treatment can have significant repercussions related to patient safety.

Impacting Patient Safety With Wireless Communications
In recent years, the advent of wireless technologies has offered hospitals new communication options. While these technologies cannot reduce the number of people who need to communicate in the hospital environment, they can simplify the nature of the communication. Rather than sending a page and waiting by the phone for a response, communication through wireless devices is instantaneous, intelligent, and directional. By enabling direct communication between the sender and recipient, a wireless device cuts out the intermediary steps that result in delays and distractions.

Whereas traditional communication is one to one, wireless devices provide communication from one to many. With a particular wireless system, a user can contact others by name, clinical role, or group. This eliminates the need to remember phone numbers, current staffing, or even names. In addition, the user can broadcast a message to all staff or specific code teams. However, unlike an overhead page, the broadcast message is sent to each individual's device, minimizing distractions to patients and ensuring a recipient wearing the device hears the call. In this way, the wireless device prevents missed messages, ensures delivery to the correct recipient, increases the efficiency and speed of communication, and results in faster responses to patient needs.

LeAnn Northam, a nurse and clinical manager at Riley Children's Hospital in Indianapolis, Indiana, recalls a recent situation in the OR in which wireless communication proved critical. "The circulator nurse had stepped out while the scrub nurse was monitoring a patient. Suddenly, the patient began rapidly decompensating into a code situation and needed the immediate attention of anesthesia staff. Without leaving the patient's bedside, the scrub nurse contacted all anesthesia staff through her wearable wireless device with an urgent message. Within seconds, support arrived, and the patient was returned to a stable condition," LeAnn says.

In contrast to wired communication devices, wireless technologies map to mobile workers' daily routines and enable a fluid workflow. When technology dictates workflow in a hospital, the results are inefficient processes. Yet, lightweight, wearable devices accompany clinicians wherever they are within a facility. For the circulating nurse in the OR, this point of distinction has particular relevance. The circulating nurse must be able to circulate in order to meet the staff's needs. When the circulating nurse can move freely to accomplish tasks while receiving incoming calls, the nurse can satisfy requests faster. This results in more immediate responses to staff and patient needs and, ultimately, produces better outcomes from a patient safety perspective.

In the perioperative unit, a nurse's ability to spend additional time with patients is critical, especially, when patients emerge from anesthesia. At the patient's bedside, nurses can help patients wake up calmly, so they can understand where they are and their post-operative status can be determined. If a patient has any adverse effects, the nurse can immediately call for assistance through the wireless device without leaving the patient alone.

When the patient is ready to move to the recovery unit following surgery, wireless technologies streamline the process and expedite patient throughput. As the patient begins to emerge from anesthesia, the nurse can contact the recovery unit early in the process and provide an estimated time of arrival and status report. In preparing the OR for subsequent surgeries, a wireless solution simplifies the steps needed to turn the room over and distracts fewer clinicians from their work.

Medical Device Connectivity
Another way wireless technology maximizes patient safety is through connectivity with other devices, such as the nurse call system, alarm notifications, and biomedical machines. There are numerous applications for wireless integration, which deliver immediate benefits at the point of care. When patients require assistance, they can press the nurse call button to send a notification to their nurse through the wireless device. Likewise, alarm notifications can be integrated so that nurses will immediately learn when, for example, a patient's hospital bed detects a weight change or the bed rails are disrupted. For elderly patients who may attempt to get out of bed contrary to the doctor's recommendation, this notification can expedite a nurse or caregiver getting to the room before a patient falls. In terms of biomedical machines, a wireless system can integrate with machines such as an EKG monitor to send an alarm when a set parameter is exceeded or levels decrease significantly. Through connectivity with patient devices, clinicians are informed instantly of situations requiring immediate action and can therefore better prioritize patient needs.

While wireless communication impacts patient safety on a day-to-day basis, crisis situations underscore its truly invaluable role in hospitals. During the bridge collapse in Minneapolis in 2007, cell phone towers were overwhelmed and eventually shut down for emergency transmission of communication from law enforcement. However, despite the mass chaos, staff and clinicians at Hennepin County Medical Center were able to communicate uninterrupted throughout the crisis, as the facility's wireless communication system ran on backup generators and did not require the cell or traditional phone networks. Employees' use of wireless voice communications to order supplies, manage staffing, and assign rooms enabled them to seamlessly handle the influx of critical care patients to the ER.

Challenges to Integration
While wireless technologies effectively address many communication issues and contribute to patient safety in hospitals, newer technologies are not always compatible with existing wireless infrastructures, leading, at times, to overhauls of hospitals' wireless networks. One challenge is the need to upgrade systems to keep up with the flow of new technology and features. The rapid pace of technological innovation can render even seemingly advanced technologies obsolete in little time.

Furthermore, start-up costs for purchasing, deploying, and maintaining a comprehensive wireless network and wireless applications are significant. Yet, hospitals are experiencing an increase in operating costs and a decrease in reimbursements. With a shrinking profit margin, many hospitals are cutting so-called "non-essentials," including IT. Without understanding the clinical role of wireless technology and its integration with patient care, hospital decision-makers may relegate communication systems to back-office capital budgets.

What hospital decision-makers may not fully appreciate is how minimizing adverse events and improving patient throughput with wireless technology actually offset the costs associated with implementation. By positively impacting staff communication and, therefore, patient safety, wireless technologies can help shorten wait-times, minimize delays in care, and, ultimately, reduce the length of patient stays — factors which have a significant impact on the bottom line.

Integrating Wireless Into an Overall Strategy
Wireless technology has a measurable and significant impact on patient safety by improving staff communication, reducing adverse events, and expediting patient throughput. However, to produce the greatest results, the deployment of wireless technology must fit into a hospital's overall strategy.

Valerie Shahriari is the director of risk management and patient safety at Clarian Health, in Indianapolis, Indiana. Shahriari's nursing experience includes the physician office setting and hospital setting, with particular expertise in the operating room in both cardiovascular and general surgery areas. Shahriari obtained her juris doctor in 2001 from Indiana University School of Law. While pursuing her graduate degree, Shahriari served as a law clerk with a concentration in the area of Medicare and Medicaid Fraud and Abuse. Shahriari graduated with honors from Indiana University with a bachelor of science degree in nursing. She currently serves as a board member for the Indiana Society for Health Care Risk Management and as a member of the American Society for Health Care Risk Management. Shahriari may be contacted at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

References

Bartlett, G., Blais, R., Tamblyn, R., Clermont, R.J. & MacGibbon, B. (2008). Impact of patient communication problems on the risk of preventable adverse events in acute care settings. Canadian Medical Association Journal, 178(12). 1555-1562.

The Joint Commission. 2009 National Patient Safety Goals. Available at http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/

The Joint Commission. (2002, June 17). Sentinel Event Alert 26: Delays in treatment. Available at http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_26.htm

The Joint Commission. Sentinel Event Root Cause and Trend Data. Available at http://www.jointcommissionreport.org/performanceresults/sentinel.aspx

March / April 2009 Table of Contents