Role of Wireless Communication in Patient Response Time: a Study of Vocera Integration

Role of Wireless Communication in Patient Response Time: A Study of Vocera Integration with a Nurse Call System

ABSTRACT:

The goal of this paper is to investigate the use and impact of wireless Voice over InternetProtocol (VoIP) communication technology developed by Vocera communications and used by clinicians and mobile workers in a healthcare setting. Of particular interest for this study was the impact of a newly installed component of the Vocera system, the Vocera Messaging Interface (VMI), which enables connectivity between external systems and the Vocera system via the Vocera Server. We focused on a specific VMI application used in the healthcare industry that directly integrates Vocera with Nurse Call Systems. In this Vocera Nurse Call Integration (NCI) application, bedside calls from patients using the hospital’s Nurse Call System trigger messages that are sent directly to the primary care giver. Primary care givers can read or play messages and either speak a command or respond to the call to the patient’s pillow speaker via the PBX/Nurse Call system. The primary objectives of the paper were to measure the effect of using NCI on response times to patient requests and to analyze qualitatively the benefits of using the Vocera Solution.

This paper focused specifically oncommunication between caregivers and patients. This data gives the relationshipbetween integrating the Nurse Call System with the

Vocera System and the time requiredfor a caregiver to respond to a patient request. In addition to this, a qualitative analysisof the use of the system for clinician-to-clinician and clinician-to-external communicationoutside of the Vocera NCI use is conducted.

In June 2005, the Center for Health Information and Decision Systems (CHIDS) was contracted toconduct a research study at St.AgnesHospital in Baltimore, Maryland by Vocera Communications,Cupertino, California. St. Agnes purchased the Vocera Communications System in 2003 and hasbeen deploying it in stages in terms of functionality and units since that time. It is currentlydeployed in a variety of units and is used by many types of clinicians and staff members, includingbut not limited to nurses, administrative staff, technicians, and physicians. Vocera and St. Agnes,with assistance from an independent consulting group, conducted a ‘Benefits Study’ in Decemberof 2003. This study yielded important findings related to the time savings and financial benefitsresulting from the implementation of the core Vocera system. However, this study did not examinethe impact of the Nurse-Call or PBX integration. The study conducted by CHIDS investigatestwo phenomena: Vocera Nurse-Call Integration system (NCI) and non-NCI utilization.

Why do we use Wireless Communication?

Communication has long been recognized as a critical factor in healthcare. There are few serviceorganizations that require the extensive degree of interaction between highly trained and skilledstaff members and the large percentage of mobile workers as is required in the healthcare environment.Clinicians and hospital staff recognize the value of timely communication and the importanceof effectively accessing knowledge and expertise. Hospital executives manage the need for timelycommunication by co-locating key medical staff and by adopting proven communication technologies. In the early 1980’s, the presence of a pager on someone’s belt marked his/her roleas a physician. Now, in many instances, cell phones have taken the place of the pager, but thereare limitations to cell phones. These include dead spots in coverage, rooms where cellulartechnology cannot be used, and the ever-present limitation of being primarily one-to-one deviceswith limited ability for broadcasting messages. New technologies are being utilized within healthcaredelivery systems that improve communication between peers, between the patient and clinician,and between subordinate and supervisor.

With the advent of wireless communications, we noware in a situation where the technology is becoming mature, stable, and easier to use. Thisubiquity will ultimately lead to real-time delivery of information to the decision-maker.

In essence,the wireless system acts as the underlying architecture for a hospital-wide information portal.

TECHNOLOGY DESCRIPTION:

The information technology that we examined for this study was the Vocera CommunicationSystem. It consists of two main components:

The Vocera System Software which controls andmanages call activity and workflow and

The Vocera Communications Badge, a wearable, voicecontrolledcommunicationdevice that operates over a wireless LAN (802.11b)

The badge weighs less than two ounces and is very portable due to the fact that is primarily wornaround the neck or clipped to a lapel and understands spoken voice commands in natural language.With one-button access, a user can connect to anyone in a designated facility, or in the case ofthis implementation, even to outside phones through PBX (Private Branch exchange) integration.

Within the St. Agnesfacility, there are three primary functions for which Vocera is being used:

Nurse-Call Integration

Clinician-to-Clinician(s) and

Clinician-to-External communications.

Figure 1:Vocera Communications System

Vocera Nurse-Call Integration (NCI):

In the simplest terms, the Vocera NCI integration enables a two-way communication link between primary caregivers (i.e., the assigned nurse) and patients. Vocera NCI enables a directcommunication link between the existing nurse call communication equipment5 integrated intoeach hospital bed and the Vocera badges carried by each nurse. The integration between theexisting nurse call system and Vocera is achieved through use of the Vocera Messaging Interface(VMI). VMI can also be used to connect patient monitoring systems,

scheduling software, bedmanagement applications and other systems to the Vocera system. The integration between theVocera system and the nurse call system gives the caregiver maximum flexibility in respondingappropriately to patients’ needs. The specific features that are used at St. Agnes include:

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 they are not acknowledged or responded to, can be escalated as definedby the hospital.

Audio tones announce the importance of the call.

Existing lights above the door indicating (through different colors) the type of requestcontinue to function.

Clinician-to-Clinician(s) Communication:

Clinician-to-Clinician(s) communication takes place using the architecture described in above Figure. The primary difference between NCI and clinician-to-clinician(s) communication issimply that the sender (a clinician or other hospital staff) initiates a call using the badge and therecipient (a clinician or other hospital staff) also is a badge holder. With this type of communication,the message is delivered as a live call or voicemail. The clinician may also call by function(i.e. charge nurse, transport, and phlebotomist), broadcast a call to a group, or perform an instantconference with others who are wearing the Vocera badge. The researchers find this to be a significantcommunication improvement for nurses because in most hospitals, overhead paging, personalpagers and personal cellular telephones are the primary communication vehicles, and the caregiveris mobile, not assigned to a specific desk phone or

voicemail box and without consistentcommunication means.

Clinician-to-External Communication:

Clinician-to-External communication is initiated when a clinician or staff member initiates a callusing the badge and calls an extension within the hospital, pages someone or dials an externaltelephone number. The call is routed through the PBX. In this situation, the sender (a clinician or other hospital staff) initiates a call using thebadge and the recipient receives the call on either a land-line telephone or cellular phone, within or outside the hospital.

Facility Description:

St.AgnesHospital is a 300-bed non-profit hospital located in Baltimore, Maryland. It is part ofthe Ascension Health system and primarily serves Baltimore and the surrounding region. It is afull service community teaching hospital, with approximately 23,000 admissions annually and isclassified as a ‘General Medical and Surgical’ hospital. The Vocera Solution was purchased bySt. Agnes in 2003 and has been deployed in stages in terms of functionality and units. St. Agneshad deployed its enterprise-wide wireless LAN in the late 1990’s. A separate virtual local areanetwork (VLAN) was also created for transport of wireless voice calls. Our field study beganJune 28, 2005 and was completed on August 19, 2005—after more than 120 hours of directobservation. Our researchers observed two units, 6 North and 6 South during this time frame.

PROJECT DESCRIPTION:

There were two distinct phenomena being investigated in this study. The first component of the research examined the use of the Vocera (NCI). This was an observational analysis of different floors within the hospital—those that had implemented the NCI feature and those that had not. In addition, the researchers conducted a before and after analysis of floors that adopted NCI during the observational period. As part of the second area of investigation, they conducted a qualitative analysis of the Vocera solution when used for a non-NCI function. The qualitative assessment examined use in a

clinician to clinician or clinician to external communication context.

Vocera Nurse-Call Integration:

The primary objective for this portion of the study was to analyze whether patient requests werefulfilled in a shorter amount of time when the Vocera NCI system was utilized. In order to measurethe time required to respond to patient requests, we stationed student-researchers, trained inobservational methods, at nursing stations on different units of the hospital. For one of the units,we were able to observe usage both before and after the implementation of the Vocera NCI system.From a central point on the floor, the researchers were able to observe when patients initiated acall to the nurse (a light illuminated at the entrance to the patient’s door and an electronic signalbuzzed at a central location). For each episode, the researchers positioned themselves within view of the patient’s door and used a stop watch to measure the length of time it took for a nurse to respond

and fulfill the patient’s request. The total amount of time, including the time to walk to atelephone 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.The data was then transcribed, coded, and categorized according to a coding scheme.

Non-NCI Vocera Communication System:

The intent for this portion of the study was not to duplicate or validate the findings from previous work conducted at St. Agnes related to the use of the Vocera Solution. Instead, our goal was to qualitatively assess, using accepted observational methods, the use and impact of Vocera for clinician to clinician and clinician to external communication. This analysis was conducted prior to observing the floors with Vocera nurse call integration and does not include any findings related to Vocera nurse call integration.

RESULTS & DISCUSSION:

Vocera Nurse-Call Integration:

Overall, we found strong, statistically significant evidence that the use of NCI between Vocera and the Nurse Call System reduces overall mean time for completing a patient request. Across 539 unique events, Nurse Call integration with Vocera was shown to improve response time by 51% even when controllingfor the type of request and the unit. Based on an average of approximately 10 patient requests per

hour, this offers a potential annual savings of approximately 1,572 person hours, approximately $37,700 savings per year per unit6, or 0.78 Full Time Equivalents (FTEs) per unit. These savings are in addition to the previous savings identified from the implementations of the Vocera Communications study. The previous study, which took place at St. Agnes in December of 2003, examined employee-to-employee communication within and across different parts of the organization both before and after the implementation of the Vocera Communication system. In contrast, the current study instead examined the communications between patients and their caregivers.

While all floors that we observed had previously implemented Vocera, the researchers found that the time required for communications among employees corresponded very closely with those found in the prior study, though a full analysis of the employee-to-employee communications was outside of the scope of this study. Overall, the implementation of the Vocera system along with the nurse-call integration system represents a total savings of 5,137 labor hours per year per unit. This yields an approximate savings of $120,000 per year per unit8. We should also point out that there may be additional efficiencies and new uses as the Vocera NCI becomes more integrated into the workflow process of the staff.

Volume of
Communication
Events / Average
Communication
Process Time
(minutes) / Total Hours
Required to
Complete
Communication
Process / Total Labor
Hours Saved
Projected per
Year per Unit
Employee-to-Employee Communication (2003 study)
With Vocera / 101,556 / 0.41 / 696 / 3565
Without Vocera / 101,556 / 2.52 / 4261
Clinician-to-Patient (current study of NCI)
With Vocera / 87,360 / 1.04 [62 sec] / 1514.24 / 1572.48
Without Vocera / 87,360 / 2.12 [127 sec] / 3086.72
The bottom line5,137 hours

Table 2:Time Savings from Vocera

An analysis of the time savings from the integrated Vocera system with Nurse Call by request type suggests that the system gives nurses additional flexibility in responding to patient requests (see Figure 2). Time savings are shown when an information exchange between the nurse and the patient is required, such as when the patient requests food or drink. Tasks which may take an extended period of time, such as taking a patient to the bathroom, may not result in the same amount of time savings with the implementation of the Vocera system. Requests for information demonstrate the most improvement through integrating the nurse call system with Vocera, cutting the overall response time almost in half. Other situations—such as equipment alert—resulted in nurses only responding by entering the room. For these, it appears that because the task requires a physical presence, the nurse tended not to utilize the Vocera NCI system for a call back into the room.

Response Time by Request Type

1. Food/Drink 2.Bathroom 3.Information 4.Medical 5.Alert 6.others

Figure 2:Time Savings When Using Vocera NCI

WORKFLOW DESCRIPTION:

After closely examining this event sequences, we were able to generate flowcharts describingtypical responses to patient requests and the order in which the tasks were undertaken. In Figure3, we mapped the process of a nurse call before the implementation of the Vocera NCI. Onemajor source of delay was related to the function of the Unit Secretary (US). When the VoceraNCI was not installed, the US answered most of the calls and decided how to proceed. The UShad the option of:

Walking to find the Appropriate Nurse (APN)

Calling the APN using the Vocera Badge

Paging or using the intercom to reach the APN

The US frequently found it difficult and/or time-consuming to locate the APN for the patient and this process sometimes took up to two minutes or more. The same process was duplicated if an Available Nurse (AVN) picked up the call instead of the US. The AVN attempted to locate an APN, which not only took time, but also pulled the AVN from his/her role of directly caring for patients.

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, while we are not able to quantify this aspect, there was a potential quality of care issues associated with the non-NCI situation in that in some cases the US forgot to tell a nurse about the patient’s request. In Figure 4, the mapping process of a nurse call after the Vocera NCI system was implemented and had been used for at least a month. The main advantage of the Vocera NCI system is the direct line of communication it offers between nurses and patients. The observation demonstrated statistically and anecdotally that the load on the US could be dramatically reduced by use of theVocera NCI. In addition to the time-savings reported in the discussion above, the primary advantage that was witnessed was the ability it gave nurses to talk directly to patients and/or listen to messages from patients while completing other tasks. This enabled the nurse to have a great deal more control in understanding patients’ needs and prioritizing the response to those needs appropriately. Multi-tasking, while not easy to operationalize, is certainly an added benefit that does not show up in our statistics.

Figure 3:Work Process Flowchart (Without Vocera NCI Integration)

Non-NCI Vocera Communication System:

In this portion of the study, our goal was to make qualitative assessments of the Non-NCI byusing a triangulation method of analysis. With this method, the researchers:

Solicited open-ended comments from the five separate observers about the use of theVocera Solution

Conducted informal interviews with Vocera users

Directly observed and coded responses from users about their attitudes towards theVocera Solution

Using this multi-faceted approach, the researchers were able to converge on some central themesand aggregate beliefs about Vocera. One of the more interesting findings relates to ‘creative’ and‘evolving uses of the technology. Prior research with new information technologies in other settingshas suggested that individuals often use technologies in value-adding ways that were originallyun-envisioned by the designers. For example, the researchers saw evidence that nurses were using the Vocerato informally organize meetings and impromptu gatherings. It was also used when face-to-facepersonal communication was not convenient—both for work and personal reasons. In much thesame way that cell phone use has permeated society—for personal and business uses—one can expectthat any use of Vocera (personal or otherwise) will increase a user’s creativity in exploring newfeatures and capabilities and result in increased usage for business-related functions.There were instances when the Vocera NCI system could have been used and it was not.