Nursing Informatics is a well-established specialty within nursing which has evolved at a rapid pace to become an integral part of healthcare delivery. This health care specialty is a differentiating factor in the selection, implementation and evaluation of health IT that supports safe, high quality, patient-centric care.
Call for Innovation
Your Voice, Your Opportunity, Your Idea
In 2013, HCA's CNO Council issued a Call for Innovation. We asked our nurses: "If you could design or create future technologies or innovations that would change the practice of nursing, enhance nursing workflow, streamline processes and improve patient safety - what would they be?"
Over 800 nurses from thirty-five HCA hospitals shared their ideas on how to improve patient experience. Nurses carried index cards through two shifts. Each time they encountered a situation they imaged could be possibly improved with a technology solution, they wrote their idea on the card. These ideas were then collected and synthesized into a technology roadmap for nursing.
Here at HCA, Connected Care enables safe, effective and efficient care that leads to improved patient, family and care team experiences and better patient outcomes.
Below are some of the technology solutions and resources leveraged to transform and enable coordinated care:
A Foundational Component of Patient Safety
Barcode Medication Administration is the building block for medication safety in the Electronic Health Record. BMCA is a part of secure medication administration that assures that medication, dose, route, time and patient identity are correct. HCA was an early adopter of BMCA, implementing the safety technology in over 160 hospitals between 2002 and 2004.
In 2013, close to 170 million doses of medication were given in HCA hospitals using this technology. The system issues 1.1 million clinically significant alerts that prevented 1.1 million medication errors.
The most frequent "wrong medication" alert involves loading the wrong medication into the automated dispensing cabinet, particularly medications that have extended release, immediate release and sustained release formulations. Often, the only difference in the printed name is the addition of ER or SR. However, the barcode identification is completely different. One close call occurred in the ICU with a patient having new onset of seizures. Depakote SR (sustained release) was loaded into the dispensing cabinet instead of Depakote IR (immediate release). If this error had not been detected by BCMA during medication administration, the mix-up would have resulted in delayed seizure control, additional medication changes and more days in the ICU.
Bar Code-enabled Transfusion Administration (BCTA) provides the ability to monitor and report on the administration of blood products.
Nurses use the existing patient armband and the existing bar code on the blood product to ensure that the correct product is being issued and administered to the correct patient for administration.
The goal of this system is to completely eliminate transfusion errors related to patient/product misidentification.
- Reduces opportunities for human error in product matching and compatibility
- Streamlines charting and inventory management
- Enables critical "double-checking" to be done by a single nurse
- Improves monitoring and reporting regarding blood administration and utilization
- Automates the reporting and trending of blood utilization in accordance with regulatory guidelines
- Automates reporting of blood transfusion reactions
Changing the Patient Care Experience by Bringing Efficiency and Accuracy to Vital Sign Recording
Despite years of training and experience in caring for patients, many health care practitioners find that a substantial portion of their working time is devoted to other activities, such as the recording and transcription of patient information. According to a 2008 report, Medical-Surgical nurses spend approximately 35% of their time on documentation. Technology solutions could increase nurse productivity, but these solutions must be designed to maximize acceptance and minimize workflow disruptions.
The 2009 publication "A Proclamation for Change: Transforming the Hospital Patient Care Environment" from the Robert Wood Johnson Foundation called for the design and use of technology to improve the quality and efficiency of patient care. This prompted the HCA Chief Nursing Officer (CNO) Council—a leadership group of Chief Nursing Officers from HCA facilities across the country, to initiate a focus on health technology management. They challenged HCA to improve the technology available to practitioners at the bedside.
In a collaborative effort, Jane Englebright PhD, RN, CENP, Chief Nursing Executive and Patient Safety Officer, led the creation of the HCA Medical Device Intelligence (MDI) team. This team of clinical and information technology experts was charged with developing, implementing, and supporting technology to simplify and improve clinical processes.
The team's first project
The team's first project was to streamline the labor-intensive task of vital sign measurement in non-critical care areas through working in cooperation with the CNO Council, HCA leadership, technology vendors, and front-line clinicians. The result is an innovative technology initiative that represents the first of its kind in the Medical-Surgical environment. The "VitalsNow" project has brought more efficiency, accuracy, and provider satisfaction to the recording of vital signs. The resulting practice changes illustrate how the use of well-designed technology can fundamentally change the patient care experience.
"VitalsNow" combines a technology module—a touch screen device—that interfaces with spot check monitors and wirelessly transmits vital signs to the patient's electronic record. Produced by Capsule Technologies, it seamlessly integrates with existing equipment in HCA's Medical-Surgical care environment. Designed as an "all-in-one" solution, the module fits within the established clinical workflow and does not require clinicians to carry an additional handheld device or log onto another workstation. Instead, the caregiver logs on to the system via the module, scans the patient's barcode wristband, collects vital signs as usual, verifies the collection, and enters any supplementary data (such as weight or level of consciousness), and submits the data. Vital sign data are available almost immediately in the patient's electronic medical record with no additional interaction required.
When the "VitalsNow" project was initiated in 2009, there were few vendor-provided technology solutions for vital sign collection in the Medical-Surgical care environment. Currently, "VitalsNow" has been implemented in the Medical-Surgical units of 163 hospitals across the HCA system. In these units, over 90% of vitals are collected using this system. This represents nearly 1 million electronic vital signs collected per month.
"VitalsNow" gives time back to staff
"VitalsNow" has altered how caregivers spend their time by changing the nature of data collection and increasing the availability of information. This system gives time back to staff by eliminating need for nurses to record vitals on paper, transfer that information to charts, and eventually transcribe into the patient's electronic record. This saves about an hour of documentation time every day, freeing nurses to spend more time with their patients. In addition, the direct import of vital sign measurements into the electronic medical record, in combination with barcode patient identification, reduces the risk of transcription, transposition, or wrong patient errors in patient records.
Before "VitalsNow," data entry into the electronic medical recorded could be delayed by up to four to six hours from collection. The immediate capture and submission process of "VitalsNow" provides access to real-time data, ensuring that a patient's most current vital signs are immediately available when nurses are passing out medication or physicians are doing rounds. Clinicians can use these data to make clinical decisions and better coordinate care based on a patient's current condition. These data can be accessed from any computer terminal with permission to view the patient's electronic record, which allows nurses to monitor vitals collected by technicians in another room or for physicians to view patient information without having to locate the physical chart.
VitalsNow is an innovative technology solution designed and created by nurses to solve real-life problems in the non-critical care environment. Nurse-led development resulted in a successful technology solution that enhanced patient safety and clinical outcomes while improving the work environment for nursing. VitalsNow met all of the objectives of the Proclamation for Change.
Virtual Sitter solutions improve patient safety by providing remote patient monitoring capabilities to replace and/or supplement traditional 1:1 sitter options.
Benefits realized through Virtual Sitter solutions are:
- Decreased patient falls and injuries
- Improved communications between nurses and sitter staff
- Improved response time to patients becoming agitated or attempting to get out of bed unassisted
EBCD: Standardizing Clinical Documentation
Evidence-Based Clinical Documentation (EBCD) creates a patient centric record that guides and informs the provision of safe, effective and efficient care by the interdisciplinary team and produces data to evaluate care of individual and populations of patients. The key characteristics are:
- Patient Centric
- Data driven
EBCD blends the contributions of multiple disciplines to create a coherent patient-centric electronic health record to eliminate duplication and facilitate interdisciplinary care. A key component of EBCD is building documentation elements to support evidence-based practice.
Standardization Supports Safety
EBCD captures patient care data using standardized coded clinical terminology. It optimizes the use of safety components of software to support clinical decision-making at the point of care.