'Smart rooms' provide patient safety info at the bedside

System gives medical information relevant to provider

The physician walks into the patient's room, and immediately his or her name and job function appear on a monitor at the patient's bedside. The same holds true for each successive health care professional who enters. Another monitor shows the providers important care information, such as vital signs, current medications, and allergies. Additional information, including warnings about a patient's risk of falls or the schedule for pain medication, also can be displayed.

This is not the future vision of some patient safety expert; this very scenario is playing out numerous times each day in the six "smart rooms" in the medical/surgical unit at the University of Pittsburgh Medical Center (UPMC) Shadyside campus. The rooms went live in early October, with plans to expand to the full 24-bed unit by April.

Addressing serious events

The system was initiated by the UPMC executive management team, says David Sharbaugh, leader of the project and senior director at UPMC's Center for Quality Improvement and Innovation.

"We look at every serious event every week and discuss them, and one of the events we discussed about two years ago was a woman who had a latex allergy," Sharbaugh recalls. "The team nurse went to start an IV; she had a latex glove on, touched the patient's arm and the patient had a major reaction." While the patient recovered from the reaction, she was understandably angry. This spurred the team to seek ways to prevent such incidents in the future.

"When we started talking about how to solve these types of problems, our focus had always been on the person; this nurse needs to go to orientation, see a safety video, or be written up," says Sharbaugh. "We assumed it was a problem with the provider because, after all, all our computer systems 'knew' she had the allergy."

But when the team started to take a different look at the problem they realized that while they did indeed have that information, the information and the provider were not necessarily both in the same place at the same time. "We reached our decision based on one of the principles of the Toyota method — that you do not separate the information from the product it describes," says Sharbaugh.

It was Sharbaugh himself who came up with the solution, which he presented in a white paper to the team. "I thought of all the other applications where we could solve problems, and where having the information at the right time would make a world of difference," he explains. "As I dug deeper, I realized it was not just important to have the right information presented in the right way, but you also needed to be able to sort, sift, and come up with the things that mattered most — so people did not have to search for them. At any point in time, there are different things that are important — and that's what we should bring to the surface."

The room became his focus, he continues, because "that's where the patient is." If mistakes are made at the bedside, he reasoned, "then shame on us; we didn't have the information where we needed it."

Trying systems on for size

It took a bit of trial and error to find the right technology, says Sharbaugh. "For the tracking system, we tried a couple of RFID [Radio Frequency Identification] solutions, but we were not happy with them," he says. "They had dead zones and other coverage issues, and we wanted [them to work over a] certain distance. We also did not want tags that would cost us a bunch of money."

UPMC finally chose a vendor, Sonitor, which is based in Norway and has its main U.S. office in Florida. "Their room-level accuracy was virtually perfect, and they were an easy company to work with," Sharbaugh says.

The system consists of badges, which are worn by the providers, and detectors inside the room. "All the other technical stuff, like the software, has been developed by a team at UPMC, "says Sharbaugh. "We already had an electronic health record, but the entire smart room application had to be written." The application, he explains, required logic to help it determine what information to present and when, and what should be shown to the patient and to the care team.

The system uses ultrasound tracking devices to identify the caregivers; each worker is assigned a unique tag — smaller than a pager — that emits a sound, unheard by humans, when the person wearing the tag first enters the "smart room." An ultrasound detector in the room reads the tag and identifies the caregiver by name and job title, displaying the information on a monitor at the foot of the patient's bed. When a caregiver leaves the room, the information disappears from the screen. To date, tags have been assigned to doctors, nurses, nursing assistants, phlebotomists, and dietary hosts and hostesses.

At the same time, the system is programmed to retrieve the latest clinical information stored in UPMC's electronic medical records. To protect patients' privacy, only limited patient identification and safety information such as allergies and precautions are initially presented on a 32-inch, flat-panel monitor viewed by clinicians. With the patient's permission to view more clinical information, the medical staff can change the display with the click of a button on the tag.

"The first thing that populates on the screen is precautions and allergies, before you see any clinical information," Sharbaugh notes. "Every patient has a [risk] assessment when they are admitted," he says. "We look at the fall risk score, for example, and if they are at risk, we deliver a message to the patient throughout day." When no one else is in the room, Sharbaugh explains, the message will tell patients they are at risk, and if they want to get out of bed, they should call a nurse.

The information presented is customized based on each person's role and need for information. For example, a phlebotomist arriving to draw blood sees only current lab orders and allergy information to prevent the use of latex gloves on a patient with a latex allergy.

Another patient safety component of each "smart room" is an infrared sensor mounted above the doorway. As anyone enters, it sends a signal to the room's computer to turn on a spotlight pointed toward the hand sanitizer mounted on the wall. "Everyone who walks in is prompted to wash their hands," emphasizes Sharbaugh, meaning visitors as well as health care workers.

"We're trying to get the entire system of hardware down to $1 per patient per day, so it will be affordable for any size hospital," Sharbaugh says. "Maybe we will end up at about $1.50."

Early concerns abated

The new rooms did not gain total staff acceptance at the start, recalls Shuja Hassan, MD, a UPMC geriatrician and "smart room" user. "I guess to be honest, I was a little bit apprehensive," he admits. "When you display information in a patient's room on a screen, there is always concern about other people being able to see it; I was concerned about HIPAA."

However, he adds, those concerns were abated when he learned that the patient controls the medical information that is displayed. "The only thing that gets shown automatically is the identity of the person who enters the room," Hassan notes. "Whoever has a badge is a licensed health care professional and you cannot activate anything unless you do have badge — plus, you have to press a button [to display medical information] and, unless the patient agrees, you can't display it."

As a geriatrician, Hassan sees several benefits from the new rooms. "The most common diagnosis an older person has while hospitalized is congestive heart failure," he notes. "We want to know how much fluid they are getting vs. how much they are putting out, and we can easily see their most recent labs."

In addition, Hassan notes, a patient may say he or she is feeling well, but the vitals on the screen may show negative trends. "Also, in the past we would look at the labs at the nurses' station, and have to remember everything later on at the bedside. Now it is all there in the room."