Real-time tracking data drive process improvements, even while ED volumes continue to climb

Technology uses sensors, infrared signals to capture patient-staff interactions

Christiana Hospital in Newark, DE, averages between 315 and 320 patients per day. It's a huge ED, taking up a lot of space, explains Amy Whalen, RN, BSN, SANE-A, the assistant nurse manager in the ED. And Whalen recalls that it used to be quite a chore just trying to locate patients, providers, and staff. "We were spending a lot of time just at triage trying to find a patient to go back to a room," she says, noting that it could be equally time-consuming to try to find a provider. "You would be calling down corridors, and looking under the curtains for feet. It was just very difficult."

Today, however, locating a patient or provider is just a few clicks away on a computer screen, thanks to the real-time location system (RTLS) that the health system installed in 2004. Using sensors that are housed in the ceilings, the technology can immediately identify the location of any patient, provider, or tech who is wearing a special badge that emits infrared signals that the sensors pick up.

It has taken time to take full advantage of the system's capabilities, but administrators say that within a year of implementing the RTLS-driven approach, the average length-of-stay (LOS) in the ED was slashed by 40 minutes for admitted patients, and by 18 to 20 minutes for the treated-and-released population. However, these improvements just scratch the surface of what you can do when you have real-time data to work with, explains Linda Laskowski-Jones, MS, RN, ACNS-BC, CEN, vice president, Emergency and Trauma Services, Christiana Care Health System. "Where you really get the benefit is when you sit down with a group of people and you focus on a particular process that you really want to optimize," she says. "It is what you can do with the information and how you can look at your world and really know your process."

Track intervals of care

Laskowski-Jones explains that continuous improvements in LOS have taken place while volume has continued to climb. Back when the RTLS system was first implemented in 2004, the ED was seeing 90,000 patients per year; today the ED sees 117,000 patients per year, she says. The efficiencies are possible, at least in part, because the RTLS system is able to keep track of all the patients as well as all of the care processes they interact with as they move through the system.

The tracking begins as soon as a patient enters the triage phase of care. "We quickregister the patient, and during that process we give the patient a tracking badge," says Laskowski-Jones. "That tracking badge is entered into the quick registration system so that it identifies the patient and their real-time location from that point of initial registration."

As the patient moves through the department, sensors interact with the badge so that any clinician can see where the patient is at any point in time by dialing up the RTLS software on a computer screen. "We have more than 400 sensors throughout the department, not just in the ED, but also in radiology and in our ultrasound area," explains Laskowski-Jones. "We have, basically, a real-time itinerary of all the patient's intervals of care. All of our physicians, nurses, and techs also wear tracker badges, so as the patient interacts with these individuals, those interactions are captured as well."

Whalen, who has been employed at Christiana Hospital since before the RTLS system was implemented, recalls that while hospital staff were apprehensive about the technology, they quickly embraced its capabilities. "Within that first day everybody became hooked. It just completely changed the way we took care of patients," she says. "It changed how we could see what was happening in the department, how we could find patients and each other. And it changed how we functioned."

The health system has gradually made the technological infrastructure of this system even more robust by building interfaces with the laboratory, radiology, and, most recently, the health system's computerized physician order-entry system (CPOE). This makes it possible for a clinician to view the patient in many different ways from the same tracking board, explains Laskowski-Jones. "You can see what labs are new orders, what labs or diagnostic studies are pending, and which ones are available — all through a color change," she says.

The RTLS system is also interfaced with the hospital's bed-management process so that when a patient in the ED needs to be admitted, ED personnel can actually use the system to provide information that the bed board needs in order to find the right bed for the patient. "The information seamlessly flows onto the bed management dashboard, and when [bed management staff] identify a bed and assign the room, and environment services is finished cleaning that room, all of those milestones are indicated back in our tracking system," explains Laskowski-Jones. "We can also then request transport via our tracking system."

Whalen says the technology makes it easy to quickly ascertain where there are holdups. "It just enhances our team approach because you can quickly figure out what someone is waiting for, whether it is a test, transport to a floor, a bed assignment, or whatever," she says. "You can get a global look at what is going on."

Use data for process improvement

There is no question that some efficiencies are realized by not having to manually make a notation every time a patient encounters a new care process. The RTLS system makes these notations automatically and the data are real, stresses Laskowski-Jones. However, she stresses the biggest opportunity for improvement comes from acting on the information. "We get a whole summary of patient movement, interactions, and basically the process of care through the tracking system," she says. "But the impact comes from actually taking those time intervals, knowing your results, and engaging in process improvement."

For example, in 2008, a group of ED leaders worked with members of the health system's Operational Excellence Department to overhaul the ED's fast track area. "At the time, we had about a two-and-a-half hour LOS for fast track patients, and we created a stretch goal of getting that down to 60 minutes or less," explains Laskowski-Jones.

The work group poured over the tracker data, including all the intervals that occur for patients who flow through that part of the ED, and they made decisions about what processes could be combined or eliminated. "Originally we had six triage rooms, but the way we had our teams configured, the six rooms didn't help us, so we actually reduced that down to two triage rooms, with a third room to be used for procedures," says Laskowski-Jones.

Using the tracker data, the work group created a mechanism so that staff would see a color change on the tracking board whenever a fast track patient was in treatment for more than one hour. "We were actually able to lower the LOS for fast track patients to pretty reliably less than 60 minutes," says Laskowski-Jones. "And we monitor those results every day."

More recently, ED administrators and staff have been focusing on the Emergency Severity Index (ESI) 3 patients. "These are the patients who typically have a very long LOS in any ED in the country," explains Laskowski-Jones. "They often have abdominal pain or some undifferentiated medical issues."

Administrators created a group called SPEED, for synchronized provider evaluation and efficient disposition, and used tracker data to identify any barriers to flow or opportunities to synchronize efforts in the care of ESI 3 patients. The SPEED group has already made substantial gains, trimming the average LOS of these patients from 5 or 6 hours, typically, down to about 3.4, but the improvement efforts are ongoing. "Our goal is to create a community of scientists so that we can then take that information and experiment, and keep trying to refine the process," explains Laskowski-Jones.

Take time to plan

While using RTLS technology is now business-as-usual at Christiana Hospital, Laskowski-Jones advises ED administrators who are considering this type of strategy to invest a considerable amount of time in planning for how you will use the technology, and for bringing staff up to speed on this vision.

"We used a business process approach where we brought all the key stakeholders, including frontline staff and ED leaders, into a room and outlined the current process very, very specifically," explains Laskowski-Jones. "This was so we could really look and see where the opportunities were, and how we could leverage the technology to be the best it can be."

A critical step in the planning process is staff education because there are likely to be some major concerns, at least by some personnel, about why you want to track their movements, says Laskowski-Jones. "You can mitigate these concerns," she says, noting that she held several meetings with staff to answer their questions. "I wanted them to understand what was in the technology for them, and there were two things."

First, Laskowski-Jones explained to staff that the technology would enable them to quickly ascertain the activity of the department and what was going on with their patients, and the second benefit was that whenever there was a patient with lice or a communicable disease, the technology would make it much easier to identify which personnel were exposed.

The safety aspects really registered with staff, emphasizes Laskowski-Jones. "They feel good about these protections, especially the staff members who are pregnant," she says. "Probably weekly we are tracking back to find out who took care of a patient who turned out to have pertussis [or some other communicable disease]," she says.

Even with these benefits, it took three or four years before administrators began tracking staff because Laskowski-Jones wanted to make sure they were comfortable with the technology, and why it was being used. "Now we have staff location tracking in place for clerks, nurses, and techs as well as for physicians, and we have never done anything with it that would cause staff to distrust us," she says.

While tracking technology would seem to be best suited to large, high-volume EDs, Laskowski-Jones says it is also proving valuable at the health system's hospital campus in Wilmington, DE, which has a much smaller ED. "It sees about 53,000 patients a year. And despite the fact that it is not a big, busy, Level I trauma center, we still can look at the data and optimize flow," she says. "There is not a minute that goes by in any part of the day that the tracker isn't up and somebody isn't using it to make a decision."

In addition, the health system will be using the tracking technology in a freestanding ED now under construction that is only expected to see annual volumes in the 20,000 to 30,000 range, says Laskowski-Jones. "Clinical documentation systems are excellent for what they do. This is another piece to an ED. This is how the system functions," she says. "It is sort of like putting a probe into your system and then assessing the health of that system. This is what RTLS tracking does that is different than other ways of deriving data that might give you a sense of your operation."


  • Linda Laskowski-Jones, MS, RN, ACNS-BC, CEN, Vice President, Emergency and Trauma Services, Christiana Care Health System, Newark, DE. Phone: 302-733-1000
  • Amy Whalen, RN, BSN, SANE-A, Assistant Nurse Manager, Emergency Department, Christiana Hospital, Newark, DE. E-mail: