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Overview

Like small hospitals throughout North America, Androscoggin Valley Hospital (AVH) balances growing workloads against ever-tighter budgets and limited resources. The 25-bed facility is located in Berlin, N.H., a city of 10,000 at the edge of the White Mountains.

But in many ways, AVH isn’t at all like most small hospitals. Its impressive range of care—from primary healthcare and pediatric services to specialty practices and advanced surgery—places AVH on par with larger facilities. Then there is its strategic approach to communications. In 2010, AVH implemented a new Polycom® KIRK® Digital Enhanced Cordless Telephone (DECT) infrastructure that efficiently alerts the hospital’s nursing staff when a patient needs help. Integrated with the Dalcon Alert! system from Dalcon Communications, Inc., the wireless KIRK handsets signal nurses whenever alarms within patient rooms are triggered, advising them where they’re needed and why. The cost-effective solution even reminds them to reposition immobile patients every two hours.

Not only does the system help simplify the job of caring for patients, but it supplies nurses with their own telephones to consult with physicians, respond to pages, or interact with staff in other departments. The KIRK handsets also have streamlined communications throughout the facility by replacing pagers for AVH administrative staff and technicians. As a result, it’s easier than ever for AVH to enhance care by responding quickly to patient needs.

Replacing an Outdated System

The legacy communications system at AVH was long overdue for replacement. “We’d been working with outdated systems that couldn’t be repaired,” recalls Clare Vallee, vice president of nursing at AVH. “Parts of it were over 30 years old.”

The communication infrastructure—a patchwork of nurse call and alarm systems linked to a Mitel PBX—worked, though far from perfectly. “We had huge issues with bed alarms,” says Vallee, referring to the systems integrated with patient beds that emit an audible signal when a weak or infirm patient leaves his bed—or worse, falls from it. “We could hear the alarm from down the hall, but we wouldn’t know which room it was coming from.”

“With the Polycom KIRK and Dalcon Alert! system, we now know immediately what problem the patient is having and where the patient is. Responding to alarms is easier now.”

-Brenda Aubin, Director, Medical-Surgical Unit, Androscoggin Valley Hospital

Alarms for chairs and IV pumps had similar problems. “We knew each alarm’s sound, so we knew what the problem was; it just took a while to find the room,” says Brenda Aubin, AVH’s Medical- Surgical Unit director. “Our culture has always been that if you hear an alarm, you just go. So several nurses would respond—not just the nurse assigned to that room. It probably wasn’t the most efficient process.”

Nurses also must reposition some patients at least once every two hours to prevent pressure sores that can lead to infection. But staying on schedule proved a persistent challenge. “Bed turns were self-policed,” says Aubin. “The expectation was for each nurse to keep that responsibility straight. But across multiple shifts and changing routines, it wasn’t easy.”

Putting Alerts in Nurses’ Hands

AVH turned to Dalcon, a Polycom VOIP Field Verified partner. Dalcon proposed a solution that integrates Dalcon Alert!, a new solution designed especially for hospitals, with Polycom KIRK handsets. When an alarm is triggered or a patient presses his bedside call button, Dalcon Alert! automatically sends nurses a brief text message describing the nature of the alert and the patient’s room number. The system interfaces with AVH’s Mitel PBX via the Dalcon Communications Manager (DCM) server, which generates the messages and distributes them via the KIRK Wireless Server 6000. An overhead monitor located at the nurse’s station also displays alerts and their status. “With the Polycom KIRK and Dalcon Alert! system, we now know immediately what problem the patient is having, and where the patient is,” says Aubin. “Responding to alarms is easier now.”

Kirk 4040 with Bed Fall Alert

The budget-friendly solution also keeps track of bed turn schedules by alerting nurses when the bed turn cycle reaches 90 minutes, and again at the two-hour mark. “It’s one less thing nurses have to worry about,” says Vallee.

Nurses use KIRK 4040 handsets. Designed to withstand heavy use without requiring recharges during long hospital shifts, the programmable handsets assign unique rings to each alert, an audible cue that saves nurses time and trouble. By functioning as a wireless telephone, the KIRK handsets also offer nurses some freedom. “Before, if a nurse called a physician, she either had to wait for him to call back, or we’d have to hunt her down when the call came,” says Aubin. “Now she can get the call directly.”

Nurses also use the phones to communicate with other AVH staffers, many of whom carry KIRK 5020 Handsets to replace pagers that lacked KIRK features like speed dialing. “Staff in radiology, our sleep center, and dietary department, along with our house coordinators, all use them,” says Vallee, “and they love them.”

The AVH solution also involved some crucial customization by Polycom. “Polycom’s KIRK team worked closely with us to optimize the handsets for use with the Dalcon Alert! platform,” notes Dalcon CEO David Condra. “Those efforts substantially streamlined integration and deployment at AVH.”

Future plans may call for replacing AVH’s end-of-life PBX. Fortunately, the new Dalcon DCM and KIRK handsets would work seamlessly with a Polycom IP-based solution—offering AVH another chance to show just how far even a small hospital’s budget can go.

Hospital Professional Liability Claim Frequency Rising

The study shows that the frequency of hospital professional liability (HPL) claims has been steadily increasing since 2007.  Prior to 2007, HPL claims had been decreasing in regularity for 7 straight years. In 2010 AON estimates that the frequency of HPL claims will be approximately 2.06% per bed, about 5.3% higher than in 2006 when HPL frequency trends began to rise.

AON suggests several different theories to explain the claim increases, including the downturn in the U.S. economy, changes to CMS reimbursement rules regarding never events, and changes in public sympathy toward healthcare providers.  Never events, in particular, have received extra attention from attorneys representing clients because they have been designated by CMS as entirely preventable.  As a result, hospitals are perceived as having a significantly weaker defense against never event claims.

Liability Claim Severity Rising

Although claim frequency trends have changed significantly from negative to positive in the past ten years, claim severity has remained consistently positive.  Research by AON shows growth in claim severity has increased significantly 2004 through 2008, starting at an average of $116,000 per claim and gaining 3.5%-6.5% per year. Estimates suggest that claim severity will continue to rise 4% per year in 2009 and 2010.

Total Cost of Liability Risk Rapidly Rising

As a result of the increases in hospital professional liability claim frequency and severity rising, the total cost of hospital liability risk has grown significantly in recent years.

Although decreases in claim frequency translated into generally lower total costs starting in 2000 at $2,790 per bed and ending in 2005 at $2,420 per bed, increases in claim severity have reversed the cost trend since then.  In 2007, when claim frequency began to increase, the total cost of liability began to rise considerably.  As a result, total costs of risk are expected to rise 5% to $3,020 in 2009 and $3,170 in 2010.

The High Cost of Patient Falls and Bed Sores

According to AON, patient falls and injuries and Bed Sores are never events that comprise a large portion of all HPL costs.  Patient falls and injuries encompass 12.5% of total costs, and bed sores encompass 2.1% of total costs. Consequently, the HPL claims from these two never events will cost an estimated $463 per hospital bed in 2010.  The large HPL costs of these select never events run in addition to the costs already incurred by the hospital due to CMS never event non-reimbursement.

These four patient safety errors make up a portion of the larger list of “never events,” which are events flagged by the Centers for Medicare & Medicaid (CMS) as “serious adverse events during inpatient stays that should never occur,” and “are reasonably preventable through adherence to evidence-based guidelines.”

Hospital expenses incurred due to never events are not reimbursed by CMS.  In addition, hospitals are prohibited from passing the costs onto patients.  Consequently, never events prove quite costly for hospitals even before the threat of litigation.  In 2007, the last year CMS reimbursed hospitals for never events, pressure ulcers cost CMS $43,180 per incident.  Falls with injury weighed in at $33,894 per occurrence.

“The increased awareness surrounding these non-reimbursable conditions may cause a rise in the frequency of related hospital professional liability claims,” said Greg Larcher, director and actuary of Aon Global Risk Consulting.

Preventing Never Events with New Technology

As the cost of never events continues to rise, new technologies such as Dalcon Alert! have been developed to help hospitals prevent never event incidents.  Dalcon Alert! is a new solution from Dalcon Communication Systems, designed to help caregivers prevent patient falls and pressure ulcers.

Never events are select hospital acquired conditions defined by CMS as treatment errors that are 100% preventable.  As a consequence, CMS has mandated that they will refuse to reimburse hospitals for any never event expenses.  Additionally, hospitals are prohibited from passing the costs on to the patient.

In 2007, the last year CMS reimbursed hospitals for never events, pressure ulcers cost CMS $43,180 per occurrence and falls with injury cost $33,894 per occurrence. Thus, in 2007 pressure ulcers cost over $11.1 billion and falls cost over $6.5 billion.

Breaking Down the Return On Investment

According to the American Hospital Association (AHA) there were 951,045 registered beds in the United States in 2008. Thus US hospitals recorded approximately 0.27 dangerous pressure ulcers per bed per year on average, and approximately 0.20 falls with injury per bed per year on average. Do the math, and the total cost sum of pressure ulcers and falls with injury was about $19,032 per bed each year.

Due to the high cost of never events, investment in never event prevention provides a great return.  Investment in technologies and policies that particularly target patient falls and pressure ulcers return especially high value.

Investments that limit patient falls and pressure ulcers even slightly pay off handsomely.  For example, a 25% reduction in falls/pressure ulcers at $19,032 annually per bed results in savings of $4,748 per bed annually. For a medium sized 200 bed hospital, that’s $951,600 per year.

A recent study by the Healthcare Management Council, Inc. (HMC) found that US hospitals stand to save millions of dollars per year by eliminating preventable patient safety errors.

According to the study, a 200 bed hospital is likely throwing away $2 million dollars yearly because of bed sores, patient falls, and other never events and hospital acquired conditions (HACs).

The reason hospitals stand to lose so much from these patient safety errors is because Medicare has refused to reimburse hospitals for any costs associated with a never event or HAC (click here to learn more about never events and HACs).  It is expected that soon private insurers will also deny hospitals reimbursement for these events.  Because hospitals are forbidden from passing the costs associated with these events on to the patient, they end up eating the price of care.

Patient safety incidents not cheap, and just a few events drive up the hospital bill significantly.  The most prevalent events hospitals are being denied reimbursement for, are bed sores.  HMC found that bed sore events were costing hospitals an average of $536,900 annually—at an average of $9,200 per event.

The most expensive events are Postoperative pulmonary embolisms and deep-vein thrombosis (DVT).  Although these occurred less than bed sores, the $15,500 average cost per event bumped the total annual cost of these events to $564,000 per hospital on average.

The monetary cost isn’t the bottom line.  Thousands of deaths occur in hospitals each year due to never events and HACs—events that have been deemed preventable by the Centers for Medicare & Medicaid Services (CMS).

Communicating in the modern nursing work environment is difficult

Juggling information from these sources is already complex, yet the majority of US hospitals add to the problem by lacking effective communication technology.  A study by Forrester Research showed that the inefficient communication methods most nurses are forced to rely on cause major drains on productivity.

A few examples from the study:

“The majority of nurses stated they would save somewhere between 30 minutes to one hour per day with instant access to experts.”

“A sizable percentage of nurses — 65% — said they spent from 20 minutes to more than one hour per day trying to reach other medical staff. This includes 26% that spend more than one hour per day and another 39% that spend from 20 minutes to one hour.”

Regarding elimination of physician-nurse missed communications and phone tag, “estimates of up to one hour per day would be saved by 54% of nurses, and another 26% indicated it would save them from 16 to 30 minutes per day.”

It is no secret that the largest item on the average hospitals expense sheet is employee compensation.  Accordingly, this collective drain on nurse productivity adds a big cost for hospitals.  What isn’t as obvious is the negative impact poor nurse communications has on patient care.

Aside from time wasted on poor communications that could be spent with patients, inferior communication platforms also lead to more troubling outcomes.  Take for example, the fall risk patient who needs to use the restroom and caregivers are too slow to respond to their nurse call request—and arrive only in time to see the patient has fallen while trying to use the restroom by themselves.

Wireless Nurse Communication as a Solution

Current nurse communication problems stem from the fact that most nurses, 78% according to the Forrester Research study, use telephones as their main communication vehicle.  Yet the majority of US hospitals rely on wired telephones, even though nurses are highly mobile.  As a result, communication breakdown is inevitable.

New nurse communication technology such as Dalcon Alert! provide a wireless solution for the modern hospital.  Dalcon Alert!, in tandem with wireless phones, allows nurses to stay in constant contact with patients, staff, and physicians while staying on the move. The Forrester Research study showed that 74% of nurse respondents could save a significant amount of time each day with wireless phones.

In addition to improved productivity, Dalcon Alert! improves patient care by allowing nurses to receive patient care alerts directly on their wireless device.  For example, caregivers receive nurse calls, iv-pump alerts, fall alerts and more on their phones.

The most high profile incident occurred in January when a patient at Massachusetts General Hospital (MGH) died of a cardiac arrest.  As it turned out, the patient’s cardiac arrest monitor had been in alarm mode for over 20 minutes before the patient died, yet nurses failed to notice the scrolling tickertape notices in the hallway or the beeps in the central nursing station.  In addition, an unknown person had completely turned off the separate audible alarm on the physical bedside monitor the night before.

So what exactly causes this disconnect between caregivers and monitoring technology? Alert fatigue.  As more monitoring devices are added into the hospital environment, each additional alert adds weight until nurses feel overwhelmed.  As a result, caregivers experience alert fatigue. Alert fatigue is the condition where caregivers begin to give up trying to manage the onslaught of alerts, and start to ignore them instead.  In extreme cases, such as the situation at MGH, caregivers begin turning down the volume of audible alerts or even turning off alerts completely.

Preventing Alert Fatigue

Stopping alert fatigue isn’t simple.  Obviously, eliminating alerts/alarms isn’t an acceptable solution, since that would defeat the purpose of patient monitoring devices.  Yet something must be done or the problem will only continue to develop as the hospital environment gets more complex.

The solution lies not in eliminating alerts, but in more efficient management of them.  Without an automatic and organized approach to managing alerts, caregivers are forced to juggle them manually.  Manual management of alerts can be effective, as long as the number of alerts stays at a reasonable level.  However, as more alerts are added to the environment, an alert management system becomes more necessary.

Developing an Effective Alert Management System

Today, new technologies such as Dalcon Alert! include an Alert Management System designed to help caregivers organize alerts.  Dalcon Alert!’s Alert Management System automatically tracks all active alerts.  Active alerts are displayed on a large screen monitor at the nursing station and are automatically updated in realtime with alert type, location, and length of duration.  The alert queue is designed to allow caregivers to quickly prioritize active alerts, and canceled alerts are automatically removed from the queue.

Reducing Unnecessary Alerts

In addition, Dalcon Alert! allows nurses to receive alerts via text message to wireless phones.  A successful Alert Management System involves quality design.  As a result, caregivers should only be receiving relevant alerts.

For example, caregivers should only receive non-critical alerts from their assigned patients, not from each patient on an entire floor.  Because Dalcon Alert! utilizes wireless phones assigned to each caregiver, relevant alerts can be tailored to the individual caregiver.

Because all alerts are managed by the Alert Management System, non-critical monitoring devices can have their audible alerts turned down in order to reduce hospital ambient noise.  Any reduction in hospital ambient noise has been shown to increase the quality of patient care significantly.

1. Use opening Key Words.
2. Accomplish scheduled tasks.
3. Address the “Three Ps”—pain, potty, position.
4. Address additional comfort needs.
5. Conduct environmental assessment.
6. Ask, “Is there anything else I can do for you? I have time.”
7. Tell each patient when you will be back.
8. Document the round.

The most critical component, according to the Studer Group, for a successful hourly rounding implementation is maintenance.  Nurse Managers must be committed to the program, and must continually validate the program or it quickly falls apart.  Validation consists of not only making sure that nurses are consistently making hourly rounds, but also that they are faithfully following rounding procedure.

Trust but Verify

The Studer Group suggests that nurse managers execute a “trust but verify” policy.  It is important that nurses do not perceive that they are being “checked up on” by their managers because they are untrustworthy.  Instead, managers need to communicate that they are simply double checking to make sure activities do not “fall through the cracks”  and that bad habits are not formed.

Hourly Nurse Rounding Validation through Technology

Dalcon provides a solution to help hospitals implement nurse rounding as a part of its Dalcon Alert! Remote Patient Monitoring system.

Dalcon Alert! captures patient monitoring device alerts and sends them to wireless phones carried by hospital staff via text message.  In addition to monitoring patient device alerts, Dalcon Alert! also sends periodical bed turn alerts to staff as well as rounding reminder alerts.  Nurses cancel their rounding reminder alert via Dalcon Alert!’s Remote Alarm Monitor at the patient bedside.  As a result, hourly rounding is assured.  However, it is still the responsibility of the nurse managers to confirm that nurses are following rounding procedure accurately and diligently.

Yet researchers have found that adding an hourly nurse rounding program in hospitals makes a dramatic impact in two important areas:

1. Significantly increased staff productivity and satisfaction.
2. Significantly increased quality of patient care and patient satisfaction.

The fact that hourly nurse rounding actually decreases staff workload comes as a surprise to many.  Yet consideration of the impact of hourly rounding on the work environment quickly explains this phenomenon.

In a traditional acute care setting, nurses typically are conditioned to react to patient problems and requests instead of focusing on preventing them.  This strategy of inconsistency creates a high stress environment.  Because nurses are not proactively resolving patient needs, patients learn to rely heavily on their nurse call buttons to get assistance.  Due to the interrupting and distracting nature of nurse calls, as nurse calls increase, staff productivity usually goes down.

Reducing these resource-consuming nurse calls is the first area hourly rounding pays off.  As patients learn to expect nurses at specific times throughout the day, they begin to rely less on the nurse call system, using it for urgent needs only.

The effects are dramatic.  A recent study across 27 nursing units in 14 hospitals by the Studer Group, a hospital consulting organization, showed that hourly rounding decreased nurse calls by almost 40%.  In addition, patient falls were reduced by 50%. According to Christine Meade, PhD and chief researcher of the study, “It’s essentially like adding the time of one full-time RN to complement the staff for a week because of the hours not used answering call lights — and the patients love it.”

A secondary benefit of hourly rounding is the increase in the quality of patient care.  Patients feel like their needs are better cared for when patient care is provided proactively instead of as a reaction.  Also, Because hourly rounding takes care of all non-urgent patient needs, the nurse call system can regain its sense of urgency.  As a result, nurse call response times are drastically reduced.

Implementing Hourly Rounding with New Technology

Dalcon Alert!, Dalcon’s Remote Patient Monitoring and Alert Management solution, has hourly rounding alerts built into the system.  Dalcon Alert! captures patient monitoring device alerts and sends them via text message to wireless phones carried by facility staff.  In addition to these monitoring device alerts, Dalcon Alert! also sends periodic bed turn reminder alerts and nurse rounding alerts.

Because Dalcon Alert! hourly rounding alerts can only be canceled via the Remote Alarm Monitor (RAM) at the patient’s bedside, accidental staff negligence of rounding is eliminated.

In fact a recent study at Johns Hopkins University Hospital has shown that loud hospital environments can have a major negative impact on patients including:

• Elevated blood pressure levels.
• Sleep disruption.
• Decreased oxygen saturation.
• Decreased rates of wound healing.

The consequences of a loud environment on staff include emotional exhaustion and burnout as well as a raised risk of medical errors due to miscommunication. Recently, a patient at Massachusetts General Hospital died because his heart monitor had been turned off by a staff member. The investigators cited “alarm fatigue” as a cause of the problem. Alarm fatigue occurs when nurses become overwhelmed by the number and variety of alarms in the healthcare environment. As a result, nurses begin ignoring or even turning off alarms.

A Mayo Clinic study performed several years ago showed peak noise levels at night in one facility rising to 113 decibels, equivalent to a chainsaw or jackhammer.

Major sources of noise include hospital ventilation systems as well as overuse of the hospital paging system and an abundance of alarms. The Johns Hopkins study noted that though audible alarms were significantly quieter than other sources of noise, patients ranked them as being more irritating than more intense sources.

New Technology as a Solution to Hospital Noise Pollution

Dalcon provides solutions that, as a secondary benefit, help eliminate hospital noise pollution.

Dalcon Alert! for Remote Patient Monitoring connects with various patient monitoring devices such as heart monitors, IV pumps, ventilators, pulse oximeters, and more. When a patient monitoring device triggers an alarm connected to Dalcon Alert!, the system sends a text message to wireless phones (or pagers) held by hospital staff.

Because Dalcon Alert! allows hospital staff to more efficiently manage hospital alarms, alarm fatigue is significantly reduced. Also, since Dalcon Alert! incorporates wireless phones or pagers to be carried by hospital staff, use of the overhead pager can be dramatically decreased as well.