Rubbermaid MiniMed Module

Customization, modularity influence decisions
with mobile computing on the horizon

Over the years, carts have progressed beyond just being a stack of shelves festooned to casters. Not only are healthcare facilities creatively designing and organizing these transportation vehicles for more efficient exchange and PAR level materials management, but manufacturers are equipping models with some of the latest tools and tricks viewed, by and large, as useful enhancements and features for bottom line results.

Healthcare Purchasing News tapped into the expertise of a variety of cart manufacturers to explore ongoing developments in cart applications and capabilities, including what innovations may be in the pipeline now and how those developments will contribute to improve performance.

Believe it or not, carts used in healthcare for devices, equipment and products have a rather humble origin from outside the industry.

"Many carts available today were designed originally as garage tool boxes and converted for use in healthcare," said Mas Kang, senior vice president, marketing and business development, Artromick International, Columbus, OH.

But that has changed considerably as vendors started seeking input and designing carts specifically for healthcare, courtesy of end user suggestions.

"Over the years, Artromick has gained feedback from hundreds of healthcare professionals to find out what they like and don’t like," Kang continued. "Stable maneuverability is key, along with flexibility, infection control, low price and high value product offering, consistent manufacturing techniques to improve reliability and durability, advanced lock systems, keyless access, auto-relock, the ability to customize for the specific application whether emergency, anesthesia, IV therapy, med/surg, cardiac care, etc." They’ve also asked for "the ability to accommodate and integrate wireless computing and power those devices with a reliable power system to permit long computing run times," he added.

While the exterior or shell of many carts may seem relatively familiar, the differences appear under the hood or behind the doors where healthcare facilities can customize the interior space for specific areas or functions.

"Adaptability in any cart is critical," Kang said. "The ability to configure as the needs fit the application, or reconfigure as they change will become the foundation of any good cart design. The ability to customize and adapt the organizational method of the cart based on the contents is key. So whether discussing drawer divider systems, drawer tray systems, external cart organizers, accessories or computing hardware, the same key features must be there. The ability for a hospital to standardize on a single cart platform across all disciplines is also important. The accommodation of integrated computing, power systems, flexibility to design the workstation to best meet the needs of the caregiver, these will all become requirements of all carts sooner than later."

The commoditized, cookie-cutter approach, in which a single cart can be applied to a variety of clinical and surgical specialties, largely has been supplanted by modular design.

Armstrong auto-locking cart w/Proximity card reader

"I don’t believe there will ever be a one-size-fits-all approach to carts," said Nick Klusty, vice president, U.S. West region, LogiQuip, Galesburg, MI. "Every application and every facility is different. Customer preferences will dictate accessories, configurations, and such, but even from a physical size aspect, we have to fit the carts in the rooms and areas where they can go. Once the size is set, with our carts we try to make the interiors flexible.  For example, they may have the same cart size throughout a facility, but with our designs they are able to change the baskets, drawers, dividers on the inside by case. Those items, which actually hold all the supplies and products, are interchangeable between carts and can be adjusted by anyone in the facility."

Armstrong Medical’s A-SMART Carts are available in steel or aluminum construction; in a variety of cart sizes (full-size models with adjustable drawer space, mini, narrow and wide carts); choice of up to 14 drawer colors; and many different locking options (Breakaway Locking, Key Locking, Push-Button Locking, Auto Locking and Auto-Locking with Optional Proximity Reader). Armstrong’s aluminum Premier Carts offer customizable locking configurations: lock individual drawers, double lock drawers, use multiple types of locks on the same cart. The company offers hundreds of optional accessories and customizable drawer configurations. "All these options make our carts customizable to fit any department," said Ryan Walker, assistant advertising manager, Armstrong Medical Industries Inc., Lincolnshire, IL.

Patricia List, vice president, sales and marketing, Medical Design Systems, Lenexa, KS, simply argued that one-size-fits all will not work, whether you’re addressing procedure carts or supply charts. Procedure carts, for example, have to accommodate specific pieces of equipment, according to List.

"The equipment may require slide-out shelves for access, the ability to access the back of the equipment to interconnect cabling, etc.," she said. "Power strips or cord management may also be an issue." They also may need to include fold-down shelves on the side and such accessories as glove box holders, IV poles and sharps containers. How supplies are packaged – boxed, peel packs – how many are needed and in what sizes also affect design decisions, she noted. 

"The right size cart for the job is imperative," List said. "No surgical team wants a cart larger than absolutely necessary in the [operating room]. The cart must address all of [these] issues in a compact, orderly design to avoid the cumbersome, unorganized relics of the past."

Supply carts, on the other hand, must be large enough to accommodate PAR levels, but not too large to be oversized, she continued. That’s why most hospitals will need two or three different sizes, including different depths for longer instrument trays, to accommodate all OR supplies.

Blue Bell Preconfigured cart

"We are currently working with a number of hospitals to design a comprehensive mobile supply storage system for their particular needs," List said. "Modular interiors that can be customized are the key to creating carts that fulfill the storage requirements of multiple types of packaging with no wasted space. We are often able to store the same number of supplies in half the number of carts because the modular interior components precisely accommodate all the supplies with no wasted space. Just imagine how much easier the workflow becomes when you totally organize the supplies and free up 50 percent of the floor space currently being occupied by carts."

Modularity will continue to be the driving force for most hospitals as different floors, different units and even different nurses all want different features, according to Jeff Chochinov, senior product manager, Rubbermaid Medical Solutions, Huntersville, NC.

"Healthcare facilities need to balance these diverse needs and find a reasonable range of workable solutions that are convenient to maintain," Chochinov said. "If facilities go down the path of trying to please everyone with a single cart, they must recognize that each unit will cost more and the resulting complexity may make the carts more difficult to manage. The facility might also be compelled to purchase a larger number of carts up front to cover long-term needs, a costly proposition that also creates storage problems. The better medication and computer carts available today offer standard features to maximize efficiency and safety – and yet are designed so that extra components can be easily added to meet specific user needs."

Unicell Inc., Surrey, British Columbia, emphasizes modularity and developed its cart design on that concept, according to Gary Schnell, vice president, sales and marketing. "Often a basic cart may be ordered at a particular time with further user requirements being needed later," Schnell said. "Unicell can send further interior components or external components like superstructures, IV poles, wastebaskets, etc., that can be attached to the cart on site. This proves advantageous as increased requirements do not render the cart obsolete to the user."

In fact, one feature that a growing number of cart manufacturers are promoting is design adaptability. That is, a cart’s design may never be final; they’re designed to be configurable at the factory and customizable within the healthcare facility. Carts can be changed and reconfigured with new dividers, external and internal drawers, baskets, bins, shelves and storage modules as frequently as necessary to protect the investment and maintain longer-term ownership.

"Best-of-class carts are designed to be inherently user-friendly," Chochinov said. "[They] offer on-the-go customizing to support various procedures and therapies, as well as evolving care delivery needs."

LogiQuip aluminum case cart, exterior and interior

Examples include power lifts to make raising and lowering seats or keyboards easier with those carts that carry a computer. Many facilities want to customize ergonomic features – keyboards that not only slide in and out, for instance, but can tilt on a positive or negative angle, swivel and adjust up or down, according to Chochinov. Some look for the flexibility to add devices to the cart, like bar-code label printers, document scanners and radiofrequency identification (RFID) pin code access readers.

"Others request drawers that can be swapped out to accommodate contents of varying sizes and shapes," he continued. "In addition, specific clinical areas require different locked storage capacities – consider the variation between the psychiatric unit or critical care and obstetrics, for instance. But differing levels of locked storage might also be needed on one floor within a single day. Let’s say a nurse starts out the morning with six patients and needs six small drawers on the medication cart. Later, a high acuity patient is admitted and her case load drops to three. Now she needs fewer drawers, but a larger compartment to care for the new patient."

InnerSpace Corporation (Grand Rapids, MI) has a line of storage and procedure carts equipped with modular cell panels that allow quick and easy interchangeability of shelves, trays and/or baskets.

All InnerSpace Harmony carts are built around a central design platform utilizing the same base and top while sharing many common components. Versatility is accomplished by exchanging drawers with cell panels to accept trays and baskets. Integral brackets and slotted corner posts provide an easy means of attaching top and side mounted accessories. Preconfigured carts with drawers are available as stock items or carts can be outfitted with trays and baskets with a "Build-A-Cart" option. Standard central key-lock secures all drawers, while optional electronic keyless entry with auto re-lock provides added security. A full compliment of accessories is available to accommodate medical equipment and provide point of use storage.

InnerSpace also has a variety of dedicated procedure carts that are based on the InnerSpace inner cell storage system with interchangeable storage accessories for maximum versatility in configuration options. InnerSpace’s pull-out Cath Managers keep catheters and hanging items organized and easily within reach. Dedicated suture storage options include enclosed or open-frame suture carts with pull-out suture modules and gravity feed trays for easy access.

The Starsys Modular System from Metro Healthcare, Wilkes-Barre, PA, allows users to choose from an array of modular units to fit their unique space and work specifications and easily reconfigure cart layouts as needs change. Pre-configured Starsys carts include isolation, critical care, med/surg and anesthesia carts, arthroscopic and laparoscopic carts, as well as a unit-dose medication cart.

The Starsys Medication Cart series includes a flexible drawer divider system that allows drawers to be organized according to medication requirements. The Starsys Unit Dose Cart features an electronic touchpad and a locking drawer for narcotics storage. Swingouts provide additional storage and extended worksurfaces when opened. To restock the cart, take the entire cart or simply remove the drawer totes or cassette for replenishment.

Metro’s Starsys Secure IV cart is a system of polymer components that features removeable totes for the creation of an inventory replacement system with pre-stocked totes. Full extension shelves allow for I.V. solution bags to be stored standing upright or lying down while providing complete access to the entire product. A clear locking door provides security.

Unicell Nurses’ station

Some vendors (like LogiQuip and Medical Design Systems) are rolling out carts with lighter weight metal frames, such as aluminum, which they contend are just as durable as traditional stainless steel carts but a fraction of the weight and easier to transport. Armstrong’s Premier line of A-Smart Carts are made of lightweight, yet durable aluminum. Others (like Phoenix-based Waterloo Healthcare) are infusing their carts with a silver-based antimicrobial agent that helps in cleaning and combating infection.

Rubbermaid Medical introduced a cart with an adjustable lift tension, maneuvered by a hand-release lever. The company also affixed a structural column onto the back of the carts to support additional devices. "The concept is similar to that of the head rail of a hospital bed, which has a track to hold medical devices like oxygen meters," Chochinov said. "Healthcare facilities are able to add wire baskets, shelves for document scanners and other items of that nature to our carts. The column is about four feet tall and is pre-wired, which provides plug-and-play convenience and makes the integration of new devices easy for the IT staff. All cables are tucked inside the column to ensure the carts appear professional and to eliminate safety issues related to loose cords."

If the industry offered a blue ribbon for creativity, Champion Cart Corp., Lawrenceville, GA, probably would be a shoo-in for the honors. Recognizing that motorized carts can be heavy, difficult to maneuver and very industrial, according to Will Parks, president, Champion simply added a motor to its light-weight EndoCart unit, billed as "EndoCart Deluxe with EndoDrive."

Parks emphasized that in their efforts to listen to the customer "we thought it would be nice to allow the customer to listen." So Champion introduced the EndoTunes option. "Now our customers can add an integrated iTunes (MP3) player to any of our EndoCart line," Parks indicated. "‘Listen while you work’ makes people happy."

Health Care Logistics Tranquillité cart

Meanwhile, Blue Bell Bio-Medical, Van Wert, OH, now offers an intriguing customer-focused option. The company’s new Web site contains "Design-A-Cart," an online custom designer where end users can build their own carts and workstations – and watch the site configure it in real time with three-dimensional images incorporating each choice made. "It has already proven to be a very useful tool for our customers and prospects," said Blue Bell’s Konnie Rutschilling.

Metro Healthcare allows users to configure a Starsys unit to their exact specifications at www.metroconfigurator.com.

Armstrong Medical also is in the process of revamping its website to include user-friendly "cart building" tools.

But Kang cautions that optioning out carts can be costly. "We like to say that anything is possible," he said. "However, the ability and inclination for the facility to pay for those features is not likely. Medical carts have become somewhat of a commodity over the years. Unfortunately, many of the products designs are exactly alike between vendors, so price becomes the most important factor."

Furthermore, adding power systems to carts can have a downside, according to Kang. Power systems are heavy and require recharging, he noted. Caregivers want lightweight carts that are easy to use. Sometimes features designed to help may create other challenges. For example, a height adjustment feature may prevent nurses from having to bend over to access items in lower drawers, he observed, but to raise that drawer up the nurse has to ‘crank’ the cart higher using a lever.

Still, Kang foresees next-generation carts incorporating features and functionality typically found on closed automated supply cabinets. They may include computing devices for clinical and operational applications but will provide wireless, real-time data management, and they’ll be mobile. "Carts are mobile for use at the point-of-care and [the supply cabinets] are stationary dispensing cabinets," he added. In fact, Artromick plans to introduce a fully integrated line of computing solutions for medical and medication carts.

Indeed, Klusty expects automated inventory management systems to be integrated into future carts to improve workflow. "The carts don’t have to be manufactured with these systems included, but they need to give end users the ability to integrate whatever inventory management system they utilize," he said. "If cart design can help reduce the amount of labor time needed to do inventory and replenish the supplies then that will improve workflow throughout the entire facility."

Klusty also sees more customers focusing on security in cart design. "Customers are requesting more locking options and the ability to lock many of our carts," he said. "Certain circles like to discuss RFID as a way of electronically tracking supplies with a cart. We don’t see this becoming widely used anytime soon. For it to be fully utilized the manufacturers of the actual supplies will have to embed the RFID transmitter in their packaging, which is cost prohibitive right now."

"For a long time, healthcare facilities have purchased equipment and then expected nurses to adapt their workflow to accommodate the new units," Chochinov said. "This will need to change. Vendors are now examining the ‘natural’ work patterns of nursing, and then assessing what can be developed to simplify and streamline the flow. This will save the nurses steps and ensure that supplies are close at hand when needed."

"Above all, the industry must be committed to making the nurse’s job easier," he continued. "At Rubbermaid Medical Solutions, for example, we’ve been focusing on ergonomics to better support nurses. We’ve added curved handles to minimize strain while the cart is being pushed, decreased overall weight and developed a sculpted base to increase maneuverability, and provided opportunities for customized storage. Nurses also tell us they love the keyboard light we added for night shifts and the document cover that protects reference material."

Crystal ball: Cart prospects push the envelope Procedure and supply carts may have progressed considerably from their ancestors in automotive garages but some cart manufacturers believe they’ll evolve into mobile cousins of traditional automated supply cabinets. The next big development in carts to expand functionality or improve performance may center on computers. Mas Kang "Having full access to patient data, lab results, inventory procurement, [prescription] orders/reorders, etc., at every cart and available anytime via a wireless network will become the norm, not the exception," said Mas Kang, senior vice president, marketing and business development, Artromick International, Columbus, OH. "‘Dumb’ carts will be replaced by ‘smart’ carts sooner than later." Jeff Chochinov, senior product manager, Rubbermaid Medical Solutions, Huntersville, NC, emphasized durability and flexibility. Future carts require longer run times and the ability to accommodate a wider range of add-on services, he indicated. "The industry will also need to develop the capability to make their carts easy to upgrade, and to accommodate a wide variety of options," he said. "Healthcare facilities may want to make the move from non-powered to powered carts, for instance, or transition from laptops to LCD monitors. Instead of starting over, facilities will want to protect their investment by modifying the equipment they already have." However, Gary Schnell, vice president, sales and marketing, Unicell Inc., Surrey, British Columbia, points to infection control as a key driver. "As infection control procedures continue to be more focused in this area, I see cart manufacturers as having to provide the ability to expose their products to cart washing systems and steam sterilization procedures," he said. "This reduces chemicals being used in the disinfection process." But some believe less technocentric improvements may be all that’s needed. "While RFID, biometric, inventory control carts are being touted by many as the answer, the most improvement can come from the most basic and most difficult source – a good comprehensive storage design," said Patricia List, vice president, sales and marketing, Medical Design Systems, Lenexa, KS. Looking ahead, some cart manufacturers yearn for developments that may be realistically achievable but sometimes approach more of the science fiction realm. Kang would design carts with medication-specific drawer modules that communicated inventory management information with pharmacy on a constant basis. He also envisions fully integrated patient clinical records management via on-board computing and remote cart inventory assessment. With such a constant view into what the cart contains, "re-supply of a cart would occur without the whole logistical requirement of inventory assessment at the cart and reordering," he said. "The carts would be monitored and automatically re-supplied." Nick Klusty, vice president, U.S. West region, LogiQuip, Galesburg, MI, tied future developments to RFID. "All the supplies in the carts are tracked by their physical location," he said. "Their use is tracked by simply taking them out of the cart with limited physical interaction or tracking." List teased the robotics angle but yanked the idea back to reality. "The most futuristic would be to incorporate robotics to deliver supplies and instruments to the site on command," she noted. "Having said that, I also believe we have to be practical in where healthcare dollars are invested. Let’s leave the robotics to the surgical application."  Jeff Chochinov Will Parks, president, Champion Cart Corp., Lawrenceville, GA, offered a simple, but thought-provoking, concept: "I am not sure how to do it, but a cart with no casters, yet ease of movement and full equipment integration with no cables." Chochinov called for a compact product that could provide full functionality. "Perhaps a future cart can even fold down like George Jetson’s aerocar. Long range, carts may integrate automated features, like self-stocking supplies complete with robotic arms, or vacuum tube delivery system compatibility," he said. "The ultimate feature for nurses would be a cart that relied on motorized assistance or levitated slightly to remove all the physical stress and strain when it is moved. There also may be opportunities for self-cleaning and sterilizing units." Still, carts should be considered part of a materials handling system, according to Schnell. This includes "complete adaptable, modular workspaces" that can be developed in various areas of the facility so that pharmacies, nursing stations and labs could all share the same system. "Workflow, if properly analyzed, can increase uptime and reduce downtime all using a sustainable platform," he added. – Rick Dana Barlow