Elastic operations

• Review operational planning with all stakeholders involved. "A hybrid operating room with fixed imaging may appear to support both a cardiac catheterization function as well as surgical procedures, but depending on staffing, procedure types and scheduling, that may not work since the two specialties do not function in the same manner."

• Survey departmental needs, prior to committing to the acquisition of potentially "elastic" equipment. Frequently, a "silo" mentality regarding capital equipment limits the ability of departments to coordinate purchases to support multiple requirements.

• Take advantage of the opportunities inherent in construction projects. "If an emergency department is being renovated, and is adjacent to the radiology department, locating a radiographic room between the two areas may afford the opportunity for shared use."

• Scan the horizon. Healthcare technology is constantly evolving. A regular review of technologies may uncover equipment that might not be "elastic" today, but could be available in the near future.

• Engage the clinical staff in the exploration of elastic operations. The front line caregivers may be able to offer suggestions based on what the current operations are at the healthcare organization. The best example of this is the expansion of surgical robotics from cardiac surgery applications, to multiple clinical specialties.

All of these suggestions have the potential to increase the utilization of expensive medical equipment, which certainly can improve the return on investment," he concluded. "With careful planning, many of the pitfalls hidden in elastic operations can be mitigated, or at the very least, identified early in the process."

Knight concurred. "From multipurpose product configurations and forward-looking engineering to cross-functional room design, a facility needs to demand the ultimate in flexibility when purchasing new equipment," he noted. "Facilities should purchase the latest technology today in order to prevent their new equipment from quickly becoming incompatible with tomorrow’s technology and, ultimately, costing additional money and OR downtime for replacements."

• Surgical lights should easily accommodate upgrade options such as high-definition compatibility, with an HD video-ready lighthead. HD cameras don’t have to be purchased and installed in all rooms since the camera can easily be moved from one room to another – considerably lowering overall capital costs. A terrific feature of MAQUET HD lights is that they are backward compatible, allowing a facility to purchase HD lights and a standard-definition camera, then upgrade to an HD camera at a later date without having to purchase new lighting. MAQUET also offers a Satellite tube mount that allows installation of up to three lights plus a monitor holder in single mount – additional monitors and lights are easily and quickly added to the configuration with minimal expenditure of money and time.

• Surgical tables are one of the best examples of multi-purpose products. Facilities should look for tables that are appropriate for a wide variety of specialties. Modularity plus accessories are the keys to multiple configurations. The MAQUET surgical table family exemplifies this idea with "easy-click" modules and more than 100 accessories quickly adjusting the table from procedure to procedure. The MAGNUS OR table takes multi-functionality one step further with its special chassis frame and compatible transfer board that allows patients to be transferred gently from their bed to the operating table top.

• When constructing a new surgical theater a facility’s focus should be on the hybrid OR, the ultimate in elastic operations. The essence of hybrid ORs is multi-functionality. One of the most important decisions in building a new OR is the choice of OR table. Healthcare facilities should always consider the design of their new OR suite for the most efficient patient workflow. Traditionally, the staff would have to move the table in and out of the OR to accommodate different surgical needs. However, this can lead to significantly inefficient patient work flow. In newer healthcare facilities, OR Tables system has been the preferred choice of surgical table for elastic operations so that the room is suitable for specialty cases such as cardiovascular surgeries, neurological surgeries and orthopedic surgeries just by a simple change of table top.

• ICU equipment, such as ventilators, should be judged on their ability to be used in a multitude of different clinical settings, according to Christoph Lenze, vice president of sales and marketing for MAQUET Critical Care. "This multi-functionality allows clinicians to standardize to one ventilator while still optimizing patient care." The MAQUET SERVO-i ventilator offers a broad range of capabilities for patients from neonate to adult including intra- and inter-transport, MR conditional, Heliox, and NAVA and Edi monitoring, he added.

Many organizations have designed inpatient rooms that can be adapted for the acuity of a patient where the patient is admitted and discharged from the same room, according to Pugliese. Such rooms can flex up to ICU care as needed. This design eliminates waste, improves caregivers work environment and personal satisfaction, creates good patient experience and solves the problems with the flow of patients, she added.

For example, it reduces the steps needed to obtain supplies or transfer patients, minimizes delays for patient placement and waits in holding areas, eliminates equipment duplication, maximizes technology efficiency, and helps to have the information for patients and caregivers readily available at the point of care.

Pugliese cited one recent study that documented the improvement on flow of patients and delivery of care after converting a coronary critical care unit and a coronary step down unit into a single comprehensive coronary care unit. The study found improvements in quality of care and operational costs, including reduction in clinical handoffs and transfers, reduction in medication errors and patient falls, decrease in budgeted nursing hours per patient, increase in available nursing time for direct care without added cost, and increase in patient days per bed with a smaller bed base.

• Evaluate and consider multi-purpose equipment with an eye toward worker and patient safety. Healthcare workers sustain nearly five times more overexertion injuries than any other type of workers, and are among six of the top 10 professions at greatest risk for back injury, according to the U.S. Department of Labor.

• Consider equipment that performs multiple functions. Devices such as shower chairs that fit over the toilet can eliminate multiple transfers, saving healthcare workers multiple lifts. A patient/resident can be moved to the shower chair, toileted, showered and transferred back to the wheelchair. Certain electric beds or combination stretchers (a combination bed, stretcher and chair) serve multiple functions.

• Consider the next-generation patient rooms that have modular components, designed to be both environmentally and patient friendly with easily movable wall panels to allow the hospital to change room and floor configurations, minimizing the need for new construction and disruption of the patient population.

• Consider acuity-adaptable patient rooms.

"The pressure on healthcare to operate like a business is enormous," Dickow noted. Terms such as economic tradeoffs, cost/benefit, return-on-investment and market base economics are used quite often, he added. "Flexibility is one of the key factors that are prevalent in business activities," he continued. "Healthcare is changing rapidly and we must keep up, so equipment planning needs to be involved in operational analysis."

• Educate employees regarding change management and adapting to a changing environment because this is the future.

• Instill equipment flexibility into the evaluation criteria, whether it be from a clinical environment, healthcare industry or changes in methods and systems standpoint.

• Remove silos between individuals, departments, organizations, physicians and nurses.

• Beware of dedicated/singular functional systems.

• Seek dramatic discounts on equipment that is "inelastic."

Multitasking equipment should be the rule, and no longer the exception, according to Hood.

• Select equipment that can multi-task, such as a med/surg bed with in-bed scales and a bed exit alarm. Requiring your equipment to work smarter reduces the workload of the clinical staff. Of course, the data should be interfaced into the patient’s electronic medical record to reduce the duplication of work and the potential of human errors when recording the data.

• Consider purchasing all medical equipment, down to something as simple as patient scales that are EMR-ready, even if you are not. This way, when you do convert, your older equipment will have the capability to interface to your EMR.

• Consider purchasing a wireless remote temperature monitoring system – even Web-based – to reduce amount of time required by staff for documentation purposes. This, of course, covers all pharmacy and lab refrigerators, but don’t forget to include warming cabinets where IV solutions are stored and all dietary refrigeration. Documentation is now electronic and easier to access through Web-based software. In addition, you won’t be losing a refrigerator or freezer full of medications due to a faulty refrigerator – you will have been notified ahead of time. When you are paid a visit from the regulatory bodies, you’ll have nice, neat documentation to present.

• Consider decentralization of supplies to reduce the amount of travel time for your caregiver staff. Several vendors offer fixed solutions for storage of supplies in the patient room; others offer mobile solutions to meet the need. If you can cut down on the amount of time your staff must travel back and forth for supplies, you can more effectively manage your staffing levels. Studies show nursing staff of some facilities travel up to three hours during an eight-hour shift hunting and gathering supplies.

• Consider the use of a rail system in treatment spaces and patient rooms to allow for flexibility of locating med gases, sharps, gloves and other accessories. The location of supplies can flex with the purpose of the space with the use of a rail system. When a rail system is in place, the staff can rearrange location of key supplies and equipment to have the workflow of the room arranged for current practice instead of how it was designed years ago. This translates to staff satisfaction and delivery of better patient care.

Ticer called the exchange of medical information vital to the operation of a healthcare facility, including population of electronic health records (EHRs) and electronic medical records (EMRs). "Medical devices and equipment must interact with different information systems and information technology networks," he said. "In short, there is a growing interrelationship between medical technology and information technology which is driving the concept of integrating electronic systems across the healthcare environment, or convergence. As clinical and non-clinical systems become more complex, the ability to share data becomes crucial to successful patient care."

• Encourage collaboration between two key services in the hospital – Information Technology and Clinical Engineering. These two groups will be vital to the selection and implementation of equipment that may be integrated into the hospital’s information systems. Historically, Clinical Engineering and Information Technology departments do not operate in the same manner, so early communication about goals, plans and functions are highly important.

• Learn how technology decisions can affect current operations, patient care and clinician work processes in other departments. For example, selection of physiologic monitors that may interface to an electronic medical record has facility-wide implications for patient care.

• Standardize on converging technology vendors/applications when applicable. Recognize, however, that this will not always be possible. Certain areas of the hospital will require best-of-suite, best-of-breed or proprietary solutions, particularly in relation to medical devices and equipment.

• Involve the various stakeholders before making any changes to the healthcare organization’s information network that could affect the performance or function of medical devices. It becomes vital to know exactly what medical information is moving across the network, and what equipment and devices that information affects.

• Perform pre-purchase trials (e.g., to assess interoperability capabilities, human factors design, and clinician preferences). For equipment purchases that affect multiple areas in the healthcare organization, it is very helpful to require approval from each of the involved departments.

• Dickow forecast a promising outlook for electronic integration. "As technology continues to escalate, opportunities are endless," he indicated. "Both cost reductions and improved patient care, through availability of more accurate and timely information, offer significant benefits."

• Make sure vendors acknowledge and consider the future benefits.

• Ensure that systems considered contain and/or accommodate information technology and future connectivity.

• Foster competition between vendors to reduce and control prices.

• Consider the ability of a system to adapt to an organization’s future methods and systems or changes prescribed by either healthcare reform or economics.

But healthcare supply chain managers should understand what all this really costs, Hood urged.

• Be sure to understand the full cost of equipment integrations. Integration with other equipment/systems such as wireless phones, cell phones, nurse call, tracking systems and hospital information systems increase efficiencies but can be costly. Have all involved equipment and systems vendors review the defined scope before signing agreements for equipment integration.

• Ensure compatibility to minimize integration issues. Don’t accept the typical response that "we can interface with anyone." Dig deeper. Ask who they have interfaced with and require references where integrations have been implemented with these specific technologies, equipment, and hospital information systems.

• Involve IT and biomed staff before committing to a particular manufacturer or solution. Occasionally there are overlaps in technology capabilities that can be consolidated to save money. Proprietary solutions may also create additional challenges. For example, telemetry manufacturers require use of a specific distributed antennae system solution, or patient monitoring integration with wireless phones may require specific middleware. IT and biomed staff can help navigate through these obstacles.

• Be aware of integration technology capabilities of upcoming equipment. Initially you may implement all integration features available, but you should also plan infrastructure to support future options. Addressing conduit, back boxes, and infrastructure is typically more cost effective during initial implementation. This will assist in avoiding equipment and system replacement upgrades due to integration options purchased in the near future.

• Maximize integration with existing equipment and systems. When possible explore existing system capabilities to integrate, providing maximum efficiencies. Examples are: utilize existing wireless network to provide refrigerator temperature monitoring, explore existing hospital information system integration product solutions, or utilize wireless LAN to provide equipment/patient/staff tracking integrated with existing nurse call system and wireless phones.

"Facilities should explore surgical equipment that incorporates a central station in which one member of the surgical team can control all of the equipment, easily and intuitively," Knight said. "This frees the surgeon to focus on the needs of the patient and not the equipment. To take full advantage of this innovation’s advantages, a facility should definitely explore the potent combination of surgical light, camera, and a centralized AV system."

Lenze echoed the importance of integration in the ICU in particular. "In the ICU, equipment should easily communicate with receiving systems and integrate with nurse call and patient monitoring systems," he said. "Data collection, recording, and even screen captures, if appropriate, are important capabilities to look for. When exploring ventilators, our SERVO-i combines all of these features. Using our CIE protocol, SERVO-i virtually communicates with any receiving system and most of the leading HIS and patient monitoring systems."

Ergonomic equipment not only is good for the healthcare worker, but good for business, too, which translates into being good for the patient, according to Ticer.

"A healthcare worker’s hands, wrists, arms, shoulders, back, and legs may be subjected to thousands of repetitive twisting, forceful or flexing motions during a typical workday," he indicated. "Ideally, using ergonomically designed workplaces or products can reduce worker injuries and illnesses, increase worker comfort, improve performance, reduce errors, decrease Workers’ Compensation costs, accommodate diverse populations, such as individuals with disabilities, and improve employee morale."

• Perform a survey of the hospital environment and injury reports to determine what areas or departments are high priorities for implementing ergonomic-areas in the hospital environment are more conducive to ergonomic equipment than others. Utilizing patient lifts in the operating room for example, will be much more problematic that in a patient care unit.

• As a parallel process to selecting ergonomically "friendly" equipment, develop a staff education system to ensure effective use of the equipment. Ergonomic equipment isn’t effective if the hospital staff doesn’t understand the underlying reasons for use, or how to safely operate the equipment.

• Understand that equipment designed to support ergonomics can be expensive. For even something as simple as an ultrasonographer’s chair, selecting a model built for ergonomically correct seating can add hundreds of dollars to the price tag.

• Do some research before purchasing the equipment. While most vendors of ergonomic equipment have supporting data on how their particular product reduces staff injuries or is otherwise beneficial, this isn’t always the case. In the face of a rash of staff injuries, it can be very tempting to assume that an "ergonomic" label on a piece of equipment means it’ll be beneficial, but due diligence can save money and improve staff injury rates.

• Trial the equipment before buying. Not all ergonomically equipment is designed the same, so testing multiple vendors’ equipment in the clinical setting will ensure it meets the organization’s particular operational needs. This is particularly important with equipment that is used to support patient care, such as patient lifts.

Hood concurred and echoed the importance of staff consideration.

•  Closely evaluate any equipment that requires staff repetitive motion. Be sure to evaluate the ease of equipment mobility and use. Mobile C-arms and ultrasound machines are two examples of equipment that may be moved regularly to be used and have potential for strain. Evaluate each manufacturer’s ability to provide product solutions that effectively address staff concerns.
  Coordinate installation of equipment to address ease of use. One example: Wall-mounted equipment, such as physiological monitors, should be installed so that buttons are easily reached by staff.

• The requirement of "meaningful use" in electronic medical records will increase staff data entry at point of care. Select equipment accessories that allow flexibility. Articulating arms with adjustable height and ergonomic keyboards are important in reducing staff muscle strain during entry of patient information.

• Select equipment features that minimize staff injury. Examples are motorized patient lift devices and power assisted patient bed for transport. During a renovation or new construction project, consider the use of ceiling mounted lifts in patient rooms. Although the initial cost is high, studies show ceiling lifts can pay for themselves in 2.5 years based on reduction of work related injuries and work days lost related to patient handling.

• Involve the design team. During renovation or addition projects describe in detail to the design team how medical technology will be used so that cabinetry, electrical outlets, med gas outlets, headwalls, and staff workflow are all coordinated to provide ease of use.

Back injuries are cited as the most common reason for absenteeism in the general workforce after the common cold, Pugliese noted. Moreover, patient transferring and handling injuries typically represent at least 50 percent of worker’s compensation costs, she added. Most healthcare work-related musculoskeletal injuries occur from cumulative injuries, such as repeated improper patient lifting and transfer.

Ergonomically designed patient beds, for example, reduce back stress, fatigue, and injuries and can also improve workforce satisfaction and retention. Consider lifting equipment for moving patients to prevent back injury among workers and reduce the risk of patient falls with injuries, she recommended. In fact, case studies evaluating the impact of mechanical lifting equipment in healthcare facilities reported report dramatic decreases in the incidence of worker injuries, workers’ compensation costs, insurance premiums, medical and indemnity costs, lost work days, and absenteeism due to lifting and handling.

• Dickow defined ergonomics as "the applied science concerned with designing and arranging things people use so that interactions are both efficient and safer."

• Make sure that vendors discuss ergonomic aspects during formal and informal presentations.

• Observe how interactions between people and equipment actually work, in real-life situations.

• Extrapolate forecasted changes to operational modalities in order to assess future compatibility.

• Carefully review vendor claims of "human engineering" to ensure that results claimed make sense for the particular application.

Looking at the big picture, if possible the entire [operating] room should be ergonomically designed to improve workflows, efficiency, and comfort for both the patient and surgical team, according to Knight. MAQUET’s 3D OR software allows healthcare facilities to plan and visualize their OR workflow to optimize day to day operations, he added.

For optimum OR lighting ergonomics two lights, one large and one small, should be combined in the surgical theater, Knight continued. "The large light provides necessary shadow dilution and should be positioned above surgeon’s head," he noted. "The second light should be of smaller size, easily maneuverable, and lightweight." He cited MAQUET’s PowerLED lights as fitting.