Published in the December 2007 issue of Today’s Hospitalist
When Banner Gateway Medical Center in Gilbert, Ariz., opened its doors in September, it was billed as a “next-generation hospital.” That’s because the brand new hospital, which is located 20 miles from Phoenix, is packed with high-tech features that might seem more at home in Silicon Valley than a U.S. hospital.
The 176-bed facility’s private patient rooms, for instance, are ringed with computer-filled modules where physicians and nurses feed the completely paperless electronic medical record (EMR) system. Hospitalists communicate with each other via wearable, wireless, touch-activated devices. And morning sign-out takes place in one of several conference rooms where patient images can be displayed on a 60-inch plasma screen.
While the hospital is clearly a technical tour de force, its computing horsepower is only part of the story. Look beneath the shiny surface of Banner Gateway’s high-tech gadgets and systems, and you’ll find that the hospital is banking on an expanded role for the new hospitalist practice.
That’s because members of the hospitalist team, which currently includes eight full-time equivalents, are functioning as the “super users” of all this technology.
According to Sandeep Sachdeva, MD, director of the new hospitalist program, the hospital planned from the beginning to make hospitalists the linchpin of its high-tech approach.
Because hospitalists live and breathe in the hospital, he explains, the hospital decided that they would be the human gateway to the hospital’s many innovations. It’s been less than three months since the hospital opened, but Dr. Sachdeva says the hospitalists, who offer 24/7 service, already play an integral role in the hospital’s operations.
Most of the specialists, for instance, use the hospitalist group as an admitting service because they aren’t nearly as up to speed on how to use the hospital’s EMR and other software “and because the hospital believes co-management is a safer route for patient care.
“The system being developed here is heavy on surgical co-management,” Dr. Sacheva points out. “As care processes get streamlined, standardized and digitized, co-management of surgical patients will be the next big growth area for hospital medicine in many hospitals and care systems.”
And even physicians who don’t use the hospitalist service to admit patients “are going to start leaning on the hospitalists even more because of the computer system,” Dr. Sachdeva adds, “particularly if they feel intimidated by electronics.”
The electronic centerpiece
The centerpiece of Banner Gateway is its EMR system. According to Marjorie Bessel, MD, a former hospitalist who is the hospital’s chief medical officer, the EMR helps physicians streamline clinical care.
“The radiologists use a voice recognition dictation system and then immediately sign off on a final report,” Dr. Bessel points out. “The system has almost completely eliminated the need for preliminary reports.”
And because of the system’s built-in connectivity, she adds, office physicians and specialists can pull up a patient chart and immediately review any inpatient encounter. That helps reduce the “voltage drop” of information between the inpatient and outpatient settings.
The software shows how hospitalists are playing a key role in getting the hospital’s systems up and running.
During a two-week orientation period before the hospital actually opened, the hospitalists spent most of their time learning the finer points of the EMR, which contains order sets and computerized physician order entry. Clinical account managers from within the Banner system were on hand to help, shadowing hospitalists on the EMR and working 24/7 on a shift basis for the first four weeks after the go-live.
Dr. Sachdeva admits that when the hospital first opened its doors, he and some of the other physicians had “that deer in the headlights” look for the first few days.
“Our biggest concern in terms of patient safety was getting our orders straight,” he says, “making sure the system was recognizing duplicate or conflicting orders.”
Because patient volume at Banner Gateway rose quickly, Dr. Sachdeva says that within a month, he was as facile on the system as the people who trained him. Consultants, however, are struggling.
“It’s not uncommon,” he says, “to hear someone in the hall getting upset at the computer.”
Leveraging scarce resources
The EMR system is also an example of how many of the hospital’s bells and whistles are designed to stretch limited resources.
While the area surrounding the hospital is rapidly growing, Dr. Bessel explains, the state has a pressing shortage of nurses and physicians. She hopes that the EMR will help physicians and nurses work as efficiently as possible to make up for the expected workforce shortage.
A telemedicine suite, for example, has been set up to access off-site infectious disease consults. “We have very few infectious disease physicians in Phoenix and throughout Arizona,” says Dr. Bessel. “That is a very scarce resource.”
And technology is being leveraged in other ways. With only one hospitalist and one ED physician in-house overnight, night-time ICU back-up is being provided by intensivists at another Banner hospital.
Those physicians can see and speak with ICU patients and access all medical records. Because night-time hospitalists, within two months of the hospital opening, were admitting as many as 10 patients a night, Dr. Sachdeva says the e-ICU is proving to be “indispensable.”
Just like “Star Trek”
Another innovation the hospital is using to keep down noise levels: The overhead paging system is reserved only for codes.
Instead of voice paging, all members of the staff started communicating with the new Vocera Communications system. The wearable wireless device, Dr. Sachdeva says, is his favorite piece of new equipment, one he likens to badges featured in “Star Trek.”
By just touching the device, which is pinned to his coat lapel, he can tell it to call any of the hospitalists, nurses or technicians by name; the device immediately connects to recipients, unless they have switched the device to hold. “It takes messages, just like a cell phone, but it’s voice-activated,” says Dr. Sachdeva. “You’re never looking for phone numbers or spending time on hold.”
The devices continue to come in handy to communicate with technicians in radiology, the lab and pharmacy, he adds. But within weeks of the hospital’s opening, some problems emerged with the system.
Hospitalists found that the devices, which transmit a conversation out-loud unless they’re on hold, are intrusive at night. More to the point, they can’t be used to communicate any patient information that could be overheard.
As a result, nurses are using the devices to ask doctors were they can find them to come and discuss a patient issue. While the hospitalists now use the Vocera system for short conversations, “We’re moving to using text paging as the main source of conveying patient information,” says Dr. Sachdeva. Nurses now text him about pain medication that a particular patient needs.
“I just log onto the computer from wherever I am and put in the order,” he says.
A team approach for nursing
The charting modules that are outside patients’ rooms are another innovation, one that replaces a centrally located nurse station. Each module includes two computers, one for each patient who needs to be charted, as well as an observation window looking into each room.
The idea is that without centralized stations, nurses will spend more time with patients. That notion feeds into another process redesign the hospital has implemented: Patients are cared for by a team of three nurses that includes one RN, one LPN and one CNA.
Hospitalist Carmen Oliveras, MD, who came to Banner Gateway from the Mayo hospital system in Minnesota, says the nursing team approach has definitely made her life easier. "It’s much better than having just one nurse who may be on break, leaving coverage to another nurse who does not know about the patient anyway,” she says.
And like many of the innovations put into place at Banner Gateway, the nursing team approach is meant to accommodate hospitalists. Eventually, when the hospitalist group grows, hospitalists will be dedicated to one floor, each with a designated nurse team.
That, says Dr. Sachdeva, will be the next generation of innovation for both the hospital and the hospitalist program.
“Each floor has 36 beds, and I’d like each to be covered by two hospitalists,” says Dr. Sachdeva. The floor-based model will allow the group to develop into physician managers, who each head up multidisciplinary teams and rounds.
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Low-tech solutions
While the big draw at Banner Gateway Medical Center in Gilbert, Ariz., may be its cutting-edge technology, the hospital has also embraced several low-tech innovations to improve safety and make the physicians’ work lives easier.
Private rooms, for example, cut down on noise and the risk of infections. And an acuity-adaptable headwall makes it possible to outfit a room with ICU equipment
if needed.
Patient safety features include sliding bathroom doors in patient rooms to reduce the risk of falls. Patient beds are fitted out with scales and fall monitors, as well as bed-to-chair options to minimize patient lifting. (Portable and ceiling mounted lifts are also available.)
ICU beds have alternate pressure mattresses to lower the risk of bed sores. And areas where medications are prepared are stocked with extra lighting, while the height of outlets in patient rooms has been raised so patients and staff don’t injure themselves reaching for a plug.
