By K. Richard Douglas
“Where is it? I need one stat, but I can’t locate it.”
Those words are heard in hospitals across the globe every day as medical devices and equipment go missing, are misplaced or become difficult to locate. This is a regular and vexing problem for clinicians; but it doesn’t have to be.
Nearly every device in a hospital can be tracked and located through technology and the problems created by a device’s disappearance, or running out of vital devices, doesn’t have to occur. Devices, along with staff and patients, can be tracked in real-time along with location. Location infrastructure can be added or modified to enhance these capabilities.
Like everything from DIY how-to videos on YouTube to evidence-based medicine, the experience and results achieved by others can be used as a guide to take on a project. In this case, it would be a real-time location system (RTLS).
At the Orlando MD Expo, in October of 2023, Michele Manzoli, CCE, and Jaspinder Singh Ratth, MS, both colleagues in the clinical engineering department at Cedars-Sinai Medical Center, presented on their own experience setting up one of these systems after a successful pilot.
Manzoli is manager of clinical engineering and Ratth is a clinical engineer. The presentation was titled: “The Real Value of Real-Time Location Systems: Lessons Learned.”
The clinical engineering department first initiated a pilot program, followed by a full implementation of an RTLS system encompassing more than 14,000 assets, and the guidance from the CE engineers is informative.
The engineers kicked off their presentation by highlighting the benefits of an RTLS system. At Cedars-Sinai, the CE team worked with leadership in device integration and nursing to form a steering committee. This group directed progress on the project, along with other stakeholders.
Any CE project at Cedars-Sinai is a big project, in a hospital with 889-beds and 15,000 employees, the CE department is made up of 30 team members. The RTLS project was no exception.
Manzoli explained that the incentive for installing an RTLS system was to reduce time searching for equipment, reduce staff frustration and improve morale and improve workflows and productivity.
Much was learned during the pilot phase of the project. There were lessons learned firsthand during this phase that allowed the CE team to plan accordingly, while using the same devices.
Would you recommend using the same equipment/devices during that phase?
“During the pilot phase, we learned the importance of choosing the optimal tag location: some devices didn’t adhere well to the tags, so we experimented with zip-tying tags to equipment power cables. We also encountered defective tags, highlighting the need for thorough quality checks before deployment. Additionally, if accessories like adhesives or cradles/brackets are involved, you would want to have a generous amount on hand. We recommend using the same devices during the pilot, as it serves as a valuable trial run to identify areas for improvement before full deployment,” Manzoli says.
One challenge of the pilot phase was that it began in March of 2021 during the COVID-19 pandemic with a go-live near the end of April. The pilot phase included approximately 700 tags and various devices including infusion pumps, cardiac chairs, transport monitors, vein finders, glucometers and others.
The entire project was rolled out in phases. Phase one took place during January through March of 2022, phase two during September and October of 2022 and phase three started in May of 2023. Phase three was still ongoing at the time of the MD Expo presentation.
The CE team focused on room-level accuracy for the med/surg and ICU floors during phase one, as well as area-level accuracy in other spaces in the facility’s main building. The goal for the team was to tag approximately 11,000 assets during that time.
During phase two, they tagged approximately 400 gurneys, 600 multiparameter modules and 650 pumps/patient warmers. Approximately 2,400 devices in total. Phase three saw 1,100 beds tagged and need-based tagging in the OR, cath lab and GI spaces, which included approximately 400 tags.
Another consideration that was discovered by the team was the need to check tag functionality right out of the box.
“Depending on the tag type, the activation of the device consists in holding a button for three seconds or removing a thin seal. The functionality verification requires our team to enter the tag ID into the RTLS application and confirm the location displayed,” Manzoli says.
The team decided on several standardized naming conventions that included asset names and asset groups. An abbreviation for the floor and department is part of the standard, followed by an agreed-upon name for the device. Within asset groups, an abbreviated unit name, followed by an abbreviation for the device name.
To provide some useful guidance for the project, stakeholders from CE, materials management, transportation, nursing, imaging, EVS, periop services, pharmacy, lab and respiratory therapy were involved.
Department representatives shared information about the challenges of locating devices; the CE team kept all involved appraised of the progress of the project and there was a review of usage along with success stories to keep all parties motivated.
A video provided end-user training. End-users fill out an online electronic tagging request form, to make CE aware of all the particulars.
The other benefit of the system is loss prevention. Low frequency exciters are placed near linen rooms, so that an alert goes out to the charge nurse and unit secretary.
INFRASTRUCTURE CONSIDERATIONS
At Cedars-Sinai, much of the infrastructure was already in place to accommodate existing systems, such as infrared emitters, and both low-frequency and ultra-high-frequency components in inpatient spaces. The system that the CE team installed used infrared emitters and tags that can communicate with Wi-Fi or ultra-high frequency.
Using Wi-Fi, packets are sent out every five minutes that allow for the triangulation of device locations. Wi-Fi is an optional pathway where battery-operated infrastructure cannot be installed.
Not all health care environments have the benefit of an existing infrastructure. How difficult would it be to add in infrastructure in environments that are not already as built-out as the facilities at Cedars-Sinai? What might need to be added to modernize any existing infrastructure?
“If a facility is looking to add room-level accuracy, they would need to allocate funds and resources for additional infrastructure. Depending on the specific RTLS vendor, the infrastructure could consist in both battery-powered beacon devices using infrared or ultrasound signals and networked proprietary access points,” Manzoli says.
He says that if structural and financial limitations are in the way, the facility can also take the “Wi-Fi- only” approach. This would leverage the existing access points that support the hospital wireless network. Depending on the specific RTLS vendor, this approach may work only with certain RTLS tags and would generally result in less granular accuracy.
To get best results from a RTLS system, the process of mapping needs to be accomplished by the project team or by the vendor they are working with. What produces best results?
“Cedars-Sinai leveraged the RTLS vendor to assist with map creation. Areas with room-level accuracy required the custom build-up of the map using MS Visio or similar application. Areas with zone-level accuracy leveraged the architectural drawing that were already available to the project team,” Manzoli says.
There are two levels of maps; one room-by-room which allowed the vendor to draw up maps using Visio. This is the more accurate approach. A second type of map is a Wi-Fi map and it has a zone-level accuracy. This has a lower level of accuracy.
SUPPORT CONSIDERATIONS
Battery management and back-end support are important components of an RTLS system. This was a focus of the CE team.
“Battery life on tags can vary, with some depleting early and others lasting beyond two years. After our pilot, we began annual battery replacements during PM for all equipment maintained by clinical engineering. We also generate low-battery reports twice weekly, with a dedicated team member handling replacement. This approach keeps our compliance at 99 percent,” Manzoli says.
Post implementation support is a key consideration and much of this will be based on the size of the facility and the numbers of assets. The pilot revealed the need to budget for one or two FTEs needed for on-site support and one FTE for system/application support. On-site support would include battery and tag management. There was also the need for server support, back-end support, expansion and reports creation.
“At our facility, we currently have two FTEs to support our RTLS and EM (environmental monitoring) system. One FTE focuses on infrastructure and EM services, while the other handles new tagging requests and routine battery maintenance. The overall FTE requirement depends on the infrastructure and on the number of assets the facility plans to tag and maintain,” Manzoli says.
The criteria for tagging included several conditions. The asset had to have a value of at least $500. The asset should also satisfy at least one of several criteria, including that the tag can protect against accidental loss of small items, facilitate maintenance workflows, improve clinical workflows and facilitate patient transport, among others. Was CE satisfied with the chosen criteria?
“Yes, we are satisfied,” Manzoli says.
POST-INSTALLATION THOUGHTS
Setting up a functioning system is just a portion of the challenge. Clinical staff need to be made aware of how the process works and there needs to be a means to provide training. The CE team and the steering committee addressed these requirements.
Manzoli says that some of the components of a staff awareness campaign can include creating visuals such as posters and flyers that can be circulated, which has been effective to promote RTLS throughout the facility.
“These posters are often shared during larger nursing education meetings, mass distributed through leadership listservs, and occasionally even added to the hospital website announcements page,” he says.
They made clinician training available through the hospital education portal.
“We encourage department leaders to have their staff enrolled in the course that provides the basics of how to navigate the RTLS application. It is prerecorded, which allows staff to rewatch any sections they need to. Our team is always available to assist and perform an in service for any departments that request so,” Manzoli adds.
Another benefit to keeping all clinical staff aligned with the use and issues of the system is a workflow committee.
“The need for workflow committee meetings on a regular schedule is important to reinforce best practices. It serves as a refresher for end users as well as training for new staff members,” Manzoli says.
Finally, naming conventions help keep all on track. The terms decided on are a good way to align all stakeholders. The initial choices that the CE team went with have proved to be adapted by all.
“We have not made any changes to naming conventions. We believe the current setup allows both our department and the end users to easy find and track equipment in the RTLS application,” Manzoli says.
During the course of the project, Manzoli and his colleagues have discovered several benefits besides tagging pharmacy and/or phlebotomy carts or infusion pumps. The tags allowed for the determination of how long the carts remained in targeted areas. This also allowed for the monitoring of time spent in each area by phlebotomists.
“We have found tagging all loaner equipment very helpful. These devices are intended to be at the medical center for a limited time and locating them without RTLS would be problematic in a facility as large as ours,” he says.
Feedback from CE colleagues, as well as clinicians, imaging, surgical floor, critical care and central transport has all been positive. The average time savings from surveys has been about 20 minutes a day per user. That equates to 8,500 hours saved annually. This time can be better allocated to value-added activities.
Loss prevention figures were impressive also with wound vac rental unit losses reduced by 80 percent in a 12-month period, with savings exceeding $65,000. The system helps with remediations and recalls. The system also helps with inventory optimization with devices like infusion pumps.
Future RTLS systems will continue to evolve and the technology will become even more precise. AI and machine learning will no doubt play a role in the future of these systems.
The experience and results of the Cedars-Sinai CE team can be instructive in determining considerations for an RTLS system, potential cost and time savings and other less-thought-of benefits. Chief among the benefits will be fewer CE and clinical staff complaining: “Where is it?”
An on-demand recording of the MD Expo presentation is available at tinyurl.com/yaddjwar.
