‘Making the invisible visible’ at advanced digital hospitalwww.ascom.com

October 2019 Volume 73 Number 9www.iheem.org.uk

JOURNAL OF THE INSTITUTE OF HEALTHCAREENGINEERING AND ESTATE MANAGEMENT

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2 Health Estate Journal Reprinted from October 2019

PATIENT RESPONSE TECHNOLOGY

‘Making the invisible visible’ at advanced digital hospitalIn September 2018, the new £200 m Chase Farm Hospital near Enfield opened to become what its operator,

the Royal Free London NHS Foundation Trust, believes is the NHS’s most advanced digital hospital. The

process – from business case, to designed, built, and operational hospital in just four years – is believed to

be unprecedented. One of the key elements of the new hospital’s digital infrastructure is an Ascom digital

patient call system which is already helping nurses and clinicians deliver better care and significant

operational efficiencies. Fiona Morcom, the Trust’s Clinical Implementation lead for the project, and Andy

Dargue, IT Infrastructure Project manager, explain how a successful patient response system that works

flexibly across all clinical areas was developed and implemented.

Nurse call systems with buzzers and lightshave been around for years, usuallymanaged by estates teams, but many areno longer fit for purpose. We neededsomething that would both change theway we worked and delivered care, andallow us to leverage the solution for otherclinical and communication needs. Thethird floor of the new 23,000 m2 ChaseFarm Hospital features a 50-bed surgicalward, with 42 side rooms and two four-bedded bays. On the second floor areeight operating theatres and a daysurgery unit, and at ground floor level, anUrgent Care Centre and busy radiologydepartment. The new hospital’s groundand first floors also house multipleoutpatient clinics, some offering minorprocedures, and the lower ground floor abusy endoscopy unit. The hospital’s highlyefficient, future-proofed design – withdigital technology harnessed in manyareas – is a real ‘sea change’ from the

cramped, outdated Victorian premises wemoved over from at the end of summer2018.

While in the ‘old’ Chase Farm mostinpatients were in four-bedded bays,running a ward safely with most patientshidden from sight inside (single) rooms at the new hospital meant we needed adigital solution that would optimise ourview. Our chief executive and director of Nursing, Natalie Forrest – who has anextensive nursing background herself, and is thus fully familiar with the practicalchallenges nurses face day to day –described the Ascom system as ‘makingthe invisible, visible’. This was an aptdescription, because on initially viewingthe long third floor corridor along whichthe 42 side rooms and two four-beddedbays are located, we had concerns overhow nursing and clinical teams would beable to keep a proper eye on patients.Moving into the 21st century ‘digital world’

also afforded us the opportunity to look atthe wider potential role of a digital system– in improving both our flexibility andoperational effectiveness.

A trawl of the marketWe scoured the market for the mostmodern and advanced patient responsecall solution, and the supplier that offeredus what we needed was Ascom, a rapidlygrowing digital communications provider.Ascom – with whose earlier nurse callequipment we had good experience atthe ‘old’ Chase Farm Hospital – was keento support our vision. Its team was equallycommitted to working closely with ourlead and clinical teams to provide atailored, fully integrated solution. As aresult, we now have a highly sophisticatedAscom Telligence patient responsesystem that directly connects patientswith their nurse via the company’s Myco 2 and Myco 3 smartphones, whichthe nurses and certain clinicians carry. The Myco 3 devices feature larger screens,and are thus better suited, for example, to viewing ward audits and patient vitalsigns data. The Ascom system alsoenables nurses, and, for example, doctorsand consultants, to instantly connect withor summon colleagues from both withinand outside the hospital.

Appointment of a clinical leadThe appointment of a clinical lead (FionaMorcom) on the Trust side to interfacewith the clinical teams and the enablers –IT, Estates, and the solution provider –was a key step in enabling programmecoordination, as well as an interface withthe clinical teams to translate what wasneeded into what could be delivered.Early collaborative working meant thatthe team engaged in the project grew, sothat traditional working boundaries werebroken down. The Trust IT team hadexpanded considerably to support the

Pictured in front of the main entrance at the new Chase Farm Hospital are (left toright): Fiona Morcom, James Webb, Susan Lau, Natalie Forrest, and Mark Bateman.

wider Global Digital Exemplar projectwhich The Royal Free London group hadbeen selected for, and a dedicatedmember of the IT team was able tosupport the development and delivery ofthe nurse call system.

Offsite visits to existing hospitals usingthe system helped, with lessons learned,and potential pitfalls identified. (In fact,Fiona Morcom and a number of projectteam colleagues visited several Ascomhospital installation sites in the US,including the Smith Care Center,Plymouth Harbour, in Florida, andAscom’s R&D facility in Bradenton near Sarasota (in the same US State).Their subsequent feedback, and clearidentification of the features andworkflow functions the clinical team at thenew hospital would require, informed thedesign of the patient response system.

The processWorking as part of the redevelopmentteam to build and equip the UK’s firstpaperless hospital meant every day was a challenge. Change was the order of theday for us, but for clinical teams it was still‘business as usual’. Delivering a ‘solution’without understanding the problem canmiss the mark, so we went back to basics.‘Selling the concept’ to busy clinical teams of a call system in their pocket was a first step. We started by processmapping while observing clinical teams

in their day-to-day work; this enabled us to demonstrate time wasted in dailyworkflows. Freeing up this time allowsmore time to be spent on direct clinicalcare, and improves efficiency; it alsoreduces the frustration which can mountthrough a working day when time iswasted.

Crucially, spending time across differentworking environments helped us tounderstand the different functionalityneeded, and how we could adapt the way in which the system works. Whiletraditional nurse call systems have a ‘one-size-fits-all’ approach, we were ableto carefully tailor our solution to therequirements of each area and its specificneeds and challenges.

Multidisciplinary involvementClose working with the clinical teams,multidisciplinary involvement from theTrust’s IT Department and Estates team(the latter led on the project by the Trust’s then Programme manager, MarkBateman, who is now head of Estates andFacilities), the main contractor on theProCure21 hospital build project, IHP, andexternal building services and electricalteams, made for some complex meetings.Inevitably, there were times when somepart of the discussion around the tablewas not universally understood, butstaying engaged and respectful about thechallenges posed by areas outside ournormal scope of experience was essentialto keep things running smoothly.

There were also some technicalchallenges to enable a system originallydeveloped for US use, designed to workacross a ‘flat’ network, to communicateacross the multi- sub-netted networkenvironment at the new Chase Farm

The Ascom viewAscom says of the project: “The new Chase FarmHospital has a range of interoperable technology built in‘from the ground up’ in its third-floor 50-bedded surgicalward. The new hospital also has eight theatres, daysurgery, endoscopy, clinics, and an urgent care centreacross five floors. The global Healthcare Information andManagement Systems Society (HIMSS) recently assessedCFH as having achieved stage 6 in the Electronic MedicalRecord Adoption Model (EMRAM), one of just threehospitals in the UK to reach this level of ‘paperless’maturity. The model has just eight stages, from 0-7.

“Central to the new hospital’s success is asophisticated nurse call system – based around ourTelligence patient response system – co-designed bynurses at the CFH with us at Ascom, and integrated withour Myco smartphones, which connect nurses andclinicians equipped with handsets with patients,colleagues, and other technology, across the hospital.Other staff, such as porters, domestic, housekeeping, andsecurity personnel, carry our I62 handsets.” James Webbat Ascom, one of those that I met at the new hospital,added: “This means that, for example, if a nurse needs aporter to take a patient to theatre, or bring them backfrom ‘Recovery’ post-procedure, they can call the porterdirectly, and the nearest available one will then arrivepromptly.” Fiona Morcom noted that this was in starkcontrast to the more ‘traditional’ scenario of having tolocate a free porter while the nurse stays with thepatient.

Enthusiastic responseAscom says nurses and doctors more accustomed to using‘traditional’ nurse call equipment at the original, Victorian-built Chase Farm Hospital – located a short distance from itsmodern replacement – have welcomed the time and labour-saving, and the enhanced efficiency benefits, of the Ascompatient response system. Alongside the many other practicalbenefits cited by Fiona Morcom and Andy Dargue, the nursessay one of the biggest benefits is that patients are more‘visible’ – thanks to the system’s speech software, and theability to monitor integrated medical devices (such as the GEand Philips patient monitors located by the bedside, whichdisplay elements such as heart rate and oxygen saturations)from anywhere in the hospital. For example, should a nursehave a concern over, say, the rising blood pressure of aparticular patient, they can either text or call a relevantclinician via their Myco device – who may be anywhere in thehospital at the time. The clinician can then not only talk tothem direct, but can also, if they wish, view the patient’slatest ‘observations’ via their own Myco, and decide what – if any – action needs taking.

Ascom UK worked hard to ensure that its nurse call systemwas fully interoperable with technology from other suppliersat CFH, including GE Healthcare, Philips Healthcare, Cerner,and various app providers. Ascom UK managing director, PaulLawrence said: “We are very proud to have worked closelywith clinical staff at Chase Farm Hospital on this project,which is an exemplar for the rest of the NHS. It has provedthat the greatest success in IT comes from asking clinicianswhat they need to do their job better, and then ensuring thatyou do whatever it takes to fully integrate it across theworkplace.”

The new £200 m Chase Farm Hospitalnear Enfield is believed by the Royal FreeLondon NHS Foundation Trust to be theNHS’s ‘most advanced digital hospital’.

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PATIENT RESPONSE TECHNOLOGY

Reprinted from October 2019 Health Estate Journal 4

Hospital, without introducing issues.Working with the Redevelopment Teamand the external suppliers, we were ableto redesign the solution to meet therequirements, while also future-proofingthe installation – from both a network anda nurse call perspective. This effectivelyresulted in a new ‘European’ configurationbeing developed. The system leveragesthe hospital’s existing physical andwireless infrastructure, allowing thehandsets to be used anywhere within the Trust.

InteroperabilityAs a hospital using multi-vendorequipment, we also needed to ensure that our nurse call system was fullyinteroperable with technology from othersuppliers at Chase Farm, including GEHealthcare, Philips Healthcare, and various‘app’ providers. This ensured that alertscan be sent via the Telligence hardwaredirectly to staff responsible for particular

patients via their Myco handsets, and,crucially, also allows them to access datawhile on the move. Working smarter, notharder, with digital integration has meantwe have moved into a larger space withan increased inpatient flow, whilemaintaining the same staffing numbers.(In fact, Fiona Morcom explained – when I met her, along with the hospital’s chiefexecutive, Natalie Forrest, and a numberof other key project team members in lateJuly – original predictions were that todeliver the same level of care to patientsin the new 50-bed inpatient ward, anadditional 12 nursing staff would beneeded).

HardwareLooking at the hardware deployed,Ascom Myco 2 handsets are held bynurses, medical, and AHP staff, as well asour concierge staff, who greet all visitorsand patients, and can rapidly direct themto where they need to be. They areeffectively internal telephone extensions,making it a simple matter for staff to keep in touch with each other. Ascom’si62 handsets, meanwhile, are held bydomestic, housekeeping, and security

staff, and porters. Nurse call panelsassigned to individual areas link allhandsets, and allow role-specific tasks tobe entered, so that individuals can bemessaged directly and directed to wherethey are needed. ‘Domestic workflow’buttons at bedheads in clinical areas arealso linked to these handsets, so porters,domestics, or housekeepers, can becontacted directly at the press of a singlebutton. Emergency buttons or pulls arelocated throughout, and, as with theentire system, are fully configurable, sousers of a range of handsets across thewhole site can be made aware instantly of an issue. Dome lights above the door of each inpatient room are linked to thesystem. An emergency pull by a nurse ordoctor will generate a flashing ‘red’, withthe nurse call software simultaneouslyimmediately alerting all relevant staff viatheir handsets. The overdoor lights alsosignal, via a colour-coded system, if aporter or domestic is required, and areused to show ‘staff presence’.

Rapid visibilityOne of the overdoor lights’ key benefitson a long 50-bed ward on a singlecorridor is that a nurse can seeimmediately such a light is illuminated,

The chief executive’s viewThe project to implement and install the Ascom system was led, and indeedchampioned by, the Chase Farm Hospital chief executive and director ofNursing, Natalie Forrest. She said: “Crucially, the technology development workwas done by clinicians, instead of to clinicians. It meant that we had genuineengagement with nurses and other stakeholders as we carefully planned thehospital from the start – taking in the views of estates, IT, domestic staff,porters, ‘admin’, and allied health and medical staff.

“With 42 single rooms we faced the challenge of making the ‘invisible’ patientvisible, and addressing our nurses’ key concern: that they might miss a seriousclinical issue while attending to other tasks away from the patient. The nurse callsystem linked to smartphones ensures that they can contact anyone, includingpatients, directly, and know what’s going on in their clinical area, even whenthey are elsewhere.”

She added: “The hospital was delivered on target and within budget – a tremendous achievement, of which the entire team is very proud.”

Nurses at Chase Farm Hospital have responded enthusiastically to the Ascomsystem’s installation; it is speeding response times and enhancing efficiency.

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A Myco 3 handset. Alerts can be sentvia the Telligence hardware directly tostaff responsible for particular patientsvia their Myco 2/3 handsets, and userscan also access data on the deviceswhile on the move.

Tricia Lenoir, a Recovery Sister at thenew Chase Farm Hospital, making useof one of the new Myco handsets.

5 Health Estate Journal Reprinted from October 2019

PATIENT RESPONSE TECHNOLOGY

and identify, via the colour, whether ascenario is routine or ‘emergency’. Unlikea ‘traditional’ nurse call system, however,alerts within the room are silent, meaningmuch less disturbance to patients. TheTelligence system’s ability to send alertsor texts direct to a staff member’shandset, meanwhile, means a need for justtwo display consoles within the 50-bedward. These nurse panels do, however,enable nurses to identify, at glance, andkeep an eye on, patients that may needadditional monitoring, and also to ‘drilldown’, for example if they need specificaudit or ‘call trend’ information. Within thebackground of the Telligence software,the Unite Analyze ‘package’ enables theproduction of regular scheduled reportsaround call response times, allowing staffto recognise peak times or bottlenecksand plan staffing accordingly.

TrainingSupported by both our Trust lead andsuppliers’ training teams, challenges wereapparent. A ‘demo’ system cannot givethe same effect as a fully operationalsystem in situ, no matter how good theset-up. ‘Training fatigue’ was beginning toshow within a staff group who had beenon the receiving end of a great deal oftraining and preparation for the move tothe new hospital. We had anticipated this,however, and in the first week after wemoved in, in September 2018, and beforewe had patients, we trained intensively,practising scenarios and ironing out anyissues. Once the staff could see thesystem in their own clinical areas, theycould make sense of how it would work.

Delivering efficiencies in practiceKey to our investment in the new systemwas, of course, that it would deliverefficiencies in practice, which it certainlyhas. Among these have been: n Integration of medical devices means

we can ‘monitor’ patients closely whomay not be in direct line of sight, butalso reduces the stressful noise andalert fatigue associated with multiplealarms. This improves both the patientand the staff experience.

n ‘Safety huddles – the handsets improvesituational awareness for the wholeteam by informing them aboutimportant changes to an expected plan– alerts about, for example, thecondition of a patient recentlyadmitted, can now be deliveredinstantly via group texting on theMycos. This saves up to 45 minutes aday, by effectively replacing physicalsafety huddles – where all staff need tobe got together – with ‘virtual’ huddles,which take about 30 seconds. Sharedinformation is recorded for use at anytime.

n Audits – nurses are saving up to 30minutes a day each on audits,

previously undertaken manually, butnow done digitally via the ‘PerfectWard’ smartphone app. Nurses canview and send audits at the touch of abutton.

n Theatre recovery throughput – savingup to 15 minutes per patient (average30 procedures a day) in movingthrough recovery and back to thewards, thanks to more efficient andeffective communications.

n Bed turnaround time – up to 40minutes per bed saved using thedomestic clinical workflow button,which helps to ensure that domesticstaff are quickly available.

n Time previously wasted in routinecommunications between theatres,

‘Recovery’, and the ward, has beendramatically reduced, with‘Coordinators’ for each area callingdirectly to each other to facilitatepatient flow.

ConclusionsThis has been a useful learning experiencefor us on the Project and Redevelopmentteam. Our key message would be to havea vision, and decide what outcomes youneed, in terms of improved care, safety,and staff utilisation – and to work backfrom that. Equally, make the system youspecify ‘future-proof’ – technology shouldbe scalable and replaceable, withouthaving to ‘rip out’ your interoperablesystem. Always have a clinician in chargeof the project, and be prepared to workacross many boundaries, including all thekey stakeholders early on. These willinclude IT, Networks, Estates, Security,‘Admin’, and Portering personnel. Staffengagement needs to be real, across themultidisciplinary team, not a token effort.Train your staff in using the technology,and check if they need more training afteryou ‘go live’. Keep the ‘tech’ simple anduser-friendly. Our staff use smartphonesthat are intuitive to use – just like theirown mobiles outside work.

Going paperless isn’t about imposing asystem on clinicians. It’s about finding outhow they want to work, and choosing thebest technology to fit. We will continue toreview the efficacy of the technology andthe organisation of clinical workflows toensure that we are making the best use ofit. Staff and patient feedback continue tobe crucial, and we will be looking at whatfurther training people need to usetechnology in the best way to make theirjob easier. We will share information fromteams in different clinical areas, so that wecan find smarter, more advanced ways foreveryone to work. hej

Key Chase Farm project playersn Main contractor: IHP.n Lead architects – IBI.n Architects – AD Architects. n M&E consultants –

Troup Bywaters + Anders.

n Electrical contractors – W Portsmouth.n Mechanical contractors – Norstead.n Structural consultants – Thomasons. n Cost advisors — Turner & Townsend.n Trust supervisors – Currie & Brown.

The workflow buttons can be assignedwhatever workflow functions the hospitalor other healthcare site wishes.

A nurse call console showing that apatient has requested a drink, and theassociated ‘wait time’.

The system of overdoor lights at thenew Chase Farm Hospital has provenespecially beneficial, given that the 50-bedded inpatient ward is on a long corridor, with 42 individual en-suite rooms.

Nurse call | mobile communications | software and device integration

…

Co-designed with nurses, built with estates teams, supported by specialist engineers…

| software and device integration

…and so much more than a standard nurse call