Effective Management of Long Stay Patients

A team initiative jointly undertaken by the department of Cardiac Sciences, Neuro Sciences and Hospital Management Information Systems at SSSIHMS-Whitefield

Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore

Information Systems at SSSIHMS-Whitefield

Satheesh Kumar S V, Ashwin V, Sai Kiran J, Ravi Kiran R

Daily monitoring of long stay patients in therespective wards

Background 2. Trends and patterns in movement of parameterswere not studied on a day-to-day basis; thus missing

The Patient Care Committee (PCC) is responsibleto review and improve parameters that assess thequality of medical care. This includes mortality,long-stay or morbidity, and out-of-turn admissions.During PCC meeting in April 2012, the need wasfelt to address the rise in the number of long-staypatients, and evolve a more effective system ofregulation and control. A team comprising of Implementation

respective wardsTo enable a active monitoring of the reasons for apatient s long-stay and assess trends of thesereasons, a standard list of clinical reasons foroverstay was introduced into the hospitals' e-HIS.These reasons are currently entered by the nurse inconsultation with the attending physician on a day-to-day basis (Fig 1.3) and can be monitored on a

were not studied on a day-to-day basis; thus missingon vital information for assessing & improvingpatient care.

3. Manual creation of reports and collection of datacreated logistical challenges as well as thepossibility of errors.

Fig 1.4

Snapshot of Post-op long stayregulation and control. A team comprising ofclinicians and managers from the respective clinicaldepartments along with a IT manager wasconstituted to address this issue.Extended stay of inpatients is a concern as it notonly leads to sub-optimal utilization of hospitalresources but also increases chances of nosocomialinfection and decreases patient satisfaction.

Implementation

Advance scheduling of patients in pre-operative cardiac wardEarlier, patients in the cardiac ward were scheduledfor surgery a day before the actual operation. In aneffort to improve surgical planning and scheduling, aprovision was created to assign a surgeon, date and

dashboard to assess the current situation in theward (Fig 1.4)

Fig 1.5

Snapshot of Post-op long stay

infection and decreases patient satisfaction.

Objective: The objective of this exercise was tostudy the limitations in the current system andimplement a robust method to actively monitor.. Inaddition it aimed to provide a more effective, visualreport to study trends in long-stay across eachdepartment. Active monitoring would help control/reduce long-stay admissions

provision was created to assign a surgeon, date andtime to each patient immediately soon afteradmission and clearance for surgery (Fig 1.1). Inaddition, it also provides other details on patients inthe ward who have not yet been cleared for surgery(Fig 1.2)

Figure 1.3

Initial ResultsThere has been a substantial reduction in the numberof long stay patients during the month of May (from1st to 25th May 2012), particularly in CTVS and

On treatment for Respiratory tract infectionAnti failure treatment

ID , Name, Age ID , Name, Age ID , Name, Age ID , Name, Age ID , Name, Agereduce long-stay admissions

Pre-Implementation The previous practice was to review the long staypatients at the end of each month. Queries wererun on Enterprise Manager (EM) before the PCCmeeting to generate the list of these cases.Managers of each department then obtainedcomments/ responses from attending doctors and

Weekly reports to the director s officeNurse in-charges from the respective wardsprovide a weekly report on long stay patients to the

1st to 25th May 2012), particularly in CTVS andNeurosurgery. The trend lines over the past 6 monthsshow that these numbers are on the fall.

In CTVS, only 13 patients were long-stay patients inMay as compared to 35 patients in April. At 10% ofthe total admitted patients, this is the lowestpercentage reading in the past 6 months.In Neurosurgery, 20 patients were long-stay patients

Figure 1.4

ID , Name, Age

ID , Name, Age

ID , Name, Age

ID , Name, Age

ID , Name, Age

comments/ responses from attending doctors andforwarded the list to the Secretary, PCC, whocollated these responses into agenda papers for theensuing meeting, and submitted them to theDirector s Office.

The previous system of retrospective analysis ofindividual cases had the following challenges:1. Clinicians found it difficult to recollect the

provide a weekly report on long stay patients to thedirector s office. In addition, the director makesperiodical physical checks during her dailyhospital rounds.

Clinical Dashboard for day-to-day monitoringA clinical dashboard has been created to visuallydisplay trends in patient long-stay. This includesreasons recorded in e-HIS. The dashboard also

Figure 1.1In Neurosurgery, 20 patients were long-stay patientsin May as compared to 33 in April. At 11.5% of totaladmitted patients, this is also the lowest percentagein the past 6 months.

Cardiology and Neurology have not had a significantrise in long-stay patients admitted to their wards.These numbers are negligible.

Figure 1.2

1. Clinicians found it difficult to recollect thedetails of each case after lapse of days/ weeks, andhence, physical files had to be sought & referredto for substantiating each entry. This time-takingeffort resulted in delays.

reasons recorded in e-HIS. The dashboard alsogives an instant visual assessment of trends in longstay. Aberrations in these trends can be instantlyidentified and the necessary action can be taken(Fig 1.4 to 1.5)

These numbers are negligible.The initial results are encouraging, and demonstratethat active monitoring of patient status duringadmission can reduce the number of long-stayadmissions.

Use of IT in microbiology Accelerating the Delivery of results to enhance Decision making in Treatment

Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore

Sai Kiran J, Satheesh Kumar S V, Dr. Smitalekha

IT helps medical technology deliver what it is meant toIT in organizing the Microbiology lab work Data Analysis/ Mining to aid decision-making

The LIS as an integrated part of the enterprise-wide hospitalinformation system (EM) defines the process followed in the laboratory

right from computerized test orders till the report reaches thecaregiver.

A report (Figure 1) is made available to the microbiology technologists

what it is meant to

The department has been equipped with automated bacterialculture system (BactAlert) as well as Identification & Antibioticsensitivity testing equipment (ID & AST - Vitek 2C).

These equipment enable early identification of bacterial infection inthe patient samples and an early identification of the organism &

IT in organizing the Microbiology lab work Data Analysis/ Mining to aid decision-making

The importance of early treatment of highly dangerous infections cannot besufficiently emphasized. And many a time, treatment is given empirically evenbefore the complete report (evidence) is known. This is true for treatment ofinfections too.

Previous data is used to decide upon the empirical treatment of choice. TheA report (Figure 1) is made available to the microbiology technologistswhat samples they are likely to receive and what is the expectedworkload of new samples for them. This is based on the orders placedin eHIS on the Microbiology department

the patient samples and an early identification of the organism &provide the antibiotic sensitivity.

Historically, the emphasis has been on interfacing the ID & ASTequipment to the LIS to help transfer the detailed reports to HIS: thishas its benefits of

Reducing the time & effort in transcribing the dataEliminating transcriptional errors

IT has been used to make it possible to make these benefits result in

Previous data is used to decide upon the empirical treatment of choice. Theraw data of antibiotic sensitivity reports of infected patients in the hospital orthe particular unit is analyzed by the system and useful information is providedto the care-givers. This information helps the clinician to decide what empiricaltreatment could be given to the patient before a final antibiotic sensitivityreport is available.This information is provided to the clinicians as reports:

IT has been used to make it possible to make these benefits result inearly treatment of the infection

Figure 1

Tests ordered Specimen type

Advantages of an integrated system in the hospital setting

%age%age

Figure 1Figure 2 shows a report showing the samples that have been registeredon a particular day. The report is used extensively by the technologiststo know the samples that are under process/ to be processed. Therecords are color coded that indicate records which are resulted andwhich are not

When the equipment identifies a bacterial growth in the sample, theresult is transmitted to LIS.The system sends an auto-generated SMS to the technologist on duty.This is made possible by having the duty roster of the technologists inthe system. The demands on the Microbiology technologist are suchthat he has to cater to the works in the media preparation room andin the serology room. Even under such circumstances, the instant,

Figure 3:Sensitivity of various antibiotics for a

particular organism

Figure 4:Sensitivity of a particular antibiotic for

various organism

in the serology room. Even under such circumstances, the instant,automated communication via SMS ensures that the bacteriologywork does not get delayed/ affected.

The technologist then reviews the result in LIS and upon this review,the system sends a SMS to the treating clinician and the nurse in-charge indicating to them the positive bacterial growth found in thepatient ssample.

Figure 2

This avoids any delay in the empirical treatment that could be given tothe patient upon knowing that he is found to be infected.

Figure 5:Report showing Antibiotic Organism Sensitivity Matrix

Bed-side Care with Computer on Wheels (COW)Kannan K S, Ramprasad G

Sri Sathya Sai Institute of Higher Medical Sciences, Prasanthi GramPrasanthi Gram

Need & Solution ImplementationBackgroundIn the year 2007, our hospitalformulated a policy of deliveringmore efficient patient care by beingpaperless and filmless . Thisincluded implementation of anenterprise wide HIS (Hospital

All medical images (DICOM) werestored directly in Synapse. Theseincluded images from the CR (X-rayimages), CT scanner, Ultrasound,Cardiac Cath Lab, OPG (ortho -pantomogram), Nuclear Medicine,C-Arm and Endoscopy. TheseInformation System) and PACS

(Picture Archiving &Communication System). Thus theeHIS 5.x and Synapse 3.0 weredeployed at SSSIHMS,Prasanthigram.

C-Arm and Endoscopy. Theseimages were available instantly toclinicians at their desktop computers.

In the wards, ICUs and OTs, imageshad to be viewed in the Nursesstations which were not situated

The advantages of being filmlesswere(1) Instant, multi-access to all

medical images across theorganization;

(2) Economy from recurring cost ofImaging films, processor

stations which were not situatedclose to every patient. This made itdifficult for the clinician to view theimages and review the patient at thesame time and place. When thephysical films were available, theycould be viewed at patient bed-side.The clinicians needed this bed-side

Today, clinicians in the wards, OTs and ICUs use the Computer on Wheels(CoW) at patient end-side in the respective clinical areas and get delay-freeaccess to patient images and patient medical records, and can place ordersfor investigations.Imaging films, processor

chemicals, physical folders andstorage space;

(3) Lesser repeat examinations asimages can be fine-tuned;

(4) Saving in personnelrequirement.

The clinicians needed this bed-sideviewing facility to aid in efficientpatient-care.

After testing various options such aslaptop, thin-client and desktopcomputer along with regular and RFmodems, the following setup was

for investigations.

modems, the following setup wasfinalized.1.A desktop computer equipped witha Nanostation2 USB Dongle.2.Nanostation2 RF Modem fromUbiquiti Networks (2.4 GHz, 802.11b/g, Antenna Gain 10dBi x 2) with atested range of 100 Meters.tested range of 100 Meters.3.A trolley on wheels with UPS (2kvA sufficient for 1.5 Hourspower backup).

SMS Alerts used in the Hospital Sri Sathya Sai Institute of Higher Medical Sciences, Prasanthi Gram

Kannan K S, Ramprasad GPrasanthi Gram

DOCTORS / SURGEONS

Call Doctor incase of EmergencyReminder of Surgery Appointments PaySlip / IncomeTax CommunicationsCount of Patients Waiting to SeeBlood Stock below reorder level

Public Relations Officer Transcriptionist / Secretary

SMSSYSTEM

Patients not checked out at End Of DayChange of DutiesCall by HOD / HR for any urgent WorkPaySlip

Foreign Patients who check into the OPD or get admitted.Deaths of Foreign Patients

PaySlip

Patients not checked out at EODPatients Invited for Surgery in OPD todayPaySlipToday s List of Surgeries with DetailsOT Schedule for the DayNo. of patient reports pending releaseStatistics of the cases done in the dayAlerts of any equipment failures

Managers / Officers

Alerts of any equipment failuresAlerts of items falling short due to any emergency.

Library Automation at SSSIHMS using NewGenLib

Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield

Bharathi Hariharan, Padma Y, Subbarao G V RWhitefield

AutomationBackground Objective of CatalogingTo enable a person to find a book ofSSSIHMS Central library has a

large collection of books andjournals for the reference of thedoctors, students and staff of thehospital. Library houses over 4000books under Medical, Nursing,General & Spiritual categories.

The four levels of library automation are :

Library cataloging systemHousekeeping operation and

networkingDevelopment of CD-ROM

library/ products

To enable a person to find a book ofwhich either the author, title orsubject (identifying objective) isknown.

To show what the library has by agiven author, or on a given subject, orin a given kind of literature The library cards having bar-coded

user IDs had been provided to all theGeneral & Spiritual categories.

Primary Functions:

library/ productsEmail system and internet

Solution- NewGenLib SoftwareNwGenLib is a Web-basedapplication. Databases created withNewGenLib reside on web servers

(collocating objective)To assist in the choice of a book

based on the edition or topical terms(evaluating objective).

user IDs had been provided to all theusers. The objective of bar-codingwas to minimize the errors duringtransaction processing.

Primary Functions:Collection & Cataloging Ordering,cataloging and de-accessioning ofmaterialsCirculation Maintaining useraccounts, loaning and receiving thebooks

NewGenLib reside on web serversand can therefore be accessed by anyclient machine connected to theInternet (via OPAC).

ModulesAcquisitions Technical processing and database development MARC (Machine-Readable

OutcomesStock keeping and cataloging ofbooks become easy

Maintenance Shelving books inthe correct library classificationorder

Library used to manage its functionsmanually for few years.

Cataloging of books was tedious.

developmentCirculation ControlSerials ManagementOnline Public Access Catalogue

Implementation

MARC (Machine-ReadableCataloging) is a standard that definesa data format for cataloging. Itprovides the mechanism by whichcomputers exchange, use, andinterprets bibliographic information,and its data elements make up thefoundation of most library catalogs.

Through bar-coding, circulation ofbooks was made smooth & error freeOnline reports enabled easy tracking of books

Cataloging of books was tedious.Circulation and tracking large

number of books took time & effort.Generating various reports was

time consuming and laborious

With the continuously growingnumber of books, manual

CatalogingA library catalog is a register of allbibliographic items found in alibrary. A bibliographic item can beany information entity (e.g.. books,computer files, graphics, etc)relevant to the catalog and to the

foundation of most library catalogs.The central library chose requiredfields from the MARC21bibliographic item list. All the booksand journals present in the librarywere cataloged in the defined format

Further Enhancements1.Online book reservation2.Automating requests for acquisitionof new books integrating withnumber of books, manual

management of the books hadbecome tedious. Hence it wasdecided to automate the processes ofthe library.

relevant to the catalog and to theusers of the library. Examples ofbibliographic items include Title,Author name, Edition, PublisherISBN, ISSN etc.

Bar-codingBar-coded accession number labelswere affixed to all the books andjournals of the library.

of new books integrating withpurchases3.Facilitating users to access theinformation over internet & mobiledevices

-I",-oIe-..-American Journal of Medical Quality26(3) 241-242© 20 I I by the American College ofMedical QualityReprints and permission: http://www.sagepub.com/journalsPermissions.nav001: 10.1177/1 06286061 0391647http://ajmq.sagepub.com

'SAGE

Electronic Discharge Summary to SpeedPatient Discharge

Voleti Choudhary, MD,I G. Chandrashekar, MCh,1Pranav K. Subaraya, MCh,1 S. V. Satheesh, MTech, ISri Krishna, MScl, and Michael Rakoff, MD,I,2

Prolonged preparation time and delayed completion ofpatient discharge summaries is a chronic problem in mosthospitals. In India, patients take their medical records withthem, so a delay in completing discharge summaries canlead to increased length of stay, patient dissatisfaction, anddifficulties with scheduled admissions. In our tertiary carefacility, it also leads to backups in postoperative units andintensive care units (ICUs) and, therefore, delays in certainsurgical cases. In US hospitals, delayed completion ofdischarge summaries prevents completion of insurancebilling. Charts are often tied up in record rooms until thedischarge summary is completed.The Quality Assurance (QA) Department at Sri Sathya

Sai Institute for Higher Medical Sciences (SSSIHMS) inBangalore, India, undertook a project to address this prob-lem with the Cardiothoracic and Vascular Surgery (CTVS)Department.Historically, discharge summaries at SSSIHMS were

handwritten by resident physicians and then typed by clericalstaff, returned to operating physicians for corrections,retyped, and then approved and signed by the operatingphysician. The process was labor intensive and time consum-ing. Delays were inevitable. Many discharges did not occuruntil late in the day and delayed the admission of newpatients. In addition, the late discharges caused untold dif-ficulties for patients returning home. In some cases, patientsface a 3-day train ride to the far reaches ofIndia and do nothave the means to wait in a hotel until the next day. Therefore,early discharge is critical for the patient and the hospital.SSSIHMS has a sophisticated in-house medical infor-

mation system (MIS) team, a comprehensive electronicmedical record (iSOFT, Banbury, Oxfordshire, UK), andthe capability to quickly create new electronic medicalrecord modules. The QA and MIS leaders met with thechairman of the CTVS Department to gain approval for anew software program they were piloting. The pilot pro-gram would allow the operating surgeon to quickly createa discharge summary on the computer in real time, reviewit, and digitally sign it. The pilot was approved.A project team worked with cardiac surgeons to identify

in detail the data elements required for the dischargesummary. For each field on the discharge summary, a "dic-tionary" of terms and procedures was developed.

Drop-down menus were created for most data elements.Free-text entries also were permitted. Most data containedin the electronic medical record system are retrievable (eg,lab results, echocardiograms); they can be included in thesummary with just a mouse click. Physician signatureswere digitized and password protected.Studies by O'Leary et all and Maslove et al2 have shown

that electronic systems can improve the quality and timeli-ness of discharge summaries. Navas et al3 showed the valueof a terminology server to improve data capture. Our modelcreated templates for electronic discharges combined withdrop-down menus and a terminology server.Within 1 week of completion, all operating surgeons

were using the electronic discharge summary. Time ofdischarge for 1122 consecutive patients from the CTVSpostoperative ward was tracked for 3 months before initia-tion ofthe project and for 10 months after the project wasinitiated. Waiting time, from time of physician order fordischarge to actual patient discharge, was reduced froman average of 10 hours to 5 hours after the introduction ofthe electronic discharge summary program. On average,patients were discharged before noon.Clinical benefits were numerous. The format for dis-

charge summaries was further standardized. Accuracy ofdetails in the summary was enhanced because they weredirectly transferred from the electronic medical record,thus ensuring accurate information for the primary carephysician to whom the patient returned. Productivity ofthe surgeons increased as time required for the dischargesummary process decreased. By using very simple auto-mated programs, the physicians found an easy replacementfor what often was an onerous task. Physician satisfactionwas shown by the fact that, within 2 weeks, nearly 100%of discharge summaries were done electronically with nocomplaints. A survey of operating physicians and

ISri Sathya Sai Institute for Higher Medical Sciences, Bangalore, India2Sri Sathya Sai Institute for Higher Medical Sciences, Sharpsburg, MD•Corresponding Author:Michael Rakoff, MD, Sri Sathya Institute for Higher Medical Sciences,Administration, PO Box 707, Sharpsburg, MD 21782Email: rakoff99@gmail.com

postoperative unit nurses showed unanimous satisfactionwith the electronic discharge system.Administrative savings also were achieved. The clerical

staff member previously assigned to type and correct dis-charge summaries was reassigned to other duties.Admission delays have been reduced. Transfers from theICU to the postoperative unit flow more smoothly. Thehospital benefited by saving staff time and being moreefficient in admitting and transferring patients. The QAand MIS Departments learned valuable lessons aboutimplementing changes with physicians and training physi-cians to use electronic medical records. By implementingcustomized discharge summary programs throughout theinpatient and outpatient areas, it is estimated that an addi-tional 8 to 10 clerical staff can be reassigned.Patients also benefited from earlier discharge time by

being able to more easily make travel connections to distantplaces. Reduced waiting time exerts less stress on thepatient and family.

Technology Advantages in aDeveloping CountryThe SSSIHMS in Bangalore, India, is a tertiary care charityhospital that provides completely free care to indigentpatients from all over India. With state-of-the-art technologyand world-class physician leadership, care is offeredin CTVS, cardiology, neurosurgery, neurology, andradiology.The philosophy at SSSIHMS is to put the "patient first."

A staff member who observed the hardship faced bypatients and their families who were discharged late in theday initiated this project. A typical patient receiving open-heart surgery may be a poor farmer from West Bengal(state) who must travel for 3 days by train to reach home.The hospital allows a longer than expected postoperativestay because of the hardship of the journey and lack ofhygiene facilities and nourishment on the train. With alimited budget at the free hospital, efficiencies are continu-ously sought, but not at the expense of patient care. This

model of using state-of-the-art electronic medical recordsshows the potential of savings and efficiency that benefitall, even in a developing nation.As a result of this project, we better understand the

potential value of our electronic medical records for furtherresearch. Comprehensive data are available in every area.We are beginning to mine that data to do further researchto improve quality and efficiency.In the United States, most hospitals have record rooms

with many incomplete and unsigned discharge summaries.Delays in completing discharge summaries impede col-lection of charges from insurers. These delays also oftenprevent utilization of patient records when they are await-ing a physician signature. US hospitals and their patientscan benefit by the introduction of electronic dischargesummaries.Developing countries can use advanced technology and

ingenuity to "leapfrog" chronic snafus in hospital effi-ciency and quality of patient care. This can be done withgreat benefit to the patient and cost savings. Judiciousinvestment in advanced technology has allowed our"patient first" philosophy to succeed at benefitingeveryone.

Authors' NoteThis project was staffed and all work provided by salaried staffat Sri Sathya Sai Institute of Higher Medical Sciences.

References1. O'Leary KJ, Liebovitz DM, Feinglass J, et al. Creating abetter discharge summary: improvement in quality and time-liness using electronic discharge summary. J Hasp Med.2009;4:219-225.

2. Maslove DM, Leiter RE, Griesmna J, et al. Electronic versusdictated hospital discharge summaries: a randomized con-trolled trial. J Gen Intern Med. 2009;24:995-1001.

3. Navas H, Osornio AL, Baum A, Gomez A, Luna D, deQuiros FG. Creation and evaluation of a terminology serverfor the interactive coding of discharge summaries. StudHealth Technol Inform. 2007;129(pt 1):650-654.