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*Department of Anesthesiology,
Division of Engineering and Technology Services, and
Division of Systems and Procedures, Mayo Clinic, Rochester, Minnesota
Address correspondence and reprint requests to John P. Abenstein, MSEE, MD, Department of Anesthesiology, Mayo Clinic, 200 First St., SW, Rochester, MN 55905. Address e-mail to abenstein.john{at}mayo.edu
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Abstract |
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 Top Abstract IntroductionDesign CriteriaDiscussionReferences |
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IMPLICATIONS: Mayo Clinic installed a computer-based anesthesiology paging system (CAPS) to inform operating suite personnel when assistance is needed in procedure and recovery areas. The CAPS is more reliable than the system it replaced. Anesthesiologists arrive at a patient’s bedside faster when they are paged with the CAPS than with a beeper.
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Introduction |
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TopAbstractIntroductionDesign CriteriaDiscussionReferences |
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Mayo Clinic has a long history of efficient management of personnel, by which the knowledge and expertise of its physicians are leveraged through extensive use of allied health personnel. One strategy, implemented >100 yr ago, is the use of visual communication systems to direct physicians and allied health personnel to where they are needed. This began with the introduction of colored wooden door tabs. Each color denoted the state of a room. For example, a green tab indicated that the patient was in the room and ready to be seen by a nurse. A blue tab indicated that the patient was ready to be seen by a physician. A red tab indicated that help was needed for an emergency.
This communication strategy spread from the outpatient practice to the hospitals, including the operating suites. Subsequently, door tabs were replaced by colored electric lights. A chime was sounded when the state of a room changed. This communication strategy was thought to improve the efficiency and quality of care in the operative environment. In 1981, a new operating suite was opened at Saint Marys Hospital, 1 of 2 hospitals associated with Mayo Clinic. This prompted updating the communication technology at both hospitals. Electric lights were replaced with video displays suspended from the ceilings or mounted on the walls in the operating rooms (OR), procedure rooms, and support areas.
This Video Paging System (VPS) used alphanumeric codes to communicate the state of each patient care location (7). Pages were initiated by use of electromechanical switches in each OR, procedure room, and preoperative and postoperative location. When a switch was closed (by pushing a button), an alphanumeric code, designating both the location and the individual needed, would be displayed throughout the operative or procedural suite, and in every procedure room, hallway, recovery and waiting area, lounge, office, and cafeteria. In addition, an emergency code was incorporated to rapidly direct staff to a particular location when a cardiac arrest, airway emergency, or other critical event occurred.
Over time, several problems emerged with the VPS. The black-and-white monitors that displayed the pages burned in after about 18 mo, making the displays unreadable. Replacement monitors were costly and difficult to find. The software was difficult to maintain, and software constraints became unacceptable as the practice grew and evolved. When seven additional ORs were built at Saint Marys Hospital, and OR numbering changed from two digits to three digits, the VPS could not accommodate the change. These problems triggered the decision to replace the VPS with a new communication system.
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Design Criteria |
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TopAbstractIntroductionDesign CriteriaDiscussionReferences |
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With little review or documentation, the VPS had evolved on an ad hoc basis with additional functions and a broader geographic distribution. Missing comprehensive system documentation made determining where the current system was used and what information was transmitted challenging. A careful analysis of new requirements was completed, redundant and unnecessary functions were eliminated, and the geographic distribution of the new system was planned.
Prototyping technologic solutions occurred simultaneously. A distributed video architecture was rejected because of its inherent instability. Because the cathode-ray tube displays had only an 18- to 24-mo useful life, liquid crystal and light-emitting diode (LED) displays were considered. LED displays were chosen because they have a useful life of at least 15 yr and a greater luminosity that prevents washout from fluorescent and natural lighting. These displays are relatively expensive, but the cost can be amortized over a longer useful life. Choosing the size of the characters on the displays was a trade-off between the distance at which the displays could be read and the required information content. The size and information layout of the LED displays were determined by their expected placement, for example how low the displays could hang from hallway ceilings. The decision was made to develop in-house a configurable, centrally programmable keypad that would replace the electromechanical switches.
Several distribution architectures were considered. Use of the institutional Ethernet network was an attractive, inexpensive option, but pages could be delayed when network bandwidth demand was greatest. Because pages are time-sensitive, this risk was deemed unacceptable. Therefore, an independent Ethernet network was chosen to drive the system. The computer-based anesthesiology paging system (CAPS) was designed to be upgradeable and easily configured. Software running on standard hardware is more easily adaptable and requires fewer maintenance personnel. Use of commercially available components also reduces costs for development and maintenance (Fig. 1).
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The software design optimizes the handling of new pages to assure the shortest possible time between placing a page and seeing it on the LED displays. If there are no active emergency pages, all new pages are processed and displayed within 1.5 s. The user initiates a page by either pressing a dedicated microswitch (hot key) or entering a numeric code on the keypad (Fig. 2). The page is sent to the keypad controller via the terminal server. The keypad controller associates the page with a specific keypad, the keypad’s workgroup (e.g., neurologic anesthesia or vascular radiology), and other necessary information. The page is then presented via a Microsoft ActiveX Data Object call to the SQL Server database engine. The database determines what text is to be displayed on the LED displays and then forwards the text to the queue manager. The database then returns control to the keypad controller, which illuminates an LED above the activated hot key. If a page for a physician or nurse is initiated from an OR, a light above that room’s door illuminates as a wayfinding aid.
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The central servers, terminal servers, operating system, and database are all commercial products. The LED displays were initially custom-made products, but the manufacturer has subsequently added them to their standard product line. These displays are located throughout the hospitals where anesthesia services are provided or anesthesia personnel congregate.
The programmable keypads were designed in-house and were assembled and tested under contract. The keypads can accept new embedded code downloaded from the server. This allows for remote reprogramming of the keypads without maintenance personnel physically interacting with each keypad (i.e., removing >450 keypads from the wall and reprogramming them with a laptop computer). Therefore, upgrading the keypads is rapid and cost-effective.
An administrative program and several specialized tools for maintenance personnel were developed. The administrative program’s graphical user interface masks the relational database’s complexity and presents a more simplified view of the system. Pages, devices, reports, and other aspects of the system can be managed without use of the development engineering group. This feature allows maintenance personnel to be trained technicians, thereby decreasing the total cost of ownership and freeing the development engineering staff for other projects.
User Functionality
The CAPS presents two kinds of pages: 1) class page, which is a page for a class of individuals to come to a patient location, and 2) person page, which is a page for a specific individual to come to a multiple-patient location. Class pages have three parts. The prefix characters are alphabetic, denoting the work area (e.g., "N" for the north anesthesia area or "CL" for the catheterization laboratory). The middle characters denote the room number within that work group (e.g., "N 808" for room 808 in the north anesthesia area or "CL 109" for room 109 in the catheterization laboratory). The suffix character denotes the class of person needed in the room. Therefore, complete pages would be "N 808 A," meaning that an anesthesiologist is needed in room 808 in the north anesthesia area, or "CL 109 N," meaning that a nurse anesthetist is needed in room 109 of the catheterization laboratory. Person pages have two parts. The prefix denotes a multiple-patient location (e.g., "P" for postanesthesia care unit or "o" for outpatient recovery). The other characters are numeric, denoting the individual needed. Therefore, a complete person page would be "P49," meaning that person "49" is needed in the postanesthesia care unit.
Using CAPS is reasonably straightforward. For example, if a resident physician in cardiac catheterization room 104 needs to confer with the attending anesthesiologist, the resident pushes the "Physician" button on the keypad mounted on the anesthesia machine (Fig. 3). An LED above the button illuminates, confirming that the page has been received. Every monitor throughout the cardiac catheterization suite, including the room initiating the page, displays "CL 104 A" in green and chimes briefly (Fig. 4). The page remains on the LED display for 1.5 s as the system cycles from page to page. A page cycles every 1.5 s until it is deactivated by a person; there is no timeout feature for pages. When the attending anesthesiologist enters the room and pushes the "Physician" button, the page is no longer displayed anywhere and the LED above the button turns off. If the resident considers the page to be urgent, the resident pushes the "Urgent" button (Fig. 3) and then the "Physician" button; "CL 104 A" would appear in orange and cycles with any other pages. If there is an emergency in the procedure room, the two side-by-side emergency buttons are pushed simultaneously (Fig. 3). This action persistently displays "CL 104 A" in bright red on every display in the catheterization laboratory, and a chime rings until the emergency buttons in the room are pushed simultaneously. In the unusual event of >1 simultaneous emergency page, the display will cycle from emergency page to emergency page every 1.5 s, sounding the chime persistently, until all emergency pages are deactivated.
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When anesthesia and OR personnel hear the "new call" chime, they can glance at the display and read the new call. If they miss seeing the new page, the system offers shortcuts so one does not need to watch all the pages cycle through the display. Personnel indicators in the lower left corner of the display (Fig. 5) identify the class of individual required (e.g., anesthesiologist, nurse, or technician). Zone indicators in the upper left corner of the display identify the work areas that have active calls (e.g., "N" for north anesthesia and "B" for cardiovascular anesthesia). If an anesthesiologist responsible for the B zone hears a new page chime but misses seeing the new page, the anesthesiologist can glance at the display (Fig. 5) and observe that the new call was for someone else (e.g., if only "D" is seen in the upper left of the display, only D zone personnel have active pages). If "B" is in the upper left and if "A" is not in the lower left, then the anesthesiologist no longer needs to look at the display because the new page was for someone else. Pages are sorted numerically within the zone, so people need to watch the display only until the codes for their rooms are either displayed or passed over. The personnel and zone shortcut indicators are cumulative for all active pages and are displayed for all except emergency pages.
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Clinical Evaluation
During the installation of the CAPS, there was a brief period during which neither the VPS nor the CAPS was available in all areas. The VPS was removed in segments as the CAPS was installed, and beepers were used temporarily as a bridging communications medium. Anesthesiologists and nurse anesthetists have used beepers for many years for person-to-person communications, such as consultations and outside telephone calls, and as a means to reach individuals when they are outside of the video paging environment (e.g., intensive care units and hospital wards). Because departmental personnel were experienced and comfortable with beepers and telephones are mounted on every anesthesia machine, it was decided to use these devices during the transition from the VPS to the CAPS. This allowed comparison of the efficiency of using beepers with the efficiency of using the CAPS.
Observations of paging with beepers occurred during a 4-day period, 2 days at each hospital. Each day, different ORs were studied on the basis of the implementation schedule of the CAPS. Data were gathered from within a randomly selected OR by recording the time a page was initiated to a beeper (beginning as the number was being dialed) and the time the responder entered the room. Because of the limitation of being able to observe only 1 OR at a time and the rapid installation of the CAPS, relatively few pages with beepers were observed (n = 12), all of which were routine, nonurgent calls. When the study was designed, it was expected that there would be 6 days of installation per hospital and, therefore, 12 days of observation for gathering beeper response times. Unfortunately for the study, but fortuitous for the practice, installation took only 2 days per hospital, which reduced the expected number of observations. The original CAPS installation schedule allowed more time for system verification in each work area than was actually needed and so the time allotted for beeper observations was significantly reduced.
Similarly, observations for the CAPS occurred over a 4-day period, 2 days at each hospital. Data were gathered by recording the time a page appeared on the LED display, which was within 1.5 s of the time the button was pressed from within the OR, and the time the responder entered the room. Because the CAPS displays its pages on LED displays located throughout the surgical suite, several ORs could be observed simultaneously by watching the displays, and more data were collected (n = 57). No urgent or emergency pages were observed.
The median response time for anesthesiologists paged with a beeper was 2.78 min (range, 1.00–7.23 min). Problem pages did occur, including incorrect beeper numbers that were given to next-shift personnel, multiple pages that were made because the caller was not certain that the correct number had been dialed, and missed or ignored pages that required repaging. The median response times for anesthesiologists paged with the CAPS was 1.57 min (range, 0.30–7.20 min). Because of the CAPS design, none of the problem pages observed with the beepers were observed with the CAPS. These results are summarized in Table 2 and Figure 6. A logarithmic transformation was applied to the data to satisfy the distributional assumptions required for the two-sample Student’s t-test. The t-test of the transformed data showed a statistically significant difference between the response times with beepers and the response times with the CAPS (P = 0.021, t67 = 2.36). The CAPS had a shorter response time for anesthesiologists than the beeper method.
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Discussion |
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TopAbstractIntroductionDesign CriteriaDiscussionReferences |
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The design of the system is consistent with the communication philosophy that has developed at Mayo Clinic in both inpatient and outpatient environments. Patient care sites are equipped with a communication tool that identifies the state of the room. For the anesthesiology practice, the state of the room reflects the personnel needs in the room. If an anesthesiologist is needed, a visual page is displayed throughout the work environment informing both the anesthesiologist and the practice as a whole that assistance is requested in the procedure room. The postimplementation review demonstrates that the CAPS is more reliable than the system it replaced, with an average downtime of less than one minute per day.
When comparing the CAPS with a system of beepers, which are the standard communication devices in many medical centers, the time to answer a page was statistically significantly less when the page was initiated using the CAPS than using a beeper and the opportunity for communication errors are eliminated. This study has a number of limitations. The sample size of beeper paging is small (n = 12). However, we have no reason to believe that these data are not representative of our beeper paging system. Also, although a statistically significant difference in response time was detected between the beeper system and the CAPS, the clinical relevance of this difference is unclear. The clinical relevance of 1.21 minutes response time depends on the clinical situation that prompted the page. If a page is initiated to discuss fluid management, it is unlikely that the observed shorter response time would make any difference. However, if the page is to secure assistance for an airway-related problem, then 1.21 minutes could make a significant difference.
Another limitation of the study is that patient outcome data were not recorded as part of our data collection. All the pages observed were for routine matters (e.g., anesthesia induction, emergence, or routine questions). No emergencies or urgent pages were recorded in either group. A review of the CAPS database shows that there were 7 emergency pages during April 2002 when the paging system covered 97 ORs, 5 recovery rooms, and >46 nonoperative anesthetizing locations. The emergency pages were answered in an average of 35 ± 23 seconds. However, there are no data to compare this with emergency response to beeper pages. A much larger study would have to be undertaken to demonstrate an effect on patient outcomes. Although such a study was considered, the anesthesiology practice concluded that it was unwilling to investigate the clinical effect of paging without the CAPS because of concerns for patient safety and practice efficiency.
The CAPS has a subtle effect on the environment of the operating suite because there is not a constant din of overhead audio pages. Instead, a brief chime announces a new page to the entire staff. Anesthesiologists in the ORs are not straining to hear garbled pages. Anesthesiology residents and certified registered nurse anesthetists are not waiting in frustration, wondering whether their pages have been heard. Pages are persistently visible on ubiquitous displays until answered.
Mayo Clinic is a large group practice (>1000 attending physicians), and it can be difficult to ensure accountability of all members in a large organization (8). One drawback of using beepers is that staff may ignore or forget pages. With the CAPS, everyone in the procedural suites can see pages and be aware of pages that are not answered. The primary value of Mayo Clinic is "the needs of the patient come first." Adherence to this principle encourages staff to respond to unanswered pages. However, even with assistance from colleagues, a continual pattern of ignoring pages becomes apparent. The CAPS promotes assistance from colleagues when a staff member is occupied with another patient and inhibits a pattern of unanswered pages in a manner not recognized by the anonymity of beepers. As a result, staff members are reluctant to have their pages displayed longer than necessary, even though there is no visible duration associated with any given page. The practice-wide result is that staff attend to the needs of patients in a timely manner without authoritarian management measures.
The CAPS was designed to be a hands-free, reliable, and low-maintenance communication system. The system is more reliable than the VPS it replaced. The development and installation of the CAPS is associated with anesthesiologists responding more rapidly to paging with the CAPS than to paging with beepers. This may be associated with improved patient outcomes and greater OR efficiency.
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References |
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