Written by Dann Anthony Maurno, Louis Sirico, and Jill Abell

Although you no longer hear much about in in U.S. media, on June 11, 2009, the World Health Organization (WHO) raised the worldwide pandemic alert level to Phase 6 in response to the ongoing global spread of the novel influenza A (H1N1) virus. A Phase 6 designation indicates that a global pandemic is underway. Seventy-six (76) countries are reporting cases of human infection with novel H1N1 flu. The U.S. alone has nearly 50% of the world-wide confirmed cases: 17,855. The flu is spreading faster and killing more people in the U.S. than any other country.

It is time for our government to enact legislation requiring mandatory patient and caregiver tracking in hospitals and medical centers. We have a right to know if we have come in contact with a person who is contagious or if we have visited a location a contagious person recently occupied. Not only does it protect the individual, but the greater population.

As Orwellian as this sounds, the real-time location systems (RTLS) and RFID technology already used in hospitals and medical centers throughout the US can significantly reduce the spread of swine flu and other contagious diseases. Through the use of similar types of technologies that the FDA already recommends (and will likely mandate) for use in ePedigree requirements, hospitals can track patients, caregivers, equipment, and inventory to allow healthcare officials to know for certain who has, and has not, come in contact with a contagious person, and help contain epidemics. Because hospitals, medical device manufacturers and pharmaceutical companies increasingly find that auto-ID solutions are the only way to meet ePedigree and similar regulations; it makes economic sense to make use of this existing framework in containing H1N1 and outbreaks like it.

How contagion spreads

The CDC suspects that H1N1 flu spreads the same way as other flu viruses. Most cold and flu viruses are spread by direct contact; mainly through coughing and sneezing by infected individuals. They may also spread indirectly, when someone with the flu sneezes onto his or her hand, then touches a door, a counter top, a toilet handle, a keyboard or another shared object. The germs can live for hours, even weeks, to be contracted by the next person to touch the germy object.

The spread of infection in hospitals is a grave patient safety issue, and epidemics such as the novel influenza A (H1N1) virus significantly exacerbate the risk. “And so I say it again and again and again, hand washing is critical,” said Dr. Richard Besser of the CDC when advising of personal swine flu precautions. “Viruses love to be transmitted by hands. Hand washing or use of gels is number one.” This is the same bulleted checklist of precautions with every flu breakout—all good measures, but clearly, no one can be trusted to comply—not even medical professionals.

The spread of infection in hospitals is a grave patient safety issue, and epidemics such as the novel influenza A (H1N1) virus significantly exacerbate the risk. Hand washing compliance by caregivers was only 9 percent in intensive care units (ICUs), and 3 percent in cardiac surgery units. Those numbers increased to 22 and 13 percent, after caregiver training; rather poor, considering that adequate compliance is considered 100 percent.

The CDC recommends “frequent hand washing after almost any event” including between each caregiver interaction with a patient. Yet hand washing frequency is shockingly low at medical centers, according to an observation study of medical caregivers conducted by the National Center for Biotechnology Information (NCBI), a division of the National Institute of Health.

The NCBI study disclosed that hand washing compliance by caregivers was only 9 percent in intensive care units (ICUs), and 3 percent in cardiac surgery units. Those numbers increased to 22 and 13 percent after caregiver training; rather poor, considering that compliance is 100 percent.

The increased installation of waterless antiseptic dispensers raised compliance to 48 percent of caregivers; but even easily accessible hand-sanitation was not enough to ensure 100 percent hand washing rates. This low conformity continues; increasing infection risk and further underscoring the need to mandate monitoring of person-to-person contact, patient/personnel location tracking, and patient-to-equipment interaction in hospitals.

Chicago-based Fast Track Technologies principal Brad Sokol, describes more startling statistics related to spread of infection through medical devices. FTT is a healthcare consulting firm, specializing in implementation of emerging technology (like RFID and RTLS) into hospitals, medical devices, and homecare environments. FTT culminated 90 procedural studies concerning medical device mortalities in hospitals from 1990-2005, to discover that –

• Infections cost US hospitals $5.7 billion per year;
• 16.6 percent of hospital mortalities are attributable to medical devices (many are in the categories of urinary and respiratory tract infections);
• 5-10 percent of inpatients acquire one or more infections;
• Medical equipment mortalities are underreported by a factor of 10;
• And an infection program can save a hospital $1.5 million/year.

Thus, the requirement is more than tracing patients, or healthcare givers; it is to trace equipment and medical devices as well.

FTT created this graphic (right) showing the body contamination zone (in red), and room contamination zone (in purple). Spread of an infectious disease may be transmitted through:

• physical contact with liquids, food, body fluids, contaminated objects - example MRSA (Methicillin resistant Staphylococcus aureus);
• airborne inhalation (influenza- flu);
• or through vector -borne spread (mosquito Malaria).

If the individual has Swine Flu, Dengue Fever or some such disease, all the equipment within the purple circle must be considered contaminated. Similarly, any contamination that penetrates the red zone threatens to sicken the patient. Still, in an emergency department, can caregivers be expected to meticulously record such events?

The Bumrungrad International Hospital in Thailand plans to use a real-time location system (RTLS) to track patients immediately upon entry into its emergency room. The goal, according to an IDG News Service story, is to control the spread of a virus by recording where a patient goes; and which doctors, nurses, and other personnel with whom the patient has come in contact. “Once we have that information, we can notify the individuals accordingly, so that they can get treated early on,” as opposed to waiting for a full-blown illness, Chang Foo, CTO at Bumrungrad International Hospital, told the IDG News. While the hospital has been spared any outbreaks, the region was the origin for both the avian flu and SARS pandemics. Bumrungrad, as a “medical tourism” hospital, serves a broadly global clientele, and an outbreak at the hospital would be disastrous. RTLS has its origins in asset tracking, but it is uniquely suitable for limiting contagion as well. The answer is not demanding compliance; it is in real-time automating compliance, using technology.

“Real-time location systems” evolve into “real-time awareness”

Hospitals use wireless RTLS to locate key equipment (like crash carts, IV pumps and wheelchairs) and maintain inventory; some use these systems to track personnel and patients (exactly the visibility required to track exposures to infection); and some use remote sensors on the networks, for condition monitoring and to gather such data as temperature.

Because the systems have evolved far more information than location, San Diego, CA-based Awarepoint calls its RTLS a “real-time awareness system” or RTAS. In February, Awarepoint implemented the largest healthcare RTAS system on record for the Jackson Health System in Miami, Fla. This system initially tracked 12,000 medical equipment assets over a 3.8 million square foot, multi-building campus and is expanding to two additional Jackson Health System hospitals; covering 5.8 million square feet and an anticipated 16,000 assets. In addition to tracking such key assets as infusion, pain and fluid pumps, and portable ultrasound machines, the system monitors equipment conditions. The Jackson Health System has installed 250 Awarepoint temperature monitoring tags, which wirelessly monitor and maintain logs on temperature-sensitive assets such as refrigerators, freezers and warmers. The system sends real-time alerts for out-of-compliance situations to protect critical temperatures and allow maximum staff response time and accountability.

Finally, Awarepoint and Jackson Health System are adapting the system to monitor patient flow, with integration into workflow automation solutions.

Healthcare demands have created the ultimate tool

As any healthcare IT professional will describe, the first priority in a hospital or clinic is patient care; they will upgrade diagnostic equipment long before they will upgrade their non-clinical systems. Thus, hospitals and clinics that implement RTLS systems have a shortlist of unwavering demands for them. Those systems must –

• Pay for themselves, rapidly;
• Install readily and without contaminating clean environments (which hard wiring and ceiling tile disruption can do);
• Offer improvement in patient care, in order to pass the cost justification “smell test”;
• Afford enterprise-wide visibility of assets and people, anywhere they may travel throughout the organization, to maximize clinical and financial ROI;
• Enable rather than disrupt workflow (with no downtime for implementation) without impacting already overworked hospital IT staff with high maintenance requirements.

Ultimately, the RTLS must add value beyond its cost; but in healthcare, the value is measured in each aspect of the healthcare value equation:

Quality of Care x (Revenue/Cost) – Risk = The Healthcare Value Equation.

RTLS can be used to directly increase all of these variables. Thornton Hospital at the University of California San Diego (UCSD) Medical Center also selected Awarepoint to fulfill those requirements. In 2005, Thornton Hospital’s Director of Preoperative Services Tom Hamelin sought an RFID solution to address the challenges of—

• Lowering equipment rental costs;
• Reducing staff time spent searching for equipment;
• Minimizing equipment theft and loss;
• Reducing equipment inventory requirements;
• Improving equipment maintenance process;
• Improving responsiveness to JCAHO and FDA requirements.

Awarepoint was selected based on its 100 percent wireless, non-disruptive installation, low cost to trial (owing to no construction costs) and fully managed service model allowing the hospital to easily scale up the system on a per-month basis. Full implementation in fact took under three weeks, at this 119-bed, 238,792 square foot general medical-surgical facility, and has since been expanded to the medical center’s larger Hillcrest campus, as well as its Moores Cancer Center.

In just four months following the Thornton implementation, the hospital reduced its rental of IV pumps from $8,000/month to $2,000/month, simply by improving its ability to locate the pumps. Thornton has maintained this cost reduction for more than 18 months —a cumulative savings of nearly $110,000 thus far. In terms of patient safety and compliance, the hospital found itself able to react rapidly to an FDA “Urgent Medical Device Recall,” identifying 200 recalled IV pumps in under 48 hours; such recalls would have taken several weeks and dozens of hours of staff labor in the past. It is a very short leap between recall response and contagion response. This both reduces the cost of care, and reduces the risk.

The University of California San Francisco (UCSF) Medical Center similarly implemented Awarepoint RTAS at its 1.2 million square foot academic facility. The Center freed up 1,600 hours per year in operating-room staff time, simply in locating equipment. Far from being just an efficiency measure, delays in locating critical equipment “show stoppers” can delay surgery, and resultantly, impact both patient safety and the hospital’s top-line revenue. As a further example of efficiency, UCSF estimates that it has reduced finding a lost asset from a 30-45-minute task to a “3-second task”. Prior to RTLS, cash-strapped hospitals have been tasked with purchasing redundant equipment to ensure adequate supply is on hand for patient care. With Awarepoint, UCSF avoided a planned purchase of additional transport monitors and intubation equipment, freeing $248,000 to be saved or spent on new technology. Thus, UCSF moved all variables in the healthcare value equation, by increasing revenue, reducing cost, reducing risk and increasing quality.

This enterprise awareness is, again, what is required in both rapid response to infection, and in identifying exposures.

Containment and control of infectious diseases through enterprise visibility

Similarly, Intelligent InSites of Fargo, ND offers its InSites Enterprise Visibility Platform™ to hospital clients to improve operational performance by providing a single system capable of locating people, equipment, and inventory. The Intelligent InSites’ solutions includes turnkey applications for asset management, patient flow, business intelligence, and inventory management and marries these applications with the provider’s existing IT, communication, and building systems through standard, open interfaces. The flexibility of the platform allows healthcare organizations to automate and optimize over two dozen systems and processes using the RTLS infrastructure, including wireless nurse call, security, access control, wander management, positive patient identification, infectious disease containment, and more.

Through the use of small tags, supplied by RTLS technology providers such as Awarepoint, the InSites Platform can automatically sense, record, and represent the location of each person as they move about the facility through its web-based interface or virtually any mobile device. This data can then be used to quickly and accurately provide meaningful real-time and historical information to care givers.

For example, when a patient is positively tested for a virus, staff can instantly run a report that identifies everywhere that patient has been in the hospital, as well as all patients, staff, and even equipment that were in the same location at the same time. The staff then uses that information for initiating the disease control protocols established by the hospital, screening exposed personnel or patients, and the provision of antiviral treatment.

The system also provides reports that help risk management personnel analyze infection patterns and assist with compiling data requested by government agencies, such as Centers for Disease Control & Prevention. This not only protects patients and hospital’s employees, but it also increases the safety of the entire community.

Addressing the urgency of action

The need for embracing the use of real-time locating and alerting technologies is unquestionable. U.S. Secretary of Homeland Security, Janet Napolitano, urges state and local governments, school districts, and the private sector to modify and update their pandemic plans, as the state of pandemic preparedness in the U.S. is still not at a desirable level. According to a recent report published by the Vendome Group, entitled “Trends in Disaster Preparedness and Recovery Technologies”, nearly two-thirds of healthcare organizations consider themselves not well prepared for a pandemic.

This is why Intelligent InSites and Awarepoint are currently working with several government agencies and healthcare providers that wish to incorporate the use of real-time locating in their emergency preparedness and continuity of operation plans. Given that this technology is capable of rapid and noninvasive deployment, it is seen by healthcare authorities as an immediate answer to managing the H1N1 virus threat, as well as preparing for other potential events, such as terrorist attacks, natural disasters, evacuations, and other emergency situations.

Patient tracking – without the risk

RTLS patient tracing enables hospital and medical centers to track patients in the intake/treatment/discharge continuum; and identify the people and items with which the patient has come in contact. A timeline of patient history can be recorded that includes location as well as every caregiver, every asset and every location in which the patient came in contact. Even if a patient is diagnosed hours, or days, after admission, the history can be recalled which allows the proper measures to taken to help contain the infection. As vital as this patient tracking in hospitals is to help halt the spread of contagion and to improve patient throughput, if not properly managed, a reusable, wearable patient tag could outweigh the benefits, by adding to the spread of disease, rather than helping to control it.

Anything the patient touches, or that may touch the patient, must be clean to avoid the risk of cross contamination and prevent the transfer of pathogens. Awarepoint has eliminated this threat with a reusable, wearable patient tag that endures steam sterilization at temperatures up to 135 ºC, as well as immersion in the most common liquid sterilization methods. Location reporting begins when the tag is associated to a patient at intake, and tracks the patient throughout the patient care continuum. This information can be used not only to identify when delays happen and provide proactive caregiver alerting, but can determine what equipment, other patients and personnel a patient has been in contact with. When a patient is ready to be released from the hospital, staff snips off the bracelet/tag, discards the bracelet, and saves the tag for sterile processing and reuse. This process completely eliminates the tag as a potential contributor to hospital acquired infections and provides a cost-effective, reusable solution to patient tracking applications.

The images below from patient and asset tracking solution provider, Patient Care Technology Systems (PCTS), illustrate aspects of a typical patient flow continuum in a surgical visit. PCTS workflow solutions, enabled by real-time locating technologies, visualize patient flow based on workflow intelligence which tracks interactions between patients, staff and movable medical equipment. This visualization not only reduces delays in handoffs between caregivers but also supports a department to monitor potential contamination risks.

Figure 2: All assets (physical, human) and the patient are linked in a single timeline and graphical interface.

If asset tracking seems unrelated to patient care, consider the returns on investment in both money and time (now devoted to patient care); and in regulatory compliance, aimed at ensuring patient care and safety.

The high-speed and hands-free requirements.

The importance of real-time, automated enterprise awareness in healthcare is underscored by myriad software application providers focused on these solutions specifically for hospitals.

Christiana Hospital of Newark, DE, is an 860-bed teaching hospital. At any one time, Christiana might process more than 100 patients in its Level 1 Trauma emergency department (ED), and handles 106,000 emergency visits a year.
There is no more dynamic or hectic environment than a trauma center. As Linda Laskowski-Jones RN, Christiana’s Vice President of Emergency, Trauma & Aeromedical Services described, “A significant patient care issue that we faced was the challenge of identifying which staff cared for certain individuals. Staff exposure to infectious and even chemical agents must be carefully tracked for effective employee safety, illness and injury prevention.”¹

The only method at Christiana’s disposal was reviewing clinical records for the name of providers (assuming those individuals documented their names and visits).

Christiana required an automated solution that would provide that visibility. It must identify providers who came in contact with a particular contagion or chemical. Such visibility would further allow Christiana to improve customer service, matching the provider with a good or bad patient experience. Finally, the solution must be hands-off; administrative compliance by emergency care providers is surprisingly low, because they are emergency providers. (Administrative compliance in all sectors, including manufacturing and education, is an ongoing challenge.)

Christiana Care in 2006 implemented the Amelior EDTracker® automatic patient and asset-tracking software from PCTS.

The system provides a map view of the ED (see image right), with such parameters as –

• Location of patient;
• Acuity, indicated by clothing color;
• Duration of stay, with an alarm clock indicating 4+ hours;
• Which rooms need cleaning, indicated by a spray bottle;
• Which caregivers came in contact with which patients.

This project was funded in part by federal bioterrorism grant money allocated to the State of Delaware’s Public Health Department. Automatic tracking of patients and staff met criteria for funding in that it enhanced emergency preparedness by, among other measures, notifying staff who have been in contact with a potentially infected or contaminated patient for purposes of prophylaxis.

Patient Care Technology Systems: Direct patient benefits of Real Time Location System-enabled workflow automation This represents only those improvements that directly benefit patients. There are several dozen additional benefits to hospital administrators and caregivers, including, improved throughput, process improvement, and rapid return on investment. Patient & Staff Safety Eliminate the operational risk of “lost” patients. Reduce delays in patient care caused by a lack of information, availability of resources, or delays in communication. Reduce patient wait times in emergency department. Identify patient acuity and status in emergency department waiting room. Reduce rate of patient walkouts from emergency department due to wait time. Reduce hours on divert status (ambulance) due to lack of bed space in emergency department. Automatically flag patient reevaluations when wait times exceed department thresholds. Easily communicate patient safety alerts such as latex allergy, bariatric needs, isolation requirements, or similar names shared by more than one patient Create a quieter, more healing environment due to the reduction in overhead pages and telephone calls required to coordinate care between staff. Measure timing of critical diagnosis-related treatments for conditions such as pneumonia, myocardial infarction, and stroke to achieve national guidelines for time-to-treatment. Improve preoperative antibiotic administration rate. Identify when refrigerated inventory fall outside of safe temperature ranges. Prepare for a surge in patients caused by a mass casualty incident through enhanced ability to track all patients upon arrival. Access an automatic log of all patient interactions for immediate staff notification of contact with patients later identified to have an infectious disease or chemical agents. Support compliance with the Institute of Medicine’s (IOM) STEEEP goals with improved Safety, Efficiency, and enhanced Patient-centric care. Support rapid response teams with real-time patient status information. Patient Service Reduce patient wait time in emergency department. Improve rate of on-time surgery starts. Assist staff in communicating the real-time status of patients (emergency/surgical/outpatient services) to family and friends. Protect patient information by eliminating manual grease boards for tracking patient flow while providing convenient and secure access to practitioners. Passively and accurately measure patient flow by key intervals to assist staff in addressing patient service comments/complaints. Proven to increase patient and staff satisfaction.

Wireless People Tracking: The Ethical Questions By Jill Abell, Staff Writer During a recent ride on the San Jose’s Light Rail, I watched the conductor unexpectedly exit the train during a routine stop. I sat in silence next to a panting co-commuter and watched the rest of the passengers erupt in a frenzy of demands. When the conductor returned he offhandedly announced that due to a "medical emergency", the train could not continue. He did not say what the "medical emergency" was, if help was on the way or how long we would be there. A flurry of chatter began as people hypothesized the cause. Whispers of “swine-flu” could be heard from people as they scurried away in different directions. Whether going to work, the grocery store, or the post office, riders of public transportation are often nestled in and around armpits, elbows and thighs. Passengers share seats, armrests and poles and less visibly, germs. The stench alone, especially in the growing summer heat, is evidence that more than friendly banter is being exchanged. In situations like these, do we have a right to know the cause of the “medical emergency”? When does it become our business? Does the victim of the emergency have a right to their privacy when the cause might inflict harm on others such as swine-flu? Especially if people are confined to small, public spaces perfect for disease transmission. Who make the decision to inform, or not to inform, others? What gives the decision makers the authority to do so? How quickly is the decision made – in time to prevent further spread? If this medical emergency was the result of a contiguous disease, authorities will undoubtedly try to determine after-the-fact who was near the infected areas, and quickly contain them before the infection proliferates. Should wireless people tracking technologies be more broadly adopted beyond hospitals to include densely populated public areas such as transportation, parks, or even schools? If not for yourself, then don’t you have a right to know if your child comes in contact with someone with a contagious disease? There is no question that the greater adoption of wireless people tracking can provide authorities with enormous benefits, not just in medical emergencies, but for security purposes as well. However, the topic raises a multitude of ethical questions that politicians, scholars, and historians will be debating for years to come.

Wireless tracking and the surrender of privacy

The objection to RFID and RTLS in healthcare is that, whatever efficiencies the technology introduces, the patient and caregivers surrender privacy.

It does require a bit of buy-in from hospital staff. VP Laskowski-Jones of Christiana Hospital advised involving frontline staff in the planning for “internal marketing” – ensuring that the staff understood the practical applications and the WIFM “what’s in it for them”. Patients sometimes prove even more reticent, some refusing to return their badges, believing that “protected health information is somehow embedded there,” wrote Ms. Leskowski-Jones. “Despite thorough explanations to the contrary, we have found that a small subset of patients will still refuse to give up the badge at the end of the visit.”

The badges contain only non patient-specific unique location identifiers; the software and systems contain the patient-specific information. And that information is subject to all the rules that govern patient privacy. This includes the traditional privacy of doctor/patient relationships. It also includes the mandates of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. HIPAA has stiffened considerably since 1996, to deal specifically with Electronic Protected Health Information (EPHI). HIPAA requires three types of security stopgaps, being administrative; physical (including control of access to networks); and technical (including documented risk analysis and risk management programs).

The requirement

It is the opinion of IndustryWizards that there is no significant loss of privacy to patients In cases of contagion, the mechanisms of the Center for Disease Control and all healthcare providers are the same as they are in the case of, for example, the spread of sexually transmitted diseases (STDs); discreet contact by professionals, and not always revealing the name of the contagious person. Besides, in an environment wherein outbreaks are no longer regionally contained—individuals with SARS, Dengue fever, tuberculosis and Swine Flu have all spread contagion through international travel—people must be willing to sacrifice some privacy in the interest of public safety. Co-author Louis Sirico experienced firsthand the precautions to which travelers in Europe are subjected (see below).

Through the same type of technology that hospitals use to track equipment and inventory, healthcare officials can know for certain who has, and has not, come in contact with a contagious person, and contain those epidemics.

Swine Flu Precautions in Europe: Louis’s First-Hand Experience

Travel abroad you’ll see just how seriously other countries are taking the Swine Flu, as I learned on a June 7th trip to Europe.

During my flight to Charles De Gaulle airport in Paris, France, all passengers, regardless of nationality, are required to complete a form issued by the Ministry of Health in France before entering the country. The form alerts travelers of the “New influenza A/H1NA” and boldly states “if you have experienced or are experiencing within seven days after your arrival in France a fever/temperature higher than 38° C, soreness, or tiredness, a cough or difficulty breathing” you are to call the numbers they provide. (After traveling 17 hours, I usually experience tiredness.)

On the form, you are required to provide your full name, home address, where you are staying in France, e-mail, telephone, and the contact information for someone in France who knows where you are.

For those that feel this may be an invasion of privacy, at the bottom of the form, it includes “The information is kept in a sealed envelope and is destroyed at the end of a 15 day period following arrival.” Of course, you have a choice. If you don’t want to provide the information, you can get on the next plane leaving France.

Once off the plane, there are repeated signs along the walls alerting groggy passengers to the influenza. The Ministry of Health explains why it is taking all of the precautions and provides regular news updates on their website at http://www.pandemie-grippale.gouv.fr/

At the Frankfurt airport in Germany, I found similar signs warning passengers in German, English, and Spanish (see photo above).

What I find most interesting is that the influenza A(H1N1) is one of the top stories every day for the European news agencies but we don’t see much coverage in the U.S. media anymore. Yet, as of 17:00 GMT, 15 June 2009, the U.S. has by far, the highest number of confirmed cases: 17,855 – more than any other country in the world, especially compared to Germany with 170 and France with 80. See for yourself: http://www.who.int/csr/don/2009_06_15/en/index.html

If the Europeans are taking these kinds of precautions with only of a fraction of the confirmed cases that we have in the U.S., perhaps our government should also be more proactive?