Changing the Rhythm: Considering Information and Workflow Management

 Clinical leaders are often faced with the dilemma of how to improve work efficiency, therefore many institutions have looked to the principles of lean.  The idea of lean was first identified in Toyota manufacturing plants; as the factories focused on optimizing production and minimizing waste focusing on a "value stream" or flow process. Lean has exploded in healthcare as organizations look for ways to improve their efficiency and patient outcomes while decreasing cost and do this by cutting out steps that add no value.

Lean focuses on the individuals who are actually doing the work as resources for improving a value stream and eliminating waste (Toussaint & Berry, 2013). The role of the leader is to facilitate the process of change while the actual individuals performing daily tasks help identify points of waste and alternative methods. In turn, these individuals feel valued and know each step in their workflow is valuable.



The same principles can be applied to information management; how the information is acquired, processes, and utilized. Here we will discuss the widespread problem regarding information of cardiac monitoring rhythm strips with the proliferation of the EHR.

Stuck in Time

As many institutions move to EHR and strive to prove meaningful use some bits of data are left in the pre-EHR era. One such pool of data is cardiac rhythm strips. Nurses, depending on the policy of the institution, are required to document the cardiac rhythm of patients of telemetry. With paper charting it was just one more piece of information that was added to the chart, now with the EHR it is one of the few pieced of data that are documented outside the chart. Here is a thread on allnurses discussing the successes and challenges of this transition.
In my institution we are required to document a minimum of one telemetry strip per 8 hours, in addition to documentation of any cardiac events. This entails printing the strip, walking to another part of the department to get the paper form for documentation, tracking down a glue stick, cutting and gluing the strip to the form, returning the chart, and then the strip is eventually scanned in the system by health records probably only to be viewed again if there is a complaint or adverse event requiring legal action.
This is of course the current best case scenario with room for error, increased inefficiency, and non-compliance. The printer may be out of the monitor paper which is in a far-off closet, the nurse may be unable to find a glue stick or the documentation sheets are out of copies, the nurse is unable to find the patient's chart which is now hold minimal information, he chart may be lost before it even gets to health information management, and once there the sheet could be lost or scanned wrong. Each of these steps increased the chance of non-compliance or error in addition to wasting nursing time and increasing frustration. In fact cumbersome documentation workflow is a major frustration and dissatisfied among nurses in institutions that transitioned to an EHR (Laramee, Bosek, Shaner-McRae, & Powers-Phaneuf, 2012). When we upgraded to an EHR our tele strip documentation plummeted because it was no longer part of the main documentation workflow and became a cumbersome task.

Integration into the Workflow

Currently we have some device integration with our EHR, if a patient is on a wall monitor their vital signs automatically pull into the EHR and then are documented by nurse verification. The cardiac strips and the vital signs come from the same device but we are still unable to verify a rhythm strip with the EHR. When automatic vital sign documentation was integrated into the EHR error rates were shown to decrease from 10% on paper and 4.4% for manual entry into the EHR to less than 1% (Smith et al, 2009). It would be reasonable to anticipate a lower error rate and higher rate of compliance with a similar move toward automatic telemetry documentation. Nursing started to ask "if we can pull vital signs why can't we pull a rhythm strip."
Well, with the spring upgrade there is a feature that will be added or turned on to allow the documentation of the rhythm strip directly in the EHR. This adds a number of advantages:

• eliminates wasteful steps
• increase ease of compliance
• allow availability for clinicians to view the strip in real time, in the chart
• allows for further integration of best practice alerts and medication warnings

 Below is simplified depiction of the change in workflow.

 As you can see the principles of lean can really be applied in this situation. Wasteful steps are eliminated allowing for increased efficiency. To document a rhythm strip will require less nursing time and improve the accuracy and availability of the documentation. Considering new ways to manage healthcare data can provide improved care quality, staff satisfaction, and workplace efficiency.

Questions

Are you experiencing a similar challenge with rhythm strip documentation? If yes, what are some solutions being utilized at your institution?

Can you think of any other areas where a change in information management would result in improved workflow?

Let us know in the comments below.

References

Smith, L. B., Banner, L., Lozano, D., Olney, C. M., & Friedman, B. (2009). Connected care: reducing errors through automated vital signs data upload. Computers Informatics Nursing, 27(5), 318-323.

Toussaint, J. S., & Berry, L. L. (2013, January). The promise of Lean in health care. In Mayo Clinic Proceedings (Vol. 88, No. 1, pp. 74-82). Elsevier.

Laramee, A. S., Bosek, M., Shaner-McRae, H., & Powers-Phaneuf, T. (2012). A comparison of nurse attitudes before implementation and 6 and 18 months after implementation of an electronic health record. Computers Informatics Nursing, 30(10), 521-530.