UPMC Hamot reports significant reduction in SSIs, OR turnover times with remote video auditing
Hospital operating rooms often have opportunities for patient safety and efficiency improvements, and the ORs at UPMC Hamot in Erie, Pa., were no exception — while the hospital had comparatively strong metrics for surgical site infections, OR never events, and OR turnover times, its leaders believed all three areas could be improved.
To conquer these challenges at once, UPMC Hamot turned to an innovative third-party service called remote video auditing provided by the web services company Arrowsight, Inc.
What is RVA?
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Remote video auditing can be likened to sports teams watching game film to make improvements. It involves using off-site trained observers who watch near real-time video clips to measure compliance with certain predetermined steps. The patient safety and OR efficiency performance feedback is then automatically streamed back to the organization via webpage scorecards on plasma boards throughout the OR and to mobile devices. There are also near real-time text and email alerts sent to designated OR staff when there are operational tasks to be performed, such as alerting the cleaning staff to come clean a room when the patient leaves the OR.
Remote video auditing originally gained traction in the food industry to improve food safety and efficiencies in the early 2000s and then made its way into healthcare in the late 2000s. Northwell Health was the first major health system to pioneer the use of RVA in healthcare, which began in 2008 with a two year study using RVA to improve hand hygiene performance in a large intensive care unit at North Shore University Hospital in Manhasset, N.Y. The study results were published in 2011 in Clinical Infectious Diseases Journal showing that RVA with near real-time feedback improved hand hygiene compliance from 6.5 percent to 81.6 percent in four weeks, and the hospital sustained those rates for 75 weeks. In 2013, Northwell Health, in partnership with their anesthesia provider, North American Partners in Anesthesia, began a second major study on the use of RVA to improve OR patient safety and OR efficiencies at Long Island Jewish Medical Center. These study results were published in 2015 in British Medical Journal Quality and Safety, reporting RVA with near real-time feedback improved surgical safety checklist performance to 90 percent and reduced turnover times by 15 to 20 percent.
RVA in healthcare earned national attention when Martin Makary, MD, with Johns Hopkins in Baltimore, wrote a 2013 JAMA viewpoint article on the power of RVA. "The potential to harness the data in these videos and drive quality improvement may be substantial," he wrote. Dr. Makary also published an editorial in BMJ in 2016 citing the 2015 BMJ publication about RVA in the ORs as being a "landmark study."
UPMC Hamot leadership saw an opportunity to improve the safety and efficiency of surgical care with RVA and in 2014 contracted with Arrowsight to implement this technology in their operating rooms. Administrators and clinicians detailed their experience with RVA in a study published in the February 2017 issue of AORN Journal titled: Remote Video Auditing in the Surgical Setting.
It took four months of preparation and communication with key stakeholders before the cameras could be turned on at UPMC Hamot.
One of the major obstacles was convincing clinicians that the video data was safe, according to Anne Pedersen, MSN, RN, UPMC Hamot's director of nursing. "The staff was initially concerned these videos could show up on YouTube," she says, since they are transmitted through the internet to Arrowsight. Staff concerns were alleviated when they understood that the RVA system transmits the low-resolution videos through the hospital and Arrowsight's highly secure VPN connection.
It also helped that the surgical consent form used at UPMC Hamot already included a clause that allowed the organization to take pictures and videos during procedures.
Through a tailored communication campaign that involved one-on-one and group meetings with surgeons, anesthesia staff, housekeeping and other workers, the system gained "universal support," Ms. Pedersen says.
UPMC Hamot leaders also had to decide on which predetermined sets of actions the trained auditors should observe. The hospital ended up with three domains for the RVA team to audit.
1. Patient safety triad. The patient safety triad, or PST, encompasses the sign-in, time out and sign-out portions of any surgery, which are crucial for patient safety. To make them visible and obvious to the observer, UPMC Hamot tweaked its processes slightly — it started using a more visible, large yellow trifold card during the PST's three phases, so the remote observers could assess the safety protocols. Everyone in the OR stops all movement during these PST events, which is both good for patient safety and makes it easier for auditors to observe via video. As a result of RVA, compliance with the three components of the PST now ranges from 94 percent to 100 percent on a daily basis.
2. Efficiency. The remote auditors monitor the efficiency of OR turnover at UPMC Hamot. Auditors monitor turnover time in three segments: patient exit to cleaning stop, cleaning stop to room sterile and room sterile to patient in. To gain efficiency in this area, the hospital started using parallel work, with anesthesia and nursing staff working side by side to prep the room. "It took work for nursing to understand anesthesia can come in when everything isn't in place," says Megan Beaton, BSN, RN, the hospital's director of surgical services, but it led to more efficient use of time. By using RVA to provide detailed performance metrics of all case segments, UPMC Hamot was able to successfully re-engineer its OR processes leading to a roughly 20 percent reduction in turnover times. They estimated that the financial impact of this increased efficiency enabled UPMC Hamot to have a full payback on the first year of RVA costs of $200,000, in a single month.
3. Cleaning. UPMC leaders realized that in addition to using RVA to improve overnight terminal cleaning performance that it would be beneficial for patient safety to leverage RVA to improve in-between case OR cleaning and also end-of-month OR cleaning.
As a result of using RVA, EVS personnel are achieving 94 percent compliance with OR cleaning requirements — which has led to an initial 10 percent reduction in SSIs as reported in AORN, which has been recently revised to about a 20 percent SSI reduction now that the readmission period following the study has passed. UPMC Hamot estimates it has saved more than $500,000 annually as a result of a decrease in these costly surgical complications.
Value of feedback
Arrowsight sends near real-time feedback to UPMC Hamot to improve patient flow in addition to safety, efficiency and cleaning. Status boards are situated in the hospital so staff can see what stage each OR is in — when one is sterile, a drape is coming down or the cleaners have entered, for instance.
"We really have come to value the RVA boards," Ms. Pedersen says. "The beautiful choreography is triggered by the status board."
Additionally, alerts are sent to surgeons' phones when ORs are ready or nearly ready so they can be more efficient with their own time in-between cases. Approximately 80 surgeons are now consistently receiving notifications on personal cell phones, according to Ms. Pedersen.
Since implementing RVA with Arrowsight, the hospital has experienced roughly 95 percent compliance on surgical safety checklist protocols. Additionally, UPMC Hamot has seen decrease of about 20 percent in OR turnover times and a 20 percent reduction in surgical site infections. The decrease in turnover times enabled UPMC Hamot to achieve a full payback on their first year $200,000 investment in RVA in a single month, and the reduction in SSIs resulted in an estimated savings of $500,000 during the first year.
"Remote video auditing has improved patient care at our facility and may shape the future for surgical care in the United States," the AORN Journal study authors wrote.
RVA options for surgery departments
For hospitals that decide not to initially implement RVA for the full suite of OR patient safety and OR efficiency services reported on by UPMC and Northwell Health, surgery departments can start by purchasing a small number of inexpensive RVA portable cameras to focus exclusively on improving OR cleaning performance to help reduce surgical site infections.
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