How do OR leaders enhance family members’ satisfaction with the communication they receive when their loved ones are in surgery? Thanks to advances in technology, many are turning to tools like mobile apps and text messaging.
At Memorial Medical Center (MMC) in Springfield, Illinois, Lexanne Darwent, BSN, RN, helped implement a program that allows confidential two-way messaging with family members, in addition to valuable internal reports. The technology boosted patient and family satisfaction. MMC is part of a four-hospital system that includes Abraham Lincoln Memorial in Lincoln, Illinois, where Darwent is now manager of perioperative services.
A 2015 study in Patient Safety in Surgery reported that patients, their designated contacts, and healthcare providers all responded positively to secure text or email messages delivered during surgery.
“We had many university hospitals working with us, and they all loved it,” says Chad Gordon, DO, FACS, a craniofacial plastic surgeon at Johns Hopkins Hospital in Baltimore.
On average, patients chose 3.5 people to receive messages. Of the 190 patients, contacts, or healthcare providers who responded to a follow-up survey, more than 90% in each category said they “felt more connected to their loved ones during surgery” and “would recommend their loved ones sign up for this service. “
Dr Gordon, the study’s lead author and co-developer of the novel app, got the idea when he was at Cleveland Clinic and in charge of updating friends and families during the nation’s first face transplant.
“I was calling people, carrying two phones, and communicating with a 50-person team,” Dr Gordon says. “It was crazy.”
Here is a closer look at how hospitals are using apps and other technology to keep patients’ loved ones in the loop.
MMC is a Level 1 trauma center and teaching hospital that performs more than 11,000 cases in the main surgery department. In 2013, surgical services expanded from 18 to 23 ORs, the surgical waiting area doubled in size, a new patient care tower opened, and a new learning and innovation center launched. Worried that all these changes would negatively affect patient and family satisfaction, Darwent and her colleagues decided to take action, starting with analyzing the current system.
Darwent observed in the surgical waiting room, reviewed Press Ganey patient satisfaction scores, and talked with nurses and physicians about what was and was not working.
“We found we had a process in place, but it was broken and manually focused,” Darwent says. Concerns included volunteers calling out patients’ names and surgeons talking to family members in public—violating privacy—as well as timely delivery of information.
Darwent says the goals of the project were to:
• provide family, friends, and other companions (all referred to as “family” in this article) with more information during patient procedures
• allow families to leave the waiting area while still remaining informed and connected
• anticipate arrival of the physician to speak with the family
• increase family visitation in the postanesthesia care unit (PACU)
• improve the overall experience of families.
To meet its objectives, MMC turned to Vital LinkTM Surgery Status Update, from Mutare Health, Rolling Meadows, Illinois, which provides streamlined communication through a cloud-based application.
“It allows us to provide confidential, two-way information with families,” Darwent says. “Updates are provided through cell phones, freeing patients’ families to roam as they please.”
Text messages are encrypted, and although the Mutare system has the capacity for return messages, at MMC the families’ response is limited to confirming that a message was received. Mutare Health worked with MMC to customize the system, which cost $50,000, to fit the hospital’s needs.
“We can send updates to multiple cell phones, and if someone doesn’t have a cell phone, we give them a pager,” Darwent says. If a family member doesn’t reply “OK” to verify he or she read the text, the system places a phone call. If the family doesn’t respond to the text or call, a nurse calls.
The Vital Link system has a dashboard that enables users to track progress (sidebars at right and on p 22). The dashboard is cloud-based and can be accessed from any computer with an internet connection. The waiting room staff send the messages given to them from the OR nurses, who have received customer service training on how to best update families.
Darwent says that from 5:30 am to 7 pm, the waiting room is staffed with two employees in addition to volunteers; after 7 pm, one employee handles the decreased volume.
Vital Link provides several reports:
• daily activity report—lists text, pager, and phone messages sent and received per day
• patient notes report—lists notes for a specified date range
• surgeon messaging report—lists all messages for a particular surgeon for a date range (useful for surgeons who want to know what their updates look like)
• OR messaging and intervals report—lists the messaging intervals for patient visits for a date range
• PACU family report—lists the time between patient arrival in the PACU and family visit for a date range.
Darwent says this last report is particularly helpful. “Family visits [in the PACU] decrease patients’ pain and anxiety, so having this data allowed us to track how soon those visits happened,” she says.
From April to December 2014, the application was designed and tested, education was provide to staff and physicians, information technology (IT) staff vetted the systems, and baseline survey data were obtained from patients and families. The system went live in December 2014.
By May 2015, the patient and family satisfaction scores on an internal survey had risen from 4.1 (on a 5-point scale) at baseline to 5. All of the following Press Ganey scores improved—information given to the family, comfort of family in waiting area, information about delays, concern for privacy, and overall rank.
“The biggest change was the improvement in concern for privacy,” Darwent says. “We get a lot of compliments from family members about the ‘wow’ factor of the service.”
During the debriefing after surgery, physicians tell the nurses when they are going to talk to the family. The nurses then ask staff in the waiting room to take the family to a private consultation room to await the physician’s visit.
“We want to give the family freedom to move about, but we want to respect the physician’s time,” Darwent says.
Consistency in communication helps make sure nurses are following the same processes. For example, timers are set to remind the waiting room staff when to communicate updates and to reinforce that nurses notify the waiting area if updates are going to be done every 2 hours, as is the case for long procedures, instead of hourly.
When parents bring their children to the OR, often their last image is a crying child reaching out to them as the doors shut. “That can be their last memory of their child as they sit for 6 to 12 hours in the waiting area,” says Ashley Hodge, MBA, CCP, FPP, cardiothoracic surgery quality and safety officer at Nationwide Children’s Hospital in Columbus, Ohio.
“What they don’t see is that children immediately stop crying because we have many avenues to make them happy.” As a parent herself, Hodge wondered, “How could we bring the family on the journey with us through surgery in an appropriate way so they would feel they were part of the process instead of feeling disconnected?”
As a result of her musings, she led the initiative to implement the Electronic Access to Surgical Events (EASE) application (Orlando, Florida), which provides encrypted messages over 3G, LTE, or WiFi connections. Texts, photos, and images disappear after 60 seconds, and the system automatically ends a session if there is no communication for more than 2 hours. “It’s incredibly simple and secure,” Hodge says.
The hospital started using EASE in 2014. Hodge first obtained surgeon support, which was easy; obtaining legal approval wasn’t as easy.
“There was a lot of technical investigation by IT to be sure someone couldn’t break into the system,” she says. EASE has several security features, and eventually IT signed off. Subsequently, the legal department agreed to the project, although it required patients to sign a consent form.
Initially, some nurses in the OR resisted using EASE because they were reluctant to take on responsibility for communicating with families directly.
In the past, a special group of nurses had handled this responsibility.
“It was hard to say, ‘You can’t have personal cell phones in the OR, but here is an iPad and we want you to text the family,’” Hodge says. “We emphasized that although our patient is our 100% priority, we have a family to care for as well.” She adds that two factors quickly dissolved resistance: Staff saw how easy it was to use the system and how much the family valued the communications.
“As soon as the child is calm [after the parents leave], we can send a picture to the family,” Hodge says. “That’s a huge relief for parents.” In fact, parent demand for the app stimulated a rapid expansion from a pilot program to all ORs.
When the child and family arrive in preadmission testing, the advanced practice registered nurses (APRNs) give the family a trifold brochure about EASE and ask if they are interested in participating. If so, the APRN obtains the signed consent form, including a list of those who will receive updates.
When the circulating nurse meets the family before the child is brought back to the OR, the family downloads the app (both Apple and Android versions are available) and registers the patient. Families choose to receive text, photos, and/or videos, and then receive a QR code so the connection is secure.
“It takes only about 30 seconds to complete,” Hodge says. The OR circulator logs in, takes a picture of the QR code, and sends a text to verify the connection.
OR Manager spoke with a representative from the Office for Civil Rights (OCR), part of the US Department of Health and Human Services, about issues related to sharing health information in the context of the electronic systems discussed in this article. OCR is responsible for enforcing regulations related to the privacy and security of health information.
Based on its provisions, the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, last modified in 2002, does not require hospitals to obtain a signed HIPAA authorization form before providing electronic surgical updates to families, as long as the patient does not object to the information sharing.
For example, if the patient requests that hospital staff share status updates with identified family members via a smartphone app, there is no need to obtain HIPAA authorization. HIPAA authorization is needed only for disclosures that are not permitted under the rule. Communication should be limited to only what is needed. For instance, although the OR circulating nurse might text that the surgery has started, he or she should not share any of the patient’s past medical history. Although the OCR understands that hospitals may choose to obtain a signed informed consent from patients as part of its institutional practices, doing so is not a HIPAA requirement.
The HIPAA Security Rule, published in 2003, and a rule that implements provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, both address the security of protected health information transmitted electronically, whether by email, text, or other means. One of the key provisions is encryption. The organization must either encrypt the data or do some reasonably compensating control that is equivalent to encryption.
One advantage to the organization is that an electronic data breach does not need to be reported to the OCR if the data was encrypted. Although the OCR doesn’t list an encryption requirement, it “defers to” standards from the National Institute of Standards and Technology. The OCR also notes that it’s important for organizations to closely evaluate data risks.
HIPAA encourages providers to involve family members and friends in the care of individuals, subject to the individual’s right to object to that particular disclosure, but, of course, organizations need to ensure transmission of data is protected.
EASE has resulted in more frequent updates. “Our average update went from over 2 hours to 45 minutes,” Hodge says. “Families are also getting better updates because we can send photos and videos.” At the end of the surgery, the surgeon records a video and lets the family know when he or she will arrive to talk with them.
OR nurses used scripted texts until they became comfortable using the app. For legal and security reasons, families cannot send messages to the OR staff. However, Hodge says specially designated OR nurses still have face-to-face contact with families at the start, middle, and end of surgery.
“Having built-in personal encounters gives the family the ability to ask questions,” she says. There is also still an attendant in the waiting area.
Technology can dramatically change family members’ experience. “Usually as I walk up to family members to talk with them in the waiting room area, they are scared because they don’t know what I’m going to say,” Dr Gordon says. “Instead, families were jumping up and hugging me because they already knew things had gone well.”
Hodge adds that technology communication fits well with the shift to quality of the patient and family experience. “It’s just like a consumer going to the store to buy groceries,” she says. “It’s your experience while you’re there; if they have the products you need, it’s how you feel and how you are treated while you are there.” Using technology to communicate with families takes that experience to the next level. “They feel connected, and they feel we value them,” she says. “It’s definitely a game changer.”
That game changer can pay off with repeat business and avoiding financial penalties associated with low patient and family satisfaction. ✥
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