In its most basic form, the ED patient-tracking tool indicates the name and location of all patients in the ED. With increasing sophistication, a tracking tool can also identify patient information including the patient's chief complaint and time in the department, as well as relevant clinical data elements such as nursing acuity score and vital signs (Table 59-1). Figure 59-1 demonstrates this information in a traditional electronic track board view.
Patient-level information consists of basic data elements necessary for clinical staff to facilitate care. Generally, this information is configured in a horizontal row that can be easily referenced by the clinician user at all clinical workstations or via a larger display monitor (Figure 59-1). In many instances, the monitor is mounted in a central location of the ED for the staff to view. (Patient privacy concerns with this hardware configuration will be discussed later in this chapter.) The display and visual access of this patient information reduces and often eliminates the need to find, communicate with, and (nonvalued added) interrupt ED staff.4 Further, it has been established that effectively used tracking tools significantly improve collaboration among caregivers (Table 59-2).
Additionally, the tracking tool can provide multiple layers of data through interfaces and inputs. Figure 59-1 demonstrates an example of information provided from an admit/discharge/transfer system interface that indicates when a patient has had a prior visit as well as a visit within the last 72 hours. By providing multiple layers of data, the EW can become an information and communication hub of an ED. The ability to have a single information platform available to the entire staff from multiple locations in the ED enhances management as well as individual patient care.3-5
Among the primary functions of the EW, bed management is perhaps the most fundamental. This function allows patient location to be referenced and updated from each clinical workstation by the appropriate ED staff caregivers. Two perspectives of bed management can be presented by the EW—“patient-centered” tracking and “department-centered” tracking.
Patient-centered tracking has 2 distinct dimensions: location and clinical course. Patient location simply indicates the physical space occupied by patients. This function can be updated by each user and is often part of the nurse or clerk workflow. Some departments prefer that determining the patient location be the responsibility of a specified nurse (charge nurse) or physician (senior attending). The practice of location setting is critical in a practical sense as care givers often identify patients by the “bed” that they occupy in the ED, that is, “… the chest pain patient in bed 4.”
If patients are moved and the EW is not updated, significant potential for errors will occur. Such errors can include an incorrect medication, treatment, or test on a patient moved into a space previously occupied by another patient. Even with the introduction of technology, these patient safety scenarios highlight the need for sound operational procedures, such as use of patient identifiers.
When patient tracking is integrated with a radio-frequency identification (RFID) system, a patient's location can be automatically updated in the EW as ED staff moves the patient. This data can be captured and reviewed, giving the picture of a patient's course from the time of arrival to the point of discharge. The data obtained from tracking patients' movements is an important element in performance improvement efforts, particularly related to ED patient flow.8
The clinical course of patient-centered tracking involves providing clinicians with ongoing clinical information of a selected patient's visit. Figure 59-2 demonstrates a tracking board that has been configured with alerts. In this case, a clipboard icon displays a pending order completion. The “lab stat” column indicates return of an abnormal laboratory value (exclamation mark). The column also indicates that 7 laboratory results are available, 9 are expected during the patients ED course, and 10 were ordered ([7/9/10]). A clear representation of important clinical information allows the clinical caregivers to have a shared understanding of the patient's status while minimizing nonvalue-added communications (interruptions). The question “What is this patient waiting for?” can often be immediately answered by observing elements displayed with on the EW.
Active clinical information communicated by an EW. The icon “a” indicates that the ED physician order is not yet acknowledged by a member of the nursing staff. The icon “b” with an exclamation mark indicates that an abnormal laboratory result has returned. Green colorization of the “bed” column specifies that a patient is ready for discharge home. Purple is used to indicate that the patient is awaiting inpatient bed assignment. Completed and expected events such as medications or procedures, order status (pending or completed), and laboratory results pending are displayed in the “patient” column.
Department-centered tracking allows users to understand many aspects of the ED patients at one time. This real-time tracking is accomplished by displaying views that answer questions crucial to managing patient flow. Many common questions can be answered and assist caregivers in their management of patients.
- How many patients are waiting for ED beds?
- How many patients are waiting for inpatient beds?
- How long have they been here?
In addition to indicating bed occupancy and patient location, the EW can designate a location or bed being held for specific purposes. For instance, a nurse may hold a bed for a patient's return from another location in the department (eg, x-ray), or the hospital (eg, MRI) (Figure 59-1). In addition, a bed can be held for a high-acuity patient, who is expected to arrive momentarily, that is, “hold EMS” or “hold aeromedical.” The ability to immediately determine a patient's (pending) location can significantly assist consultants responding to the ED, once those consultants are trained to use the EW. Additionally, staff can designate beds requiring special services including housekeeping, isolation, and so on.
RFID, in addition to enhancing patient-centered tracking, can provide department-centered tracking information when used to locate items, equipment (infusion pumps, ultrasound machines), and even individual team members. The equipment and personnel can be displayed on the EW as icons in an electronic ED map. This real-time display facilitates the clinicians' ability to locate equipment and ED staff more quickly, allowing for more focus on patient care.
The graphical user interface (GUI) is the visual environment that allows a human to interact with a computer. Mature applications tend to have elegant GUIs with well-thought-out designs that anticipate users' needs, yet remain simple to use. The adoption of an EDIS by members of the staff occurs more easily if its GUI is intuitive and of high quality. Data and information displayed with clarity in the GUI can significantly improve a clinician's efficiency.9
An application is considered intuitive when the user can learn to operate it simply by observing its use or with minimal instructions. However, even intuitive clinical systems often require end-user training to optimize system use and minimize clinician frustration. Another critical design aspect for an effective GUI involves attention to clinical decision-making and workflow processes that facilitate adoption and usability.10
An application improves efficiency when it reduces clinician time required to complete a task. The EW GUI can improve efficiency by displaying readily recognized contextual data. The use of color splash and icons within the GUI improve usability, learn-ability, and efficiency.11 Completed and expected events such as medications or procedures due, and laboratory results pending can be displayed in a patient row. Colorization and iconic representation as shown in Figure 59-2 communicate several clinical elements to users.
The EW can render useful perspectives and views of the ED. An “ED map” view can indicate a schematic depiction of the department indicating bed occupancy, patient location, and the status of their work-up (Figure 59-3). Icons and color codes can be used to indicate which caregivers are responsible for patients. For instance, colors can visually indicate the stages of a patient's work-up. In Figure 59-3, the colors represent
- Yellow: Waiting for bed
- Pink: Waiting for ED MD
- Green: Admitted awaiting transfer to inpatient unit
Map of the ED displayed on an EW. Colors indicate a patient in a location. Each color indicates the clinical course in the context of the patient. The yellow in bed 10 (arrow) indicates that the patient is waiting to be seen by a physician, the green at bed 4 × (star) indicates that the patient is ready for discharge.
This color status system is one example of a sophisticated functionality that exists when EW data is integrated with the EDIS.
Jeopardizing patient privacy is a significant risk of any tracking system, whether a large dry-erase board or an EW. Display of patient information including name and potentially sensitive information such as age, chief complaint, and location in the ED are helpful to maintain the department's efficiency and caregiver collaboration. However, the “public” display of this information has the potential to communicate protected health information to those for whom it is unintended.
Hersh has acknowledged that privacy risk exists in both the electronic and nonelectronic platforms.12 An advantage of the EW display is the ability of clinical workstations to have multiple layers of protection. Screen savers, automatic timed application log off, and screen filters (filters that prevent viewing unless directly in front of the monitor) are ways to reduce broad access to the displayed information. When a large central EW display is used, the listed privacy solutions cannot be employed without severely limiting the functionality of the display. One solution is to mount the large EW screens in an area that limits the potential for nonstaff to view the display. Examples would include a staff lounge area or a nursing area facing away from the patient areas. However, even these solutions do not prevent access to information by nontreating staff members.
A consequence of employing too many limitations to access of the tracking board (location of computer screens, login challenges, etc) is that staff members may be less able to frequently monitor the global status of the patients. There is a need to continually balance safety, privacy, and operational efficiency; the tracking board and device strategy play a critical role in privacy and security.
Perhaps a last word on whiteboard privacy comes from Feied, Handler, Smith et al:
“When clinical information needs are in conflict with privacy or security rules, the best possible clinical outcomes should be supported even at the expense of security and privacy.”13
As such, prudent attempts to protect patient privacy must be pursued. However, if crucial system configuration decisions create conflicts between potential privacy and the ability to improve overall quality, ED leaders should provide solutions that optimize the latter. Hersh notes that perfect security is probably not achievable and calls for the healthcare industry to manage area of risk by instilling a culture that demands privacy and confidentiality.