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Intelligent Hospital™ ICU/NICU Script 2015 PLEASE EMAIL [email protected] with any suggested changes

Table of Contents

Asset Management Visibility and Analytics: Increase Operational Efficiency, Patient Safety and Lower Costs (STANLEY)

1 Intelligent Hospital™ ICU/NICU Script 2015 PLEASE EMAIL [email protected] with any suggested changes

Revised / Updated: Mar 25, 2015 Scenario Patient Name: John Millhouse (Male) Age: 32 MRN: Status: Multiple Injuries from an Automobile Accident transferred from the ED

NICU Patient Baby Alice Premature Birth transfer to the Neonatal ICU Start: (Actor 1, presses play on mp3 player, and starts by the bedside, Actor 2 starts outside the door after everyone has entered the room. As soon as the script starts, Actor 2 enters the room and walks to other side of the bed.) ICU4 Staff Identification (Airista) Updated Mar 31 Hello, I would like to welcome everyone to the Intelligent Hospital™ Pavilion developed by the Intelligent Health Association. This ICU demonstration will address both critical manage of adults and neonatal patients. As you can see, I am automatically identified as I enter the room by the RTLS Staff Badges that I am wearing. (Actor 2 points to AiRISTA RTLS Badge). An enterprise RTLS solution capable of staff identification and locating enables an organization to automate processes and workflows improving the quality of patient care. (Actor 2: Points to large display showing screenshot 1 “staff location”) Integration to existing hospital systems such as Nurse Call, Single Sign On and Nurse Rounding/Scheduling increases the efficiency of healthcare workers and their managers. (Actor 2: Points to large display showing “Staff Rounding Report”) Multiple dashboards and business analytics are present to assist in the management of time consuming processes associated with staff management. ICU 4: Passive RFID Zonal Tracking (Borda) The Intelligent Hospital provides multiple levels of asset tracking functionality including zonal tracking of assets with UHF Passive RFID. Every asset has a passive RFID tag attached on it with a unique ID. (Actor points to a device with UHF Passive RFID tag attached on it).

With this solution; Assets entering to a specific zone or leaving from a zone is detected and a picture or a video is captured through an integration with CCTV systems when leaving a critical zone. Zonal tracking can also be combined with real time rule engine so that any biomedical device with an expired calibration date would create an alert as soon as the device gets into the ICU room. (Actor, (1) points to the Borda Display (2) brings a mobile biomedical device into the room and an alert condition will be shown on the Borda Display (3) clicks on the alert to show the details) ICU5 Network and Wireless Infrastructure (Extreme Networks) The Intelligent Hospital combines a robust network and wireless infrastructure, providing a seamless blend of multi-carrier cellular and Wi-Fi services. This enables real time operational intelligence from multiple RTLS / RFID and Wi-Fi systems applications as well as several modalities of communication and visualization providing rapid enterprise level interaction as observed on the large screen on a portable tablet or a hand held device. Actor 1 points to large display, Actor 2 holds up iPhone and HP tablet.)

We pick up the Scenario in the Intelligent Hospital ICU, where patient safety and continuity of care are paramount and great emphasis has been placed on asset, data and alarm management through multidisciplinary collaboration of the clinical staff, as well as informatics and biomedical engineering experts and a host of high tech venders. The ICU is cognizant of the recent Joint Commission Alarm Management National Patient Safety Goal and many of our solutions will help meet this goal.

ICU 1: Staff Management: (CBORD) Make it Easy for Employees to Spend with You Within the ICU the high acuity of patients makes staff response patient paramount. The high patient to staff ratio requires staff to manage time and breaks affectivity and ensure that the proper coverage is provided. If a nurse needs to go on break and only has 15 minutes, and knows the lines at the coffee kiosk downstairs will be long right about now. [Employee gets out phone while monitor shows screen shots progressing through quick online order] Instead of wasting time in line, she gets out her phone and places a quick online order, paying at the end with her Intelligent Hospital ID badge -- the same one you received when you entered the Pavilion today. [Employee holds up badge] She will now have time to run to the restroom and return a few phone calls before heading down to the coffee kiosk, where she will skip the line entirely and pick up her coffee and scone. She loves the convenience of

3 Intelligent Hospital™ ICU/NICU Script 2015 PLEASE EMAIL [email protected] with any suggested changes online ordering, and hospital administrator’s love giving their employees a strong incentive to do business with them instead of heading off campus. [Employee leaves to go on break] (Employee looks at watch.Employee gets out phone while monitor shows screen shots progressing through quick online order. Employee holds up ID badge. Employee leaves to go on break at end.) The ICU has just received John Millhouse from the ED. He is a 32-year-old male patient who was one of the drivers from a car crash. He presented to the ED awake with multiple injuries, however he deteriorated and now requires critical care support including mechanical ventilatory support.

ICU6 Medical Device Connectivity (Cardiopulmonary, Nuvon, Sunquest) In this facility, continuity of care has been established through medical device connectivity enabling surveillance, monitoring, and documentation, even in transport. Institutional RFID systems provide the ability to locate the patient in route and at specific locations such as Radiology or Radiation Oncology. Aggregated clinical information coming into the EMR, Laboratory system and PACS is delivered to a hand held and available for review anywhere in the hospital. This increases patient safety, by allowing clinicians throughout the institution and at remote locations to access clinical information to support, monitor and communicate. [Hold up hand held device and point to shared monitor] ICU 7 Bedside workstation/ Tablet authentication (HID, Zebra) This room is equipped with a bedside PC workstation which can be wall or cart mounted or a hand held tablet replacing the larger solutions. This PC or tablet is capable of running all the hospital applications and provides the clinician bedside access to the EMR, PACS, Lab information system, cardiology management data or medical history data. Proving you are who you say you are, by utilizing One Time Password security into cloud applications can be accomplished leveraging your ID Badge and NFC communication protocol with a single tap of the card. The innovative technology card both generates and sends a One Time Password without the inconvenience of re-entry. (Actor picks up the tablet and taps their ID badge to the tablet – screen shot of the authentication application).

In addition the PC provides the capability to print and scan barcode labels, and can also be integrated with RFID reader. These integrations ensure patient centric identification and association of all devices, supplies, medications, samples and documentation is directly associated to the patient. (Actor 1 Walks in at the start of the next paragraph, and immediately uses the hand washing dispenser) ICU8 Hand Hygiene (Airista) Updated Mar 31 Hello, I would like to welcome everyone to the Intelligent Hospital™ Pavilion developed by the Intelligent Health Association. This ICU demonstration will address both critical manage of adults and neonatal patients. As you can see, I am automatically identified as I enter the room by the RTLS Staff Badges that I am wearing. (Actor 2 points to AiRISTA RTLS Badge). An enterprise RTLS solution capable of staff identification and locating enables an organization to automate processes and workflows improving the quality of patient care. (Actor 2: Points to large display showing screenshot 1 “staff location”) Integration to existing hospital systems such as Nurse Call, Single Sign On and Nurse Rounding/Scheduling increases the efficiency of healthcare workers and their managers. (Actor 2: Points to large display showing “Staff Rounding Report”) Multiple dashboards and business analytics are present to assist in the management of time consuming processes associated with staff management. ICU9 Bed/Nurse Call (Stryker / ASCOM) Typical of most high acuity patient environments, our patient lies in an instrumented smart bed giving a secure dynamic environment capable of monitoring patient weight, side rail status, wheels, and patient communications. (Actor points to the bed) The bed integrates with a nurse call platform, providing patient to staff communications. Caregivers and staff wear staff badges that use IR, ultrasound, or low frequency RF technology through receivers located throughout the hospital and patient rooms. (Actor1 puts down bed rails, and points to other actors ASCOM Device) (Actor 2 holds up ASCOM Device to the audience to show that it was alerted when the rails went down). Calls and alerts such as bed exit or rails down can be immediately directed to the appropriate and available caregiver through the staff worn or handheld wireless device.

ICU10 Alert Notification (Vocera ASCOM) In this case the rail down condition is detected by the nurse call platform and the alert is sent to the primary caregiver (Actor 2) but she responds via her Vocera Badge (pushes a button on the Badge) that she is unavailable which in turn transmits the alert to the secondary caregiver (Actor 1 then holds up the and shows that he got a call when Actor 2 could not respond) who accepts the alert and attends to the potential bed exit alarm situation. It is important to note that caregiver one is carrying an entirely different personal communication device than the secondary caregiver. (Vocera) (Actor 1 picks up the bed rails to cancel the alarm) ICU11 Nursecall Communication & Workflow (ASCOM) The nurse call platform also server to enhance communications and workflows of the nursing staff. In this case the nurse observes that the patient’s IV appears to be tissuing and requires a new catheter at a new location. The staff member touches the “IV Team” touch point on the workflow station. The request is immediately sent to the appropriate group of staff via their wireless device. When a member of the team “accepts” the event using the soft key on the handset the rest of the team is notified that the request has been accepted saving steps. The staff member accepting the request has the option to speak back into the patient room to communicate with present staff prior to arrival. ICU12 Physiological Monitoring (Draeger)

Mr. Millhouse is also placed on physiological monitoring as ordered by the physician. At the Intelligent Hospital™, physiological parameters are monitored by a high acuity networked monitoring platform. This provides real time measurement, visualization, archiving and dissemination of critical parameters to other middleware including the EMR, hand held devices and alarm management systems.

Here, Mr. Millhouse’s heart rate and ECG rhythms, blood pressure, and O2 saturation are continuously monitored and are also available on the central station as well as on mobile devices carried by nurses and doctors. (Actor Points to physiological monitor) This monitoring platform also integrates with the hospitals wireless WiFi network enabling continuous monitoring at all locations in the hospital, during transit, at Radiology or any testing or treatment location. Critical to the objectives of the National Patient safety goals is alarm management. The ICU uses a distributed alarm notification methodology, where in addition to 6 Intelligent Hospital™ ICU/NICU Script 2015 PLEASE EMAIL [email protected] with any suggested changes annunciation at the central locations alarms and waveforms are delivered directly to the nurse at the point of care [ Hold up mobile device with alarm and waveform] ICU13 Alarm Distribution / Management (ASCOM) Emergency alarms such as physiological monitor VTACH alarms are dispatched to the assigned nurse and the supporting handset to enhance nursing response and optimize workflow. The hand set identifies the alarm type via the top display and the color bar indicates severity at a quick glance. The nurse is able to view the event (look at the wave file from the monitor that generated the alarm. Upon assessing the alarm she is able to accept the event and take care of it. She also has the option to select “Busy”, if unable to take this alarm, to have the alarm dispatched to the backup nurse. On the Unite View (shown on a wall mounted monitor) central dispatch can see what staff members have accepted or escalated the event. ICU14 Data Distribution The Intelligent Hospital utilizes a combined data distribution approach. This includes the delivery of information to a central location (screen shot Draeger) for continuous surveillance, directly to the point of care via hand held devices carried by the staff or to off-site clinicians via web based applications. The delivery of critical alarms or test results to the point of care, to selected team members, eliminates the need for bedside team members or lab tech’s to play phone tag especially when a critical result is being transmitted.

ICU14a: ICU for wearable alarm interface: (Cardiopulmonary) For devices that have no visual or audible alarm capability such as a battery operated wireless wearable patient monitor the system has FDA Class II clearance and provides the primary alarm functionality. This system collects and relays the real time data including alarms, settings, battery status and direct measurements generated by the patient monitor utilizing the hospital's wireless infrastructure (Actor points to the mannequin). The central monitoring station of the system is the primary alarm device displaying and distributing the real time alarms and data to the clinical staff (Actor points to the central monitoring nurse’s station displaying the alarms and real time data). Alarms can also be transmitted to clinicians via any mobile devices available such as smart phones or tablets. (Actor points to the tablet and smart phone displaying data at the nurse’s station).

A complete set of data generated by each patient monitor is archived by the Bernoulli system or forwarded to any EMR system where it can be stored and analyzed.

ICU15 Clinical Data View – EMR (Sunquest) Flow sheets in the patient’s electronic medical record are automatically updated from bedside devices minute by minute. Critical data are trended and correlated with ventilator settings, arterial blood gases, Intake and output data, medication data and vital parameters over time through at the point of care. Correlating data allows physicians to see patterns and abnormalities or areas of concern, while viewing relationships between data. Show EMR w/ Clinical Data Viewer for Mr. Millhouse Clinical Decision Support and knowledge based charting can be used when placing orders to manage conditions noted from the review of data in the ICU, helping to manage best practices for ICU Insulin Protocols, Sepsis Early Warning and Treatment, Pain Management, and Catheter related blood stream infections. [Show EMR w/ display of an ICU Insulin Protocol Order for Mr. Millhouse] ICU25 Find Available Device (Ventilator) (Emanate Wireless Mar 31 Returning to our case, our patient requires mechanical ventilation, the staff must quickly locate an available ventilator. Using the RTLS system the nurse is able to locate the nearest available clean ventilator. (Point to the tag upon starting the script.) The inline power tag mounts directly on the pump in line with the AC power. It contains a rechargeable lifetime battery so once it’s mounted on the asset; you never need to replace it. The solution can assess the true utilization of your devices based on power consumption as measured over time. (Point to the utilization report on the monitor when highlighting reporting power consumption.) This is valuable information as your determine your par requirements and requirements for purchase, leasing or rental budget for the next fiscal period. The tag has a low energy Bluetooth interface to connect with your mobile device. The PowerPath mobile application can help find the device within the last 30 feet. (Point to "finder mode" screen shot when talking about mobile application.) Note that the finder mode lists all the ventilators within range. By selecting the device from the list, the tag

8 Intelligent Hospital™ ICU/NICU Script 2015 PLEASE EMAIL [email protected] with any suggested changes will provide an audible and visual alert to quickly discern which device I’m looking for. (Push button on mobile device to have tag blink and flash)

ICU16 Centrally Monitored Ventilated Patients (Cardiopulmonary) He is placed a ventilator which is connected to the hospitals infrastructure using either hardwire or wireless solutions. In fact, all ventilated patients can be centrally or remotely monitored with alerts delivered directly to the care provider at the point of care via a variety of hand held devices. This application also enables the hospital to dynamically monitor all ventilated patients independent of their location providing a virtual ventilator community and ensuring a standard level of safety across the facility. ICU 16b Analytics (Cardiopulmonary) ** Updated Mar 17 The platform provides a series of comprehensive reporting and analytic tools that function to provide hospital subscribers with reports detailing operation within their health system. This platform summarizes and de-identifies high-fidelity, real- time data from the enterprise wide system where subscribers can generate reports at the click of a button. Subscribers can generate automated reports ranging from alarms trending over time to bed occupancy to average length of patient stay, even including alarm limit reduction analytics, and compare them across their health system. (CPC)

ICU 16a Hemodialysis Systems (BBraun) ** Updated Mar 6 In the event this patient required additional support such as hemodialysis The automated systems provides self test and recirculation or standby mode, simplifying set up time enabling rapid deployments and eliminating the chance for errors. To prepare a patient for dialysis treatment, the Dialog+ is setup with the connection of the concentrate, (actor point to the Solcart cartridge), patient bloodlines connected to the dialyzer and primed, (actor point to the bloodline tubing, dialyzer and saline bag), and confirm system is ready for final testing and initializing hemodialysis treatment. The system provides a wide range of clinical options with the ability to profile every major parameter (UF, conductivity, temperature, heparin, dialysate flow, and its wide range of parameter settings, tailoring the treatment to the patient’s needs. With the Online information, trends and treatment parameters, therapy profiles can be viewed and changed at any time during the treatment to provide enhanced

9 Intelligent Hospital™ ICU/NICU Script 2015 PLEASE EMAIL [email protected] with any suggested changes flexibility and better manage clinical outcomes and treatment anomalies for the patient

As you can see in this acute care setting, patients are typically connected to a variety of devices in addition to physiological monitoring and ventilators; which includes pulse oximetry, intra-aortic balloon pumps, dialysis machines, cardiac output computers, infusion pumps and hemodialysis. ICU17 Connectivity (Cardiopulmonary) It is vital that data from these discrete devices and systems is time synchronized and available to share the information providing an enhanced and comprehensive view of the patient’s condition. However, for devices and data to integrate with other applications like alarm management or the EMR, the medical devices must additionally associated with the correct patient.

To provide this local and remote real time connectivity and surveillance a multiport bridge provides high-speed, high-fidelity data acquisition from all the devices (actor plug devices into MPB so they activate and display on the MPB screen as transmitting) Continuous acquisition of ICU monitored parameters from an array of devices along with additional functionality may include the integration of video, activity or temperature monitoring, using a wireless temperature transducer and/or accelerometer directly to the patient providing continuous patient body surface temperature. This combined real time data is displayed on a web-based clinical surveillance system (actor points to the patient data surveillance monitor in the room), which is also available via a web browser from any remote location ICU23 Alarm Management (Cardiopulmonary) As a result of the ventilator failure the patient becomes immediately agitated. As observed the disconnect triggers a variety of alarms throughout the hospital. Data may be delivered and viewed in any telemedicine location using a wide range of fixed viewers or any mobile communication device. Shown here, by way of a non- limiting example, a clinician disconnects a ventilator, which triggers an alarm that is sent to a VoIP badge to indicate a potentially dangerous risk condition has arisen with a patient. (CPC) (Actor 1 disconnects ventilator tube or triggers an alarm on the ventilator. Vocera badge on Actor 2 activates to indicate an alarm has been sent with applicable message.) (Actor 1 then holds up iPhone and points out the red icon for the ventilator at the bottom of the patient shield.) 10 Intelligent Hospital™ ICU/NICU Script 2015 PLEASE EMAIL [email protected] with any suggested changes

ICU18 Decision Support (Sunquest)

Importantly, the real time collection and integration allows for active patient monitoring and alarm management and for fusion of this data with other EMR data elements to implement algorithms, and for data analytics and clinical decision support within the EMR or thru third-party venders to identify patients at risk for deterioration, and prevent adverse clinical events. Importantly, Clinical Decision Support can be utilized to monitor and track many Quality and Outcomes indicators helping to prevent, identify and reduce the numbers of adverse patient and reportable events. Actor: Show Facility Board, Clinical Summary View, and Clinical Analytics View, viewing multiple alerts ICU19 VOiP Communications (Vocera) Updated Mar 28 The nurse just received a message over her VoIP phone that the intensivist will be coming to the unit to insert a central line in Mr. Millhouse for hemodynamic monitoring. Each staff member of the Intelligent Hospital wears a Hands-Free communication Badge that enables staff-to-staff communications, as well as notifications from critical clinical systems and the hospital’s phone system. (Both Actors hold up the Vocera Badge) ICU20 Supply Management Automated Documentation (DeRoyal) ** Updated Mar 4 Protocol dictates that the central line kit is set up and ready when the physician arrives. A nurse places the kit on a procedure tray, alongside the other supplies required to perform the procedure. The Cloud based Continuum Safe will display applicable patient information from the ADT system on the screen. The nurse will open a supply needed for the patient and then simply toss the wrapper in the Safe. By doing this, the Safe captures usage for charging and verifies the item has not expired. The system also associates any relevant item information such as serial and lot number to the specific patient for documentation and traceability purposes. Because of the teamed approach to care in the ICU the same action may also be performed by other ancillary providers who care for the patient such as respiratory and radiology .The item usage may then be sent to the clinical record and/or financial system. (The nurse picks up a supply,

11 Intelligent Hospital™ ICU/NICU Script 2015 PLEASE EMAIL [email protected] with any suggested changes opens the package, and tosses the wrapper into the Continuum Safe (bin). The nurse will then see the item is now displayed on the screen.

ICU21 Labs Sample Collection (Sunquest, Zebra) Blood samples are also routinely collected for processing in the stat laboratory. Once the Nurse logs into the EMR, they scan the patient’s armband to electronically confirm positive patient identification and view existing orders in real time for that patient using Collection Manager on their handheld device. The Nurse selects the appropriate orders and prints the labels from a mobile printer in the patient’s room. The nurse then attaches the labels to the containers, collects the specimens from the patient and places them in the labeled containers, all at the patient’s bedside to prevent the chance of mislabeling or losing the specimen before leaving the room. The nurse scans the sample and inserts it into the pneumatic tube carrier. The carrier is then inserted into the pneumatic tube system which automatically reads the RFID chip embedded in the carrier and tracks the sample throughout the transport. The entire transaction is tracked within the pneumatic tube station’s software, providing complete chain of custody, which monitors and confirms all sends, receives delays or missing carriers. ICU22 Eliminating Transfusion Errors & Increasing Efficiencies (Sunquest, Zebra) If a patient requires a blood transfusion, the caregiver uses Transfusion Manager on the same handheld device to positively identify the patient by scanning their armband. The caregiver scans the unit of blood to electronically confirm the right blood is going to the right patient. This electronic verification saves time by eliminating the need for a second nurse verifier, and can save money by replacing secondary blood bank wristbands. Once the patient and blood unit are positively matched, the caregiver can proceed with the transfusion. If there is not a match, the system will give a hard stop, preventing a mis-transfusion from occurring. (Actor/Actress uses handheld device to scan patient ID and carries out positive patient identification. Using the same device, a unit of blood is scanned. The match is confirmed, and the patient is given the blood transfusion.)

ICU24 Staff Duress (Stanley, ASCOM) The patient continues to become increasingly agitated. He is tachycardic with a decreased pulse, and the nurse finds it necessary to request assistance in the management of the patient. Since she is busy trying to keep the patient claim and in bed she uses the event buttons on the RTLS tag generate an alert defined as staff duress or assistance required. This is event is globally visible on the RTLS map and can be annunciated in a variety of ways. ICU26 Staff Workflow: (ASCOM) Once the patient is restored on ventilation, the nurse must contact the attending physician directly, through the attending physician button on the workflow console (Actor closest to the nurse call system presses the attending physician button)The physician responds directly to the nurses hand held device, and after evaluating patient orders prescribes additional medications to be delivered.

ICU 26a: ePrescribing HID According to DEA requirements, to write a schedule II-V prescription on-line the physician needs to be identity proofed and bound to a certified credential. Within the EHR module, two factors of authentication must be presented. You need to prove you are who you say you are. The prescriber can do any one of the following supported methods: [Actor#1: Holds up ID Badge, inserts it into desktop reader, types four digit PIN 1234] Insert their ID credential for presentation of their digital certificate, and add PIN. [Slide 2: Screen shot: Identity accepted] OR, the prescriber can initiate a One-Time-Password from the certified credential, types in six numbers. 123456 [Actor#1: Holds up ID Badge, types six digit PIN 123456] [Slide 3: Screen shot: Identity accepted] OR, the prescriber can use a biometric that matches the issuer profile. [Actor#1: Holds places index finger on the sensor] [Slide 4: Screen shot: Identity accepted]

[Slide 5: Prescription successfully sent to the Pharmacy] Again, any ONE of these three authentication methods meets DEA requirements. Two-factor authentication when E-Prescribing for all drugs increases security and improves both the physician and patient’s experience.

ICU27 Mobile Med System-Remote Med Queuing App (Omnicell) ** Updated Mar 4, Mar 20 The Nurse remotely accesses the electronic medical record on the Mobile Medication System. From here, she can review the medications currently ordered for the patient and with a few clicks, can easily queue up medications for the patient. When the nurse logs into the automated dispensing cabinet, she is immediately presented with the option to remove that very same medication that was just queued up. This connected system between the bedside mobile workstation and the medication cabinet increases nurse efficiency and reduces time spent away from the patient. ICU28 Advanced Infusion Pumps Medication Administration (Hospira) The Intelligent Hospital has deployed an advanced infusion system operating wirelessly and with interoperability to the EMR system. CPOE and BCMA provide tremendous value in patient medication safety. But they are not enough. This Infusion pump has onboard safety software, including drug-specific hard and soft dose limits, that can serve as a final line of defense for the patient by guarding against an incorrect dose or type-o during infusion setup.

Our patient's physician has ordered a Dopamine IV infusion with a concentration of 400 mg / 250 mL and a Dose of 5 mcg/kg/min. To ensure the complete 5 Rights administration of this powerful medication the nurse first scans the patient wristband with the clinical vendor's Barcode Medication Administration device to verify his identity, then, using the same device, scans the bar-coded IV medication, and finally scans a permanent barcode on the IV pump. (Where indicated by script, Actor will use the wireless handheld Barcode Medication Administration prop to scan the patient's wristband, scan the barcode of the IV medication bag hanging on the IV pole, and then scan the barcode on the pump.)

These actions associate the patient, the IV medication and the infusion pump, and automatically program the IV pump to the pharmacy verified, physician order. The nurse then verifies the order, as displayed on the pump, and starts the device. (Actor mocks veryifying the onscreen order by tracing it with their finger, the mocks pressing Start button on device – do not actually press)

With IV pump integration, not only is the device automatically programmed, but infusion data is automatically documented to the patient's eMAR and I&O Flow sheet. This combination of Auto-programming and Auto-documentation strengthens the clinician’s ability to enhance patient safety, improve outcomes, and spend more time with patients thanks to a more efficient workflow

(Intouch robot moves to bedside)

ICU29 Remote Consultation (InTouch) As the patient develops new problems, the nurse accesses the remote clinician. The robot is sent to the patient’s bedside, providing support to the ICU nurse for clinical inquiry. The robot remotely examines the patient, actor with stethoscope and sono probe and the remote doctor views bedside monitoring devices and the EMR. The intensivist decides to coordinate the care plan with the pharmacists and pulmonologist. In addition the patient’s family is remotely connected to receive updates and review the new care plan. NICU - PICU [Actor moves to the NICU part of the room] Managing critically ill pediatric or newborns requires a specialized intensive care facilities design focusing on the issues common to critically ill infants, children and teenagers. Premature and newborn babies who need intensive medical attention are often admitted into a special area of the hospital called the Neonatal Intensive Care Unit (NICU). The NICU combines advanced technology and trained health care professionals to provide specialized care for the tiniest patients. NICU1: Security Data Access (Zebra – Zatar) Maintaining security around patient sensitive information is paramount in the Intelligent Hospital and the NICU. NICU staff can access critical patient information on a tablet (Nexus Tablet) based on approved authorization levels. The clinician or physician has a badge that is a combination of NFC and beacons, this badge allows them to gain access to the patient bedside tablet and access approved information. The beacon on the badge allows the tablet to detect when someone walks to the bedside and offer some basic patient information,

the physician or clinician is then prompted to identify themselves which then allows the screen to open up more information based on approved authorization levels. This information includes patient temperature, glucose levels, feeding, fluid levels, any falls, sleep or sedation and what medications had been administered. NICU2 Infant Security- (Stanley) ** Revised Within the Pediatric areas of the hospital infant security is of paramount importance to all hospital operations. Hospital accreditation Standards defines patient abduction or a pediatric discharge to the wrong parent as a sentinel event.

This NICU also offers electronic infant security. The clinician has determined that baby Alice has sufficient body mass and strength to safely wear the small wireless infant tag on her ankle. [Actor points to tag on baby’s ankle] Once attached, the tag automatically enrolls in the infant security system [Actor points to shared monitor screenshot]. Baby Alice is immediately protected in three ways: the tag cannot be removed without authorization, exits will lock if she is brought near, and the system continually monitors signals from Alice’s tag so that she can be located not only in the NICU but anywhere in the hospital covered by Wi-Fi.

Alice’s mother is also wearing a wireless wrist tag [Actor points to tag on mother’s wrist] to help staff ensure that Alice is always properly matched with her mother when she visits the NICU. The two tags bonded together when Alice’s tag was attached. Now, whenever Alice’s mom comes to visit, Alice’s infant tag automatically checks for a correct match and emits an audible alert tone [Actor points to shared monitor screenshot] should a mismatch occur. This is an important defense against mothers inadvertently nursing someone else’s child. NICU3 Incubator (Drager) These infants or preterm births are housed in an environmentally controlled incubator. These systems Oxygenation, through oxygen supplementation by head hood or nasal cannula, or even continuous positive airway pressure (CPAP) or mechanical ventilation. Patient observation of modern neonatal intensive care involves sophisticated measurement of temperature, respiration, cardiac function, oxygenation, and brain activity, and includes protection from cold temperature, infection, noise, drafts and excess handling: The incubator provides provisions for nutrition via an intravenous catheter or NG tube, administration of medications and

16 Intelligent Hospital™ ICU/NICU Script 2015 PLEASE EMAIL [email protected] with any suggested changes maintaining fluid balance by providing fluid and keeping a high air humidity to prevent too great a loss from skin and respiratory evaporation. NICU3a: Kanban inventory management with real time intelligence (Cardinal) The Nurse caring for the neonate needs some supplies for the management of the neonate. She walks over to the general supply area and grabs four general supplies needed, from the 2-Bin Kanban solution. The 2 bin Kanban solution allows for usage tracking of low dollar items at bin level instead of item level which eliminates the need for par optimizations and cycle counting. The 2-bins ensure that there is no stock-outs based on suggested par levels from historical usage data. It also triggers a replenishment signal to the materials management system to re-order needed products as bins are scanned empty. While the order is being replenished the second bin allows for product availability (no stock-outs) keeping both the clinicians and materials managers satisfied – and supporting effective First in First Out (FIFO) management of materials.

(Actor goes to general supply and grabs 4 supplies. She also pulls out an empty bin and places on top shelf marked “Place empty bins here”)

The solution also allows for charge capture of billable items. The patient list information is pre-populated from the ADT system to associate accurate charge capture with the correct patients. (Actor walks to screen near 2 bin system and interacts with touch screen, selects patient and scans barcode/or hits +/- on the touch screen for the item). Initially, the system can be pre-configured to only show billable items on the screen. The system is smart enough, to self-learn from historical utilization data topre-populate those chargeable items most often used within each area. As a result, the screen configures itself accordingly, helping capture billable items as well as leveraging Integrated Advanced Analytics to provide powerful reports impacting the bottom NICU4 Medication Administration: Patients in the NICU are very susceptible to medication issues. In premature infants, the immaturity of developing body systems affects the absorption, distribution, metabolism, and excretion of drugs and therefore an exponential risk for medication errors is present Medications are universally weight-based,

17 Intelligent Hospital™ ICU/NICU Script 2015 PLEASE EMAIL [email protected] with any suggested changes requiring calculations for each dose. NICU patients often have long hospital stays, which increases their exposure to medications and medication errors. NICU 5a: TPN bedside electronic Order Entry (BBraun) Updated mar 20, Repositioned Mar 25 In pediatric cases [Pharmacist 1 : physician holding an iPad or tablet provided by bbraun shows how to pull up prior parenteral nutrition orders through screen shots of TPN Manager.] In this case the doctor is seeing a pediatric patient Sarah admitted 2 days ago with short bowel syndrome and sepsis stemming from her catheter site. She is being treated with IV antibiotics and total parenteral nutrition, also known as “TPN”. While reviewing the labs, the doctor sees that with the exception of low serum calcium, all of her electrolytes are within normal limits, but her height and weight put her below the growth curve for her age. Her small stature concerns him about whether she is receiving adequate nutrition, and her low serum calcium could result in poor bone development. Using a tablet computer, the doctor reviews previous TPN orders for this patient. [slide 1] The doctor updates Sarah’s weight to 24 kilograms and acknowledges that he has reviewed it and yesterday’s order [slide 2] for TPN on this tablet computer using a special "app" designed specifically for ordering and managing TPNs. [slide 3] Once he knows what he wants to modify, he makes changes to yesterday’s order right at the bedside. [slide 4 - WITH RED CIRCLE APPEARING AROUND 1.5 (TROPHAMINE) AND 6.25 (DEXTROSE)] [Brief pause, 2 seconds] Because he chose an amount of calcium that is too high, a calcium‐phosphate curve... [Slide 5: RED CIRCLE ON 2.00 (CALCIUM GLUCONATE 10%), HIGHLIGHT CHART ON SCREEN SHOT 5] ..displays showing that the calcium will precipitate if this amount is allowed to be given. He uses a special tool within the system that guides him to a recommended amount of calcium & phosphate that will not cause precipitation and adjusts his order accordingly.

[Pharmacist 1 : still holding the iPad illustrates the calcium-phosphate curve that the software generated.) [Slide 6: WITH RED CIRCLE APPEARING AROUND 1.00 (CALCIUM GLUCONATE 10%] [Brief pause, 2 seconds] Within a short time, he has entered a new TPN order customized to meet Sarah’s current nutritional needs. The clinical decision support incorporated into the software flags [Slide 7] him with warnings about being below the per liter limit of lipid and exceeding the warning levels of phosphate and aluminum. He acknowledges the warnings and submits the order. [Slide 7?: receipt of the order shown through screen shots of TPN Manager] This order will now be transmitted electronically back to the central pharmacy we saw earlier in our tour. [slide 8] The order will be reviewed by that central pharmacist for… [Slide 9] …appropriateness and accuracy, and then be [slide 10] authorized for compounding to begin without any need for order transcription or reentry by the pharmacist. [slide 11] Also important here is the fact that the precipitation error was averted during the ordering phase of the medication use process, the best phase to catch an error! Had this not been caught at the ordering stage, it would have been transmitted to the pharmacy. If it were lucky enough to be caught by the pharmacist, it would have resulted in a delay of care while the physician is paged or called for an order clarification, a timely and inefficient process. NICU6 Medication Dispensing System: (Carefusion) The nurse taking care of baby Alice has determined it is time for her medication. This medication happens to be stored conveniently in this automated dispensing cabinet system which provides an efficient, patient-focused workflow allowing a nurse to easily see their patients and their medication due times. The workflow gives each nurse the ability to easily remove the right medications for their patients quickly and accurately.

[Screen shot: (1) Shows close-up of nurse touching My Patients, (2) selecting the

19 Intelligent Hospital™ ICU/NICU Script 2015 PLEASE EMAIL [email protected] with any suggested changes patient from their My Patients list, (3) and accessing patient order information, including DOPamine.] The system also includes a label printer that enforces the printing of a barcoded label for any medication, as configured by pharmacy.

[Actor: Point to printer]

Thanks to the capacity of the highly configurable pockets, larger IV bags, syringes and other bulky medications can be securely stored here.

[Screen shot: (4) Shows image of drawer open and CUBIE pocket with syringes.]

In this case, the nurse is removing a syringe of medication which needs to be labeled specifically for baby Alice.

[Screen shot: (5) Shows image of label, (6) and labeled syringe.] [Actor: Go to label printer, pick up label, pretend to put it on syringe, show syringe already labeled.]

The medication – centrally stored and readily available for nursing use – is now appropriately labeled for baby Alice’s specific order, ensuring medication safety and accuracy.

[Transition to Actor who is standing next to an Alaris pump, begins to simulate Alaris programming]

NICU8: Final Available Pump (CareFusion / Stanley) The nurse is ready to start an infusion, but the clean equipment room is empty. Because our Intelligent Hospital has deployed a wireless system allowing the RFID tags on the pump to communicate to a tracking system, the nurse can use “Find near me” features on mobile devices to find the nearest available pump to their specific location. (Stanley Healthcare) [Actor nurse picks up the iPhone and executes a search (iPhone 6Plus so the screen can be seen by the audience).] [Screen Shot: iPhone - search]

There are no locally available pumps so the nurse submits a request through the

Asset Management system. This sends a request to Central Supply and simultaneously to the technician, generating equipment orders for delivery of the asset to the patient room. [Actor central supply goes across the room and brings the pump to the bedside] [Screen Shot: iPhone – request for pump]

(Alaris) With integration between RTLS and the infusion system, biomed has optimized the distribution of infusion devices. This is enabled by having visibility into the status of every infusion device – whether it is currently infusing and how frequently it has been used. This information then enables the hospital to allocate the optimal number of infusion modules, like pumps, syringes and PCA modules to the care areas with the highest historical usage. [Screen Shot: iPhone – request for pump]

NICU9: Asset Management Visibility and Analytics: Increase Operational Efficiency, Patient Safety and Lower Costs (Carefusion / Stanley) * Updated Mar 20 As you just heard, the integration of RTLS and infusion systems improves operational efficiency, staff communication and patient safety with immediate decision making—like locating the nearest available pump. This integration also allows business status to be accurately tracked— you not only know where your equipment is, but whether it is in use, clean, soiled, needs maintenance or part of a recall. Now you can take it a step further by transforming the real-time data collected in the systems into visual analytics dashboards to make better decisions, identify process improvement opportunities, and apply predictive analytics to optimize performance. Whether you employ on-demand or par-level delivery, streamlining equipment utilization is key to operational efficiency… and in the NICU, it’s crucial to stage for high-acuity patients with the right numbers of functional, life-saving equipment. This dynamic analytics dashboard [Actor points out wall monitor and then taps iPad to drill in to dashboard – changes on large monitor] gives managers rapid visibility into every step of your equipment process in real-time, assuring the NICU has the necessary equipment they need. This data allows you to identify, analyze, diagnose, and address process challenges. Efficient utilization of your high-demand devices is paramount to keeping your equipment costs down, while still saving lives and providing outstanding quality of care. NICU5 Infusion Systems: (Carefusion) * Updated Mar 20 Syringe pumps are most commonly used in NICU. These environments often require the precise delivery of very concentrated drugs or antibiotics.

The nurse receiving intravenous medication will now get it ready for administration using a smart pump like this. What makes this pump smart is that it has an electronic brain that contains a library of drugs with individual maximum & minimum dosing limits and safety parameters. These limits help prevent programming errors which can lead to over and under dosing of the medication. [Nurse Actor scans the barcode on the patient wristband, drug label, and syringe module] [Screen Shots: workflow: scanning of wristband, scanning of drug label, scanning of syringe module]

The Intelligent Hospital has deployed a wireless system enabling the pumps to communicate with the hospitals electronic medical record. As soon as the nurse scans the barcodes on: the patient ID band, medication, and on the syringe pump an association is established which pre-populates the order for this drug on the pump with the exact dose and rate that the physician ordered. The nurse simply verifies the order, eliminating the need for manual programming, decreasing an opportunity for error. This is especially important in the NICU where the sickest and most vulnerable patients are. [Nurse Actor loads the syringe, verifies the parameters, presses NEXT, finishes verification and presses START.] [Screen Shots: verification of parameters on pump, pressing NEXT / START]

The association between the smart pump and EMR system is bi-directional, which allows all of the infusion status information to flow back to the EMR. Every titration, pause, start and stop is recorded in near real-time. This provides a single reliable record to increase accuracy and timeliness of infusion documentation. The nurse simply verifies the data being sent by the pump, and if appropriate, completes the documentation by accepting it. [Nurse Actor stands at the workstation on wheels as if typing in documentation. Monitor shows a close up of the pump screen with I&O flow sheet receiving documentation messages.] [Screen Shots: EMR documentation, data feed going into EMR.]

This concludes the demonstration within the ICU / NICU, which highlighted how the integration of different technologies and applications to enhance patient care and safety, optimize staff workflow, meet Joint Commission and statewide mandates and

22 Intelligent Hospital™ ICU/NICU Script 2015 PLEASE EMAIL [email protected] with any suggested changes assist the inventory and supply management. Please visit the other rooms in the Intelligent Hospital™ to find out how the other patients fair. Thank you.