Toronto East General Hospital (TEGH) is a large, full-service, community teaching hospital, situated in the east end of the city in Toronto, Canada.  Its population ranges in age and ethnicity, making it a unique and challenging facility with a mixture of patients, families and public to provide care and information for.  Last year, the hospital treated over 60,000 patients in its emergency department; one-third of whom were admitted into inpatient care.  As a public place, TEGH does not refuse a patient and is accessible to anyone in our service area of almost half a million people.

Workplace violence is a concern in any environment, but for health care workers, whose surroundings are ever changing, it's an issue that is often unpredictable and unavoidable.    It's necessary for hospital workers to have instant reaction and communication in order to be protected from violence.  This is why TEGH adopted a zero tolerance policy towards violence.  With nearly 3,000 staff, physicians and volunteers, the hospital has developed many creative approaches to dealing with violence prevention; most notably the Patient Care and Workplace Safety Project and its introduction of a technological device, known as Vocera.

Vocera is a breakthrough wireless platform that provides hands-free, voice communication for team members to communicate instantly and effortlessly throughout the entire facility.  Through voice commands, users in every department, regardless of job title can communicate with each other either one-on-one or as a group.  Group messaging ensures that everyone on a unit receives the same message and can be alerted of any threats.  This also decreases miscommunication and error.

The goals of the year-long safety project were to address and enhance the safety of patients, staff, physicians and volunteers throughout the building by providing effective communication tools.  Foremost, Vocera is a personal alarm system, but its multi-feature capabilities make it useable in every day situations, which has resulted in a high degree of compliance by users.  The technology was incorporated for staff to have an alternate method to reaching a phone.  The instant contact with security reduces the previous lag time in communication, which included an external call centre.  Additional goals were to enhance patient satisfaction and staff productivity by improving communication.   

The hospital's wired and wireless infrastructure was upgraded to enable connectivity on every floor and department, including the basement, stairwells and elevators  quite an achievement.  There are currently 1,125 badges and over 2,700 users who have been trained on the capabilities of the device.  When employees arrive at the hospital, they pick their badge from the docking station and login by saying their name.  Vocera is now as much a part of the daily routine to staff as logging into a computer. 

Vocera is part of a larger workplace violence prevention strategy that uses these operational tools as security devices.  By signalling the 'panic' button, a message is sent to all security personnel on-site, who are able to communicate, locate and instantly arrive at a scene.  Constant communication helps prepare the officers as they enter a department by letting them know what the situation is and how it's developing well before they walk into it.

Vocera has surpassed TEGH's expectations in numerous ways; most notably Vocera has decreased security personnel's turn around time to both urgent and non-urgent situations by 61 per cent.  The demand by staff' physicians and volunteers to get connected also encouraged the team to deploy badges as quickly as possible.

When employees are working in a safe environment, they feel cared for and protected.  This enables them to provide better care for patients, thus improving satisfaction which enhances overall patient flow and quality of care. 

The device, system and wireless infrastructure are all elements of modern day technology, which enabled the project to be conceptualized and implemented.  A Vocera badge contributes to instant communication among users and groups; providing constant connection between anyone on the campus.  This contact, whether it's between nurse and patient, surgeon and administration or volunteer and security personnel, has resulted in a multitude of tasks made easier for everyone within the hospital.  

Furthermore, the badge provides personal security to staff, physicians and volunteers; many of whom feel secure in their work environment, but are conscious that they are in a public facility whose hallways and departments are easily accessible to anyone who wanders in.  These individuals include spouses learning about the death of their wife and lash out at staff; mental health patients who use furniture as objects of destruction; and intoxicated groups arriving in the emergency department after a heated sporting event.  These environments, although normally safe, can be hazardous to employees and other patients.  Toronto East General Hospital's responsibility is to minimize the harm to one's self and others.  Vocera badges are lifelines and have resulted in security personnel arriving faster and better prepared. 

Vocera badges at TEGH would not be possible without the creation of a 'wireless world' throughout the one million square foot hospital.  This phase of the project began in early 2008 with a wireless site survey and took three months to complete.  TEGH utilized a team to perform the survey in order to install an updated wireless and wired infrastructure.  There are just under 300 access points in the hospital that aid 50,000 calls a month; a large percentage of those calls are basic communication among colleagues rather than security distress calls.

Wireless capabilities enable reliable communication that is immediate, clear and easy to use.  The programming allows voices with various tones and accents to be understood so that the device performs up-to and beyond users' expectations.  These aspects of the device have made it possible for everyone in the organization, regardless of age, sex and ethnicity to be trained on the technology and adapt it to their everyday work-life.  

For Toronto East General Hospital, Vocera has improved safety, quality and productivity.  The three-tier approach has increased satisfaction for both staff and patients and has improved productivity; reducing costs.  The wireless technology allows users to utilize Vocera anywhere on campus.  Whether it's the emergency department contacting a surgeon in the OR to inform them of a patients' arrival or volunteers asking their coordinator which room they are meeting in; Vocera gets the message out quickly and easily.  By having every department connected, users are more efficient, which has reduced wait times and discharge times.  The speed of workflow is reducing error, stress and resulting in more patients being treated faster.

Having the technology hospital-wide has leveraged other opportunities, such as the nurse call-bell integration, porter transport tracking and will foster future IT programs.  The nurse call-bell integration with Vocera enables patients to have constant contact to their care provider, while teletracking improves efficiency of portering throughout the campus.

Yes

Yes

The project changes the way Toronto East General Hospital can provide health care.  It gives staff, physicians and volunteers access to immediate information.  Its unique functions connect users to one another from anywhere within the building; without being inconvenient or a distraction.  The entire community at TEGH feels better connected and informed as well as a part of the team.  Groups who have never had readily available access to computers or phones are now given the same technology as everyone else.

Most importantly Vocera provides the personal safety net for staff, especially those working in higher risk departments and/or at night when staff, patient and public traffic is a lot lighter.  These employees feel confident that if anything were to go wrong, they would have security listening to them instantly and have them by their side in under a minute.  

Cedric,
Nurse Practitioner, Complex Continuing Care.
There are a lot of benefits to using Vocera.  I now have easy access to anyone and if I need assistance, I don't even need to leave a room.  My safety and that of my patients has improved.  As well, the call-bell makes patients feel really good about their care.  For example, one of my patients called for me, but I was with another patient.  Before, they would have waited until I was finished to hear from me, but now I can talk to them through my Vocera to let them know that I will be there right away.

Dr. Carmine Simone,
Thoracic Surgeon, Director of Intensive Care Unit.
Vocera is excellent.  It's hands free communication, which means I can keep it under my gown during surgery and still be reached.  

This morning I was in the OR and I had a call to my Vocera telling me that a 20-year-old patient had arrived and had swallowed an object.  I told them I would be down soon to monitor her.  They called back to tell me she was complaining of stomach pain and was vomiting blood, at which point I told them to get her an intravenous and a CAT scan and to get her into emergency.  I continued my surgery.  An hour later, a call came again to say she wasnt looking good.  I told them to get antibiotics for her and get her ready for the OR.  She was there in a stretcher waiting for me when I walked out of surgery.  Without Vocera, things wouldn't have happened until I was finished.  And that's just today  I have a million situations like this.  You can essentially be in two places at once.  It gets things rolling much quicker.

Another example is when I received a call on my Vocera asking me to come to the ICU.  My patient didn't have much longer and her husband was very upset and not taking it well.  He began throwing chairs and we werent able to control him.  I tapped the panic button on my badge twice and literally within seconds, security were telling me they were on their way and seconds later they showed up.  They were right there to diffuse the situation and no one was hurt.  From a security perspective  this thing is brilliant.

Phil Simoes,
Security Agent, Protection Services Department.
A recent security call to our badges connected us to a staff member in the mental health unit.  We asked them if they needed assistance, but there was no response.  All we could hear was screaming.  Every security agent in the building could hear the commotion and knew it was a serious situation.  We rushed to the department and found a patient lashing out in their room.  Fortunately we had enough agents to restrain the individual.  In this case, the user was unable to speak, yet we were still able to get to them quickly since we could locate their position.  The line was also kept open the entire time until the situation was over.

Toronto East General Hospital is the first hospital in the world to deploy a personal communication device, hospital-wide for all staff, physicians and volunteers.  Having the device function throughout every corridor, hallway or elevator is unique and aligns with the organization's goal of having constant communication for users no matter where they are in the building.  

Having a security perspective at the forefront of the project was the original concept for the technology.  The panic button feature is unique in the way TEGH uses it, since it instantly alerts all security personnel.  Never before have health care workers had such accessible means to every security agent on-site.  As soon as a user activates the security feature, a line of communication is opened between them and every staff member in the protection services department.  Not only can the agents talk to the user, they can also locate their device within the building.

Vocera has led to a significant reduction in both urgent and non-urgent response times.  For example, code white response times have been reduced by over 61 per cent; down from 2.5 minutes to 59 seconds.  Non-urgent response times have been reduced by 95 per cent.  This has also led to a decrease in overhead paging and a reduction in cost for pagers.

What is also innovative is that TEGH has a record of all distress calls, such as the time, date, user and details about how long the line of communication was open.  Vocera's reporting capabilities provide a more accurate recording of violent statistics, which gives security the ability to flag violent persons and track their incident history within the organization.  As well, TEGH can identify areas within the facility whose needs are changing or require risk assessment.  

The multipurpose device has opened up several other areas for Toronto East General Hospital to improve quality, safety and efficiency.  The most notable achievement is the integration of the nurse call-bell system, which has already been deployed in several departments and will continue to be rolled-out in the upcoming months.  When a patient activates their call-bell, their care providers are notified through the Vocera badge, allowing patients to communicate from their bedside.  Nursing staff are able to multitask and patients feel that their needs are taken into consideration at a rapid speed.  

Another very notable aspect is Vocera's ability to offer staff a sense of security throughout every square foot of the building.  Many staff do not have an office or easy access to a phone, but now have the ability to contact their colleagues and managers instantly.  Vocera allows every employee to be connected, which no other technology has been able to provide until now.

Everyone, from the executive team to housekeeping to the coordinated care team, are connected to Vocera.  Carrying the device is not a matter of seniority, position or status; it's about creating a culture that is open, connected and working collaboratively as an organization to improve health care.  This new way of working has opened new relationships and comfort between all employees, making Toronto East General Hospital an even better place to give and receive care.

In a world of blackberrys and pagers, the innovative thinking of management to not only bring in another form of communication, but to successfully launch it hospital-wide is not something many people would have taken a chance on.  Yet, from the beginning, TEGH was committed to ensuring all staff, physicians and volunteers would be connected and protected.  Along the year-long road, there were challenges, but none that the team couldnt overcome.

In the initial pilot deployment, when the project was in its infancy and most fragile state, there were technical problems with the badges.  These defects, which took a month to resolve, made the team question whether or not they should pull back and delay the project entirely.  The frustration amounted to an issue with system integration as the new model of badges were bouncing in and out of the wireless signal.  The team understood that any new technology has risks, but did not comprehend the amount of time, energy and intelligence it would take to resolve the issue. Looking back, the team recognizes had they not been so committed, Vocera may have failed early on.  The persistence of the group is what ultimately kept a positive focus on the project.  The badges were redesigned and the project moved forward, but the delay sent the project onward with tighter deadlines and increasing pressure.

Soon after the wireless network was engaged, the Vocera team had to deploy badges.  This daunting task of delivering training to nearly 3,000 staff members became the next obstacle.  In a hospital it's difficult to determine common times for training since employees work around the clock; including evenings, overnight and weekends.  This is why the hospital was committed to holding training sessions for all staff, when it was convenient for them.  The training staff, too, had to work on a 24-hour schedule.  During the sessions, the technology was introduced and tested; demonstrating all of its capabilities.  

To ensure questions could be answered outside of training, the hospital identified Superusers who are experts on the technology.  These individuals are on shift work around the clock to immediately walk-though issues and concerns users have about Vocera.  TEGH used the Superuser model previously for the successful transition of new technology.

With careful organization and planning, initial nursing units had to be tested.  Since every department is unique, it took time and analysis to determine how Vocera could integrate into a specific areas workflow so that the technology adapted to how employees were already working.  For example, units that included the nurse call-bells on their Vocera would be programmed very differently than badges in Human Resources.

Lastly, since this was the first of its kind, the hospital developed the TEGH way of implementing the technology.  There was not a single reference point to call upon or a book to answer all of the organization's questions.  No one had developed a system of this size and functional capabilities.  This resulted in many trial and error scenarios, but through the challenges, TEGH could foresee the possibilities and knew the great accomplishments and benefits that lay ahead.

Change of any kind is complex in large organizations; especially ones that are as diverse as health care.  Great resistance often spurs from great change and in this case, it was no different.  The technology was originally intended to be introduced in 16 months; an incredible speed for a new initiative to get off the ground.  When Vocera badges were first introduced, the team knew that the culture of the hospital was about to change for the better, but initially not everyone saw it that way.  

The training team had to overcome fears that 'big brother was watching' and new users were apprehensive to learn that the device had tracking capabilities.  Concerns over whether or not managers would know where their staff were at all times and who was logged in or out, made the team be forthcoming and transparent with all parties involved.  During training they emphasized that locating capabilities could only be accessible to security personnel and would only be activated during distress calls.  The Vocera team worked with the Unions and the Violence in the Workplace Committee; an internal group that creates policies and discussion on violence prevention initiatives, to explain the new technology and address concerns or resistance.

Today, finishing almost four months ahead of schedule, Vocera has integrated itself into the TEGH culture.  Throughout the project, staff recognized the benefits of Vocera and were eager to get trained and have their own badges.  Vocera badges are now as common as identification badges and are engrained into the way of life at the hospital.  

Exceeded

The success of the Patient Care and Workplace Safety Project will continue to grow further with each passing month.  As users become more and more comfortable with the technology, we expect to see a rise in calls, therefore leading to a further reduction in wait times, better patient flow, work efficiency, and most importantly safety response times.  

Having an updated wireless infrastructure has put other technology projects at the forefront, as they are that much more attainable since almost half of the work has already been completed.  The nurse call-bell systems have already begun deployment and will continue to spread throughout all departments until every patient is connected to their care provider from their bedside table.  This step has already improved access to patients, generated better response times by staff and is increasing patient and family satisfaction.

Other areas of the hospital that have been successfully affected by this technology are the portering services with the integration of teletracking.  Teletracking is an electronic portering dispatch service, which has reduced portering response times from 45 minutes (from the time the call was placed to the porter arriving on the unit) to 19 minutes.  This decrease is reducing staff frustration and again improving efficiency and patient flow.  Patients arriving in our busy emergency department are being transferred to areas of care and inpatient beds much faster; reducing wait times.

Projects that have been placed on hold are now moving forward thanks to the work that has already been completed by Vocera.  One example of this is bedside computing, where physicians and nurses can access a patient's health record electronically from the patients hospital room.  This project would not have moved forward as quickly as it has without the hospitals new wireless capabilities.  

Thanks to recent media attention, the word has spread that TEGH has developed a revolutionary technology for both staff and patients.  The coverage has intrigued the health care community and sparked curiosity by several other hospitals in the Greater Toronto Area.  Our team has held several tours and meetings with these groups to explain our experience with this technology and offer our advice and suggestions for their own implementation.  As a reference point for these organizations, we're able to assist them overcome obstacles and mistakes weve encountered, while encouraging them on the vast benefits of Vocera.

Here are some of the articles that have been written about this initiative at Toronto East General Hospital:

The Toronto Star:
http://www.thestar.com/News/GTA/article/588489

Hospital News:
http://www.hospitalnews.com/modules/magazines/mag.asp?ID=3&IID=115&AID=1477

The benefits of using Vocera were recognized very early by staff and management.  Departments were anxious to receive Vocera and the user feedback has been overwhelmingly positive.  As TEGH nears the end of the targeted implementation date of March 31, 2009, we expect some of the hospital's best practices to include the use of Vocera and the nurse-call bell integration.

This technology has created a new culture at the hospital, one that connects everyone, and a new vocabulary has developed, with phrases like, Ill Vocera You is now commonly heard around TEGH.  The general understanding that its now simple and reliable to get a hold of anyone, makes providing health care easier.

The device has and will continue to provide enhanced communication for all staff members, resulting in a more efficient work environment.  This in turn assists in positively impacting patient wait times and flow.