14:49 PM

Carilion's patient transport command center is reducing inefficiency and stress

A woman arrives at a small medical clinic in rural southwestern Virginia, unresponsive and unable to speak. A blood clot smaller than a pea, lodged in her middle cerebral artery, has severely restricted the flow of oxygen-rich blood to her brain. Two realities loom large: First, every delay in getting her to the proper treatment increases the likelihood that she’ll lose vital functions, such as the ability to speak or to move an entire side of her body. Second, her best hope for full recovery lies at Carilion Roanoke Memorial Hospital, more than 60 mountainous miles away. Still, the patient has a fighting chance. The physician picks up the phone and calls Carilion Clinic’s Transfer and Communications Center, or CTaC. For the past eight years the CTaC has been the go-to command center for Roanoke Memorial as well as six other hospitals and multiple clinics across 20 counties in southwestern Virginia and southern West Virginia.

A Center that Never Sleeps

With more than 40 full-time employees, the CTaC operates 24 hours a day. At peak times, more than 20 workers—including registered nurses and emergency medical technicians trained in critical care—sit before expansive flat screens generating a constant flow of data on everything from the location of helicopters and ambulances and the traffic levels in units throughout the Carilion system down to which patients are likeliest to be discharged soon. Serving as Carilion’s eyes and ears, it’s their job to ensure that patients enter and leave the system as smoothly as possible. And it’s their job to be there when physicians in remote locations call needing urgent care for patients on the brink of death. The nurse who fields the call about the woman with the clot in her brain becomes a sort of symphony conductor responsible for ensuring that professionals throughout the system, performing many different functions, operate as a unified team. “In certain situations, such as an aneurysm, ischemic stroke, trauma, or heart attack, a few minutes can save lives,” says Paul Haskins, M.D., emergency medical physician at Carilion and CTaC’s medical director. “You have to have the ability to arrange transport, have a place immediately ready to evaluate the patient, and intervene on their behalf.” The nurse’s first step is to alert the transport team and ensure that a helicopter is available and ready to go. As the only Level I trauma center in a 150-mile radius, Carilion operates a fleet of three rescue helicopters. In this case, the helicopter will replace a journey over winding country highways with a speedy flight lasting a few minutes. As the emergency crew prepares to take off, the R.N. turns her attention to ensuring the hospital is ready. In a traditional system, the first step might be to deliver the patient to the emergency room for evaluation—but that could cost precious time. Instead, she alerts Carilion’s specialized Stroke Center. Physicians from the Stroke Center’s neurointerventional team speak directly with the clinic doctor to discuss the patient’s condition. Meanwhile, the CTaC medic stays in touch with the helicopter crew about the weather conditions and estimated time of arrival. “That way, the physicians know what timeframe they’re dealing with,” says Melanie Morris, R.N., senior director of CTaC. The specialists will be waiting for the patient the moment the helicopter lands.

A Bed for Every Head

Behind the scenes, those precise operations are the result of years of training, new procedures, constant adjustments, and rethinking. The CTaC, located in Carilion’s Parkview campus, resembles nothing so much as “an air traffic control center for the hospital,” says Morris. Advanced tracking software plays a major part in the operations. The software helps Carilion manage the three helicopters, 44 ambulances and, crucially, 1,026 beds. While less dramatic than responding to a life-threatening emergency, bed management is every bit as vital to the quality of patient care. Like airplane seats, beds are at a special premium during busy times. Carilion’s bed occupancy, which hovers above 90 percent year-round, spikes during flu season and other periods. Leaving empty beds unfilled, or overbooking beds in a crowded unit, can lead to problems similar to those of a packed airport terminal at Thanksgiving, yet with the added pressure that the occupants of those beds are dealing with serious medical issues. In the CTaC control room, workers keep constant watch on the “bed board.” “We have a real-time view, refreshed every 30 to 60 seconds,” says Morris. “We have eyes on every bed in all of our hospitals on all campuses.” When a doctor writes a discharge order or transfers a patient, the system receives an alert that a bed will be opening soon. As soon as the bed is empty, the software system instructs the environmental services team to start cleaning. Back at the control center, Morris adds, “We can see what phase of cleaning the bed is in, and how close it is to getting ready.” The moment the bed is cleaned, another alert gives the CTaC the green light to send the next patient to it.

Emphasizing Human Cooperation

As impressive and useful as the technology is, the center could not function as it does without the close coordination of the humans who staff it. Indeed, the innovations around human behavior have as much or more to do with what makes the CTaC tick. One of the key concepts is called “distributed situation awareness”—an idea that has become increasingly prevalent among “high-reliability organizations” such as NASA, maritime navigation units, air traffic control centers, and other operations requiring pinpoint movement and precision timing. The idea, essentially, is that specialists can’t mind just their individual areas of expertise. For maximum efficiency and, in the case of a busy hospital, patient safety, they must remain fully aware of what’s going on in all areas, and be ready and able to communicate and coordinate with others. “Today’s health system is too complex to train humans on all the interactions they need to have,” says Paul Davenport, R.N., M.B.A., Carilion’s vice president of emergency services and care management. Thus workers must be encouraged to move beyond rigid checklists and procedures and develop the ability to understand and react in real time to the needs of those around them. “The more you can integrate teams using technology and dashboards,” Davenport adds, “the less you have to train a worker to notify someone else when something is happening.”

Breaking Logjams

Before CTaC, Carilion, like most busy health systems, struggled to adapt to ever higher caseloads. Despite their individual professionalism and desire to help patients, workers often created barriers and stress for one another. Some patients were staying longer than they needed to, or were admitted for conditions that might have been treated on an outpatient basis. And because patients might enter the system through multiple portals, potential logjams were often not detected until they had already occurred. That meant added wait times for patients and their families, and stress for busy physicians spending too much time dealing with logistics rather than patient care. “Our goal is to keep physicians off the phone and at the bedside as much as possible,” Dr. Haskins says. “If someone’s asking for a cardiologist when what’s needed is a cardiothoracic surgeon, that’s a delay. Yet if you can eliminate those roadblocks, you’ll have the right physician accepting a phone call from the transferring physician. They’ll know they have all the services they need available to them, and they can just acceptthe patient.” While the principles of distributed situation awareness apply throughout the hospital system, the nerve center and primary driver is the CTaC. One of the most important steps in achieving that level of awareness was to move the transfer staff and the communications staff (responsible for transporting patients), once located in different areas, into the same large room. “When we began to align these people and their functionality and teamwork, we began to have a more harmonious working environment,” Davenport says. “Yes, we can accept your patient, we do have capacity, we do have a helicopter in route to you now. We know the ETA back to the hospital and what treatments we should start. Within one phone call, we can answer all those questions and help those who are trying to send new patients or transfer patients throughout the system.”

A Beacon of Success

The results have been remarkable. Within eight years, the center has eliminated 30 minutes of wasted time for each patient—or an astounding 720,000 hours per year. A vastly improved alert system for the Emergency Department has cut the time it takes to put patients in rooms by half, Dr. Haskins notes. And the CTaC has contributed to a .3-day reduction in the time patients spend in intensive care. Such successes have caught the notice of the wider medical community in the United States and globally. Some 60 health systems from as far away as the United Kingdom and Singapore have made the trek to Roanoke in recent years. In early 2019, after sending a team to Roanoke, Ohio’s Kettering Health Network opened a $10 million, 17,000-square foot command center using many of the same procedures and advanced tracking software to move patients around its system more efficiently.

Buy-In from the Top

According to Davenport, one of the questions visitors most frequently ask is, “How do you get administrative buy-in for this?” In Carilion’s case, the thinking behind CTaC came from the top. More than a decade ago, Nancy Howell Agee, now president and chief executive officer of Carilion, formed a task force to investigate ways to better coordinate Carilion operations. The CTaC is a natural extension of Carilion’s commitment to constant improvement, informed by open and continuous communication across various medical disciplines and between clinicians and administrators. That’s the idea behind Carilion’s “dyad leadership” model, which pairs clinicians and administrators. “As long as you can keep open lines of communication between the providers who are seeing the patients and the administrators who are overseeing the hospital system, then we all have an idea of our goals,” Dr. Haskins says. “It’s important that we’re all moving in the same direction.”

Looking to the Future

While perfection is a goal, the CTaC remains a constant work in progress, Dr. Haskins says. And that’s not likely to change. Because health care is evolving so rapidly, solutions to today’s challenges may become outdated with breathtaking speed. And success breeds its own new complications. Thanks to CTaC’s efficiencies, Carilion in recent years has been able to accommodate a thousand additional patients each year in the same number of beds. Yet continued growth in patient volume will inevitably require ever-evolving solutions. Indeed, the focus is not just on finding better ways to bring more patients to Roanoke Memorial, but also on directing patients, where possible, to other hospitals and clinics within the system. Among the latest developments is a remote telemetry center, located just upstairs from the CTaC, that will soon be capable of monitoring at-risk patients at a central location. “For some patients, usually elderly, who are at risk of falling, we need to have people making sure they’re staying in the bed, staying safe,” Morris says. From the centralized location, tech workers acting as “virtual sitters” can keep track of up to 12 patients each—freeing busy floor nurses for other tasks.

Behind the Curtain

Those patients will likely have only the most tangential knowledge of all the personnel, technology, and planning being brought to bear to ensure their safety. So, indeed, will the stroke patient and her grateful family. Using interventional radiology techniques unavailable even five years ago, the team at the Carilion Stroke Center removes the woman’s clot, and she is out of danger, with an excellent chance of full recovery. The nurse who fielded the original call has alerted the intensive care unit, to make sure a bed is open and waiting so the woman can receive the postprocedural care she’ll need. For CTaC, Morris says, staying “behind the curtain” is part of the design. “Patients don’t need to worry about what we look like or what we’re doing,” she says. “They and their families just need it to feel right, and to know that they’re getting the care they need when they need it.”

By Charles Slack