Automation Nation: The Rise of the Machines in Healthcare

By Kelly M. Pyrek

While the saying goes that no one comes to work looking to make mistakes, they do happen, and they can lead to serious adverse events and poor patient outcomes. Where humans can introduce errors into a process, machines can help ensure standardization and uniformity, and an increasing number of healthcare organizations are evaluating and purchasing automated systems that boost their risk management strategies and patient safety efforts. Automation-driven processes are free from human fatigue and error, so they can help provide consistency and accuracy and potentially lead to a reduction in patient complications, infections and deaths. More predictable outcomes are possible with automated technology, and higher throughout can be achieved.

In addition, automation can help fulfill hospital leadership's quest for cost-reduction measures and increased efficiency as part of their fiscal imperatives. Applying automation solutions to healthcare can derive several significant benefits, including cost-savings on labor, as automation can supplement and/or replace manually intensive tasks that are better performed by machines. Healthcare personnel are then freed up for higher-functioning roles that take advantage of their clinical and technical expertise. Machines can also provide a data-driven perspective that is essential to reporting and transparency mandates that are fueling pay-for-performance in healthcare currently. Automated technology can provide data that can be then used for feedback and performance improvement and optimization.

When considering technology-driven systems for your healthcare institution, Gail Horvath, MSN, RN, CNOR, CRCST, a patient safety analyst and consultant at ECRI Institute, recommends doing your homework. "An organization, when they are making technology decisions, must perform their due diligence," Horvath says. "Examine the technology closely and make sure it fits your needs for your organization and patient population, and that you can support this technology in the long-run. It's not a one-size-fits-all, so you need to look at what your needs are and how the technology can meet those needs. Overall, I do think that technology enhances patient care."

Studies have indicated the benefits of automated technology, but not all studies are created equally, Horvath cautions. "When I was in the clinical arena and I had to make purchasing decisions, I always wanted to see studies that had been conducted by an impartial, non-biased research group or academic-based researchers, and published by someone other than the manufacturer of the technology," she says. "It wasn't always possible, but when it was, that's what I would look to, in order to verify -- in unbiased studies they did not fund -- what the manufacturer was claiming. That's part of the due diligence process when you are looking to bring technology into your organization."

To that end, ECRI Institute is currently undertaking the testing of ultraviolet light-based disinfection robots, and the results should be available later this year. "ECRI subscribers are asking for information about these technologies and we pride ourselves on being able to provide unbiased evaluation and recommendations," says Horvath. "We performed the testing and sought to validate the claims and rate the devices in different areas of performance. The validation testing was approved by the companies -- there was a lot of back and forth between ECRI and the companies to make sure it does stay unbiased. And the technology is being tested on the same set of criteria."

Horvath adds, "We are testing the UV systems out in the marketplace but have not yet reached any conclusions as to which technology is better, if any, and it is certainly not mitigating the need to perform the human aspects of the cleaning -- technology is designed to enhance, not replace, certain key aspects of manual processes."
In the medical literature, numerous experts have underscored the importance of healthcare professionals understanding that technology such as UV light and vaporized/mist disinfectant systems are adjuncts to proper and rigorous manual cleaning and disinfecting practices mandated in industry guidelines and recommendations.
"These devices are adjunct technologies to processes already being done in patient rooms, operating rooms and other critical areas of healthcare delivery," Horvath says. "In between cases and patients, and at the end of the day during terminal cleaning, staff is still performing the manual cleaning. I've had the fortune and pleasure of doing multiple onsite consults, mainly for perioperative areas and sterile processing in hospitals, where I have seen robots used, and the staff fully understand that these are adjuncts and they didn't replace manual cleaning and disinfection."

Horvath reminds healthcare professionals that there are limitations to the use of machines. "Automated technology is only as good as the person using it," she emphasizes. "Take automated washer/disinfectors in the sterile processing department, for example. You couldn't survive without them, but you have to make sure that sterile processing technicians are using them in the way they were intended to be used. Also, are the detergent concentrations correct? Do you have monitors for either reverse osmosis or deionized water systems to ensure that the water quality is as it should be? Are technicians loading the instrumentation into the machine the right way, taking care not overload it and to make sure the water and the detergent can get into crevices and nooks of the instruments? All hospitals should be using technology like ultrasonic units and washer/disinfectors, as you can't get by with just handwashing instruments anymore. While there are a few instruments that are not immersible and need to be handwashed, for the most part, these machines are the backbone of your sterile processing department. Because you can't sterilize something that's not clean."

Horvath continues, "Technology's function depends on the operator of the machinery, so hospitals must ensure staff are properly educated and trained. Their performance should also be monitored to ensure they are operating the technology correctly according to the manufacturer's directions."
Competencies become critical because technology is introducing another layer of technical knowledge for staff. "Technology has enhanced healthcare delivery but again, like anything, it depends on whether you are using it correctly," Horvath says. "So we need to reinforce the education and training it requires, and often some of the departments like the SPD are forgotten in this process.  We must monitor processes to make sure the machines are being used correctly and staff are being trained on the equipment and use it in the way it is intended to be used. Often it takes time for staff to develop trust of the automated technology and to develop a comfort level with it."

Horvath says that infection preventionists can serve as liaisons between department managers and frontline healthcare personnel who will be using the technology, in order to help facilitate this education and training, oversight and competencies review. "Any processes or technology that has to do with disinfection or sterilization, or hand hygiene, etc., should be vetted through the infection preventionist. And I advocate, especially in the central sterile area, that we use certified technicians that have undergone training and achieved certification. You need to include them in any education that has to do with equipment, you need to develop competencies, then monitor them to make sure that things are done the correct way, and finally, you must document your findings."
Breaking financial barriers related to technology acquisition and implementation is a significant challenge for some hospitals and healthcare systems. "Obviously an organization needs to be fiscally responsible," Horvath says. "With this kind of equipment, you don't get return on in-vestment, what you get is cost-avoidance -- one healthcare-acquired infection probably is the cost of one of the UV disinfection robots and if you can avoid that infection, you probably have already paid for the cost of the device. It's the same with automated washer/disinfectors -- they increase efficiency through automation and move facilities away from the manual process. You can move instrumentation through more efficiently than when you are doing everything manually, and it helps to reduce the potential of infection related to inadequately cleaned scopes or instruments."

Horvath adds, "There are many ways that hospitals can try technology and find ways of paying for it.  I don’t know of any manufacturer that doesn't allow a trial of the equipment, and obviously you need to do a trial in order to do your due diligence when you are making your decision. Many  manufacturers offer choices such as pay-per-use, or using the machine on a short- or long-term rental basis, or outright purchase -- so it's whatever fits your organization's needs."
Automation has been introduced into a number of healthcare applications, including area decontamination and hand hygiene compliance monitoring.

Automated Hand Hygiene Compliance Monitoring
The weaknesses of direct observation and the unbiased nature of technology make automated hand hygiene compliance monitoring systems a good choice for healthcare facilities that have tried everything in their quest to boost compliance but failed to see process improvement.

Technology-assisted direct observation technologies have a wide array of features and capabilities. As Ellingson, et al. (2014) describe them, "Intelligent hand hygiene systems are being developed with the idea that the system should have a wearable/mobile component, record all hand hygiene opportunities, provide a feedback or reminder system, and, ideally, respond to HCP behavior and actions. Sensor networks are designed to sense when HCP enter a patient-care area, such as a room or bedside; detect when hand hygiene is performed; and, if hand hygiene is not performed, remind the healthcare worker to do so. Older networks used light beams and motion sensors along with audible tones, worded voice prompts, or flashing lights to remind HCP to clean their hands. Newer systems use personal wearable electronic monitors that communicate with ceiling-mounted infrared emitters, or they use Wi-Fi or radio frequency signals to establish defined zones around patient beds or at the threshold of patient rooms. These systems usually capture entry and exit into a patient zone, comparable to WHO moments 1 and 4, but are less successful at capturing WHO moments 2 and 3 within the patient care episode. They cannot distinguish whether the healthcare provider touched the patient or only touched the environment (WHO moment 5)."

Using automated systems eliminates the selection and recall bias of human observers and provides a just-in-time reminder that allows HCP to correct hand hygiene errors before they reach the patient; however, the challenges inherent in some systems include issues such as dead batteries in recording units, non-operating dispensing units, and recording errors.

The Joint Commission’s 2009 monograph, Measuring Hand Hygiene Adherence: Overcoming the Challenges. Suggests the use of product use measurement, and patient, family and healthcare worker surveys. In the interval since that publication, monitoring methods have evolved. But also in 2009, the World Health Organization (WHO)’s monograph on hand hygiene implementation offered suggestions for the ultimate hand hygiene compliance monitoring system, which includes the proper power and ability to capture:
- Unbiased observations
- Exact numerator/denominator measures of HH opportunities
- Quality assessments of the microbiological HH outcome
- Minimal human time input
- Immediate and maximal data output with feedback capability
- Economical price tag for installation and maintenance
That monograph also noted any future automated monitoring systems with those elements must also have reliable data delivery, consider any ethical issues of tracking individuals, and be mindful of impact on staff and patients.

A recent systematic review by Ward et al. examined current evidence surrounding available electronic and automated systems. The review’s purpose was to examine new systems in terms of their real-time effectiveness in healthcare settings. With a search including studies from Jan. 1, 2000 to March 31, 2013, more than 3,500 papers were initially captured, with 42 papers making the final cut. As with any systematic review, the authors acknowledge pertinent studies could have be excluded due to study parameters. The review clustered new monitoring systems into slightly different categories: electronically assisted/enhanced direct observation, video-monitored direct observation, electronic dispenser counters, and automated hand hygiene monitoring systems. Results were discussed with respect to four characteristics:
- First, the authors noted that with selected studies about systems requiring monitor network implementation, installation costs were included, but not salary costs if video observers or cellular contract costs were needed. In addition, video observation methods raised privacy concerns when an adequate field of vision also included patients, not just healthcare workers.
- Next, in regard to attitudes toward monitoring networks, studies revealed healthcare workers were not averse to electronic monitoring. Instead, they suggested design improvements, such as silent alerts in order to not disturb patients at rest, and monitoring systems that could be included in already-carried devices, such as pagers and phones.
- Thirdly, the review looked at papers from the perspective of monitoring for all five WHO hand hygiene moments, admittedly one of the most challenging metrics of hand hygiene monitoring. Most systems capture moments 1 and 4, room entry and exit. But, recent studies reviewing nursing biomechanics may be able to help differentiate activities such as standing inside a room just talking with a patient, from administering an intravenous medication, or emptying a bed pan, thus incorporating additional monitoring of moments 2 and 3.
- Finally, within the limits of their study, the authors noted a paucity of published articles addressing accuracy and predictive values of electronic systems. Four studies found "little to no hand hygiene compliance rate differences between direct observation and automated or electronically assisted systems, including electronically enhanced direct observation, electronic dispenser, counters, and automated hand hygiene monitoring networks," the authors said.

Automated Area Decontamination
The marketplace currently offers a number of systems that are UV light-based (continuous as well as pulsed), plus vaporized hydrogen peroxide mist and other similar technologies that are designed to reach the areas that are missed by environmental services personnel who perform manual cleaning and disinfection of environmental surfaces. These systems are designed to serve as adjunct technologies and do not replace manual cleaning and disinfection practices.
Boyce (2016) describes the gamut of commercially available no-touch room decontamination technologies, which include: aerosolized hydrogen peroxide, hydrogen peroxide vapor systems, gaseous ozone, chlorine dioxide, saturated steam systems, peracetic acid/hydrogen peroxide fogging, mobile continuous ultraviolet devices, pulsed-xenon light devices, and high-intensity narrow-spectrum (405 nm) light. As Boyce (2016) summarizes, "Manual cleaning and disinfection of environmental surfaces in healthcare facilities (daily and at patient discharge) are essential elements of infection prevention programs. Because many factors make it difficult to achieve high rates of effective disinfection on a routine and sustained basis, continued efforts to improve the quality and consistency of traditional cleaning and disinfection practices are needed. Given the many challenges in achieving desired levels of surface disinfection, adoption of modern technologies is indicated to supplement traditional methods. Further research into the efficacy and cost-effectiveness of newer technologies, and when to best apply them, is needed. As additional data become available, it is likely that newer liquid disinfectants and some no-touch room decontamination systems will be more widely adopted to supplement traditional cleaning and disinfection practices."

Last October, a study from Duke Medicine found that using a combination of chemicals and UV light to clean patient rooms cut transmission of four major superbugs by a cumulative 30 percent among a specific group of patients -- those who stay overnight in a room where someone with a known positive culture or infection of a drug-resistant organism had previously been treated. The randomized trial was conducted at nine hospitals in the Southeast from 2012 to 2014, including three Duke University Health System hospitals, a Veterans Affairs hospital, and several smaller community healthcare centers. The trial studied how three cleaning methods affected the transmission of four drug-resistant pathogens: MRSA, vancomycin-resistant enterococci (VRE), C. difficile and Acinetobacter. Deverick J. Anderson, MD, an infectious disease specialist at Duke Medicine and lead investigator of the study, noted that "Several groups have demonstrated that enhanced cleaning strategies such as using portable UV machines can kill these germs, but this is the first well controlled study that shows these techniques can make meaningful difference in patient outcomes.”

The standard approach for room cleaning involves the use of a quaternary ammonium disinfectant. Participating hospitals used three methods for killing the germs: irradiating the room with UV after using a quat, replacing the quat with bleach, and replacing the quat with bleach and irradiating the room with UV light. The researchers found that the most effective strategy was to proceed with standard disinfection quats, followed by a 30- to 50-minute cycle with a portable UV irradiating machine.

References:

John M. Boyce JM. Modern technologies for improving cleaning and disinfection of environmental surfaces in hospitals. Antimicrobial Resistance & Infection Control. 2016. 5:10. Available at: https://aricjournal.biomedcentral.com/articles/10.1186/s13756-016-0111-x

Ellingson K, Haas JP, Aiello AE, Kusek L, Maragakis LL, Olmsted RN, Perencevich E, Polgreen PM, Schweizer ML, Trexler P, VanAmringe M and Yokoe DS. Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene. Infection Control and Hospital Epidemiol. Vol. 35, No. 8, August 2014.

Joint Commission. Measuring Hand Hygiene Adherence: Overcoming the Challenges. 2009. Available at: http://www.jointcommission.org/assets/1/18/hh_monograph.pdf.

Ward M, Schweizer M, Polgreen P, et al. Automated and electronically assisted hand hygiene monitoring systems: A systematic review. Am J of Infect Control. 2014;42, 472-478.

World Health Organization. A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy. 2009. Available at: http://www.who.int/gpsc/5may/Guide_to_Implementation.pdf.