Royal Adelaide Hospital: A benchmark in healthcare
On 6 September 2017, the doors finally closed on the much-loved Royal Adelaide Hospital as an honour guard of about 100 staff members gathered outside its Emergency Department, spontaneously cheering and applauding as the last patient was wheeled out the doors and carefully loaded into an ambulance for the trip to the $2.3bn new RAH.
This marked the completion of a progressive 'soft opening' process. Minor surgical procedures and outpatient appointments had been taking place at the new RAH for some weeks to accustom staff to the different systems. As many as possible of the 600 in-patients had transferred to other hospitals. The remainder were moved across at the rate of approximately 100 a day on 4, 5 and 6 September. The official opening of the new facility can be best placed at 7am on Tuesday 5 September, at which point the old emergency department closed to new admissions and the emergency department of the new hospital simultaneously took over.
It's more than 30 years since a new hospital was commissioned in South Australia, so the opening was always going to be a landmark event for the state's 1.6mn citizens. But the new RAH is much more than added tertiary healthcare capacity. It is the most advanced hospital in the whole of Australia, and the single largest infrastructure project in the history of the State of South Australia. The financing, design, construction and operation of the non-clinical services for the next 35 years was undertaken by SA Health Partnership Consortium (SAHP), made up of Hansen Yuncken, Leighton Contractors, Macquarie and Spotless. SAHP, incidentally, has recently rebranded as Celsus. This state-of-the art hospital, delivered as a Public Private Partnership under the State Government’s Partnership SA Model and forming part of the South Australian reformed health system, will provide world-class care for the people of South Australia.
Rooms with a view
But more than this, it can lay a justified claim, at least for the moment, to deliver the most technically advanced healthcare in the world, including complex medical, surgical, diagnostic and support services and 'super speciality' services including renal transplantation, major burns, and complex spinal care. The new hospital takes over all the services of the current RAH and some of the more complex services from The Queen Elizabeth Hospital. It will also provide high quality teaching and research facilities. “We don't expect the new RAH to rank as the world’s leading high-tech hospital for long,” says Bill Le Blanc, CIO of SA Health. “Technology advances fast these days and each new hospital project learns from the last and leapfrogs to the front.”
Le Blanc is responsible for all aspects of ICT across the whole of SA Health, leading a division of 700 ICT specialists with responsibility for capital and operating budgets over $240m annually. Thirty years ago, when medical technology was emerging, the IT team was still looked on as the backroom boys and girls of healthcare, whose main job was to keep the lights on. The new RAH, since the project was started 10 years ago, has grown up in a different universe, one in which every stage of planning is strategically directed by a partnership of IT and medical professionals.
“The technologies themselves are tried and tested,” says Le Blanc. “We have pulled them all together, borrowing ideas from other new hospital builds round the world in the last decade. What is leading-edge is the sheer amount of technology in a single facility. As for the move, it has gone remarkably smoothly. We have had very few issues and we have managed them without affecting our service to the public. I am smiling from ear to ear.”
Nobody wants to be in hospital but if you have to be, the new RAH is the place to be. It has 800 beds, but you won't find a traditional ward. Every single in-patient has his or her own room with en-suite facilities and, if they are mobile, easy access to outdoor garden areas. A variety of internal gardens, terraces and courtyards provide an interactive and uplifting environment, with internal and external performance spaces accessible to patients, staff, visitors and members of the public. Depressing corridors and waiting areas are also relegated to history - art integrated right across the 10-hectare site celebrates South Australia’s unique landscape and cultural history, creating a welcoming, attractive place of healing with the overarching creative design theme of “a hospital within a park – a park within a hospital”.
Typical of a hospital stay is the trip downstairs for an x-ray, scan, blood test or other specialist check. Patients at the new RAH won't have much of that to do, as the hospital is equipped with mobile equipment that can be wheeled into their room. Apart from CT and MRI scans, mobile imaging allows the bulk of x-rays, ultrasound procedures, and scope investigations to be conducted in the patient’s own room for in-patients. This cuts down on anxiety as they wait for their turn to come round.
All this may sound expensive but: “We believe it is efficient because it is designed to shorten length of stay,” says Le Blanc. “We expect better clinical outcomes, lower reinfection rates than you get in ward based hospitals and reduced readmission rates.” Without increasing staff numbers, he adds, more patients can be processed annually with the same number of beds. The simple innovation of having opening windows, looking out on greenery and controlled by the patients themselves, has been shown to speed healing and wellbeing.
The team dedicated to deploying technology to this hospital and its systems number around 200, but the people who put it to work day by day are the clinical staff. Getting everyone familiar with the systems ready for the move was the joint responsibility of the equipment manufacturers and the IT teams: and part of the planning had to encompass agency staff too. It is no longer enough for agencies to send along qualified temporary nurses, who will always be needed to fill gaps in capacity and cover staff leave and sickness, unless they are ready to hit the ground running, so the hospital had to work with the firms it uses to pre-train the people they would send along to the new RAH.
When everything is as smart as it can get it is hard to single out what to feature. After only a few weeks, though, some of the new systems are delivering quantifiable results. “I am very pleased with the investments we have made in the clinical data integration (CDI) technology. We are getting early feedback from doctors that this is already helping them make better-informed clinical decisions, resulting in better outcomes for the patients. I have been given examples where treatment decisions, that might not otherwise have been taken, have been made because of the technology they have access to. Better outcomes are already beginning to emerge”.
Le Blanc also referred to the Enterprise Patient Administration System (EPAS) which has been implemented at the new RAH, replacing paper medical records at the old RAH and now being implemented across South Australia. This will generate significant reductions in medication errors and improve patient safety. This single system for state-wide electronic medical records now has close to 2,000 users at any given time.
Automation that benefits patients
The 25 automated guided vehicles (AGVs) that deliver linen, food, surgical instruments and medicines across the hospital work round the clock and provide efficiency savings in terms of porterage and logistics. “The pharmaceutical robots give us efficiencies in staffing but, more importantly, reduction in errors, picking the right drug and dose, and getting that to the right patient,” Le Blanc enthuses. “There are huge benefits in terms of volumes that can be picked in a day and accuracy. This allows the pharmacists to do what they are trained to do which is to consult with the clinicians on treatment and medical outcomes rather than process-based tasks.”
Robots in focus
The largest hospital Automated Guided Vehicle (AGV) fleet in Australia and New Zealand
The fleet delivers hot and cold food and beverages, laundry, pharmaceuticals, sterilised items and other supplies as well as several forms of waste between the patient wards and the kitchens, stores and the many other functional areas within the hospital. These flat, stainless steel robotic devices, measuring 1.7m in length, 60cm in width and just over 30cm in height, can carry large trolleys with goods at average walking pace and can talk to lifts, specific doors and portable phones.
- A fleet of 25 RA-GVs.
- Contour/Range-sensing navigation.
- Trolley pick/drop stations with automatic RFID signalling.
- Automatic Park'n'Charge area.
- Central fleet control station with automatic scheduling of RA-GV movements plus elevator & auto-door activation controls.
- Greater efficiency & traceability.
- Increased safety.
- Reduced costs.
- Less damage to equipment.
- More staff time can be reallocated to direct patient care.
Both of the new RAH’s pharmacies use medication dispensing robots. The system decreases turnaround time for dispensing and reduces the amount of inventory required by 20-30% and reduces wastage from expired stock. In addition, there are more than 100 automated dispensing cabinets in patient wings. Nurses input the patient ID and biometric authorisation using staff fingerprints. The cabinet ejects a drawer containing only the medication (and correct dosage) prescribed for the patient. This technology also contributes to the physical security of medicines, cutting the opportunities for drugs, especially narcotics and other controlled drugs, to go astray.
Another smart application is the wireless system that tracks such assets as wheelchairs, infusion pumps, barouches. Over 3,200 wireless access points throughout the hospital can locate them in real time via embedded chips and IoT technology, much like triangulation from mobile phone towers. This locates the nearest available asset when it is needed by staff. Additionally, the system allows security officers to locate and attend staff quickly when they operate a wearable alarm.
Within the operating theatres, the integration of clinical data onto monitors allows surgical teams real-time access to medical record information, data captured by cameras on medical scopes, biomedical metrics and x-ray, CT and MRI imaging. High definition video capture and transmission in all theatres and treatment rooms allows junior doctors and students to be virtually present at an operation. The surgeon can consult with other specialists, and with only key participants present the risk of cross-infection is much reduced.
The hospital's 40 operating theatres, or technical suites, give surgeons a data-rich environment thanks to the ‘clinical data integration’ approach.
- Each suite measures 65 square metres
- Most suites have large windows to allow in natural light
- Critical trauma suites linked to the emergency department and the helipad by “hot lifts” for fast transport of patients
- Ceiling mounted swing arms carry up to six computer monitors
- Simultaneous data feeds from medical scopes, electronic medical records and biomedical metrics in real-time from the operation
- Imaging, including x-rays, CT scans and MRI
- Equipped with Clinical Digital Integration (CDI) technology high definition video cameras that capture all procedures on video
- Ability to consult with specialists during the operation
- Students observing the procedure see more but don't crowd the theatre
- Result: less risk of infection, better outcomes
Premiums from partnership
Design changes as technology advances. The building was originally designed to have three separate IT networks - one for biomedical traffic, one for conventional e-health and EMR patient administration data traffic and another for the PPP partners' IT systems that operate services like climate control, security and cleaning. However, over the construction period, Multiprotocol Label Switching (MPLS) technology, a data-carrying technique for high-performance telecommunications networks, progressed enough to justify simplifying this to a single physical network.
“That was new for government, and relatively new for the industry,” says Le Blanc. “In the past, biomedical data was something you'd always want to isolate physically rather than running it over the same wire as our administrative IT traffic and the builders' IT traffic. It saved money because instead of having to route and switch networks for three different physical fibre networks, we are now on just one.”
Since the building has the largest physical footprint in the southern hemisphere, the savings in wiring alone was considerable. Similarly, over the same period, wireless networks developed, so more data traffic could safely be transmitted that way. “When it was first designed we would never have dreamed of running any biomedical equipment data over a wireless network,” Le Blanc says. “A lot of it still is wired but we are now running biomedical traffic over the wireless network as well.”
The IT team has to go through a rigorous competitive process when awarding contracts. Value for money is important but in a medical environment it is not the primary parameter. Maybe 10 years ago, hospitals were not so dependent on technology as they are now to perform their core function. Now if some of that technology is not available the hospital will not be able to function. Robustness, stability and reliability are vital, according to Le Blanc. “We look for examples where the technology has been used in other medical situations and if that is not available, in other mission critical industries – banking, finance, defence even. We can't do it all ourselves. These modern environments are so complex that you have to have a consortium of service partners who can assist you. We are physically a long way from the rest of the world here – if something goes wrong we can't wait a couple of days for someone to fly out from Europe or the USA - we need local partners on the ground and that comes into the selection criteria as well.”
So, an overseas technology supplier needs to be able to give strong local support. “One of the advantages for us in using that local offering is its tight integration with pharmacy reimbursements through our Medicare system which is more difficult for an international provider to keep up with,” Le Blanc observes. Examples include DXC Technology, which provides the iPharmacy pharmacy management system used by the new RAH in common with hospitals across Australia; Allscripts, the partner for electronic medical records and patient administration; Carestream for the medical imaging system and Cerner's Millennium pathology system. “As far as possible we try to draw a straight line from any technology to show how that contributes to patient outcomes,” Le Blanc adds.
IT in healthcare is all about finding new and better ways to do things. “We can't take much of a breather now that the hospital is up and running because there is always room for improvement,” Le Blanc continues. “I am happy that the hospital's first month has gone so smoothly of course, and that has been down to every member of my team. We've had to ensure that the right people are available to deal with the inevitable speed bumps that come up. And because there is so much technology in this facility we have to make sure that once the patients move in the right technical people are on the spot. We have had a small army of technical people in the building to address any glitches. For me, it has been more a matter of keeping the executive radar scanning and checking that there is no impact on clinical service delivery.”
And he doesn't take all the credit for IT, applauding the clinical and admin staff whose core skills do not lie in delivering a project of this nature. “Our staff were under pressure delivering high quality service at the old hospital while at the same time working out how the change to a new hospital would affect their work practices. That is a significant workforce change management challenge but they embraced it.” Technology is not about replacing people, he says, more about enabling them.