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Introducing bar-coded patient wristbands

Paula Lilburn  
Chartered Scientist, IT Developments Project Manager, Kettering General Hospital NHS Foundation Trust, Northamptonshire, UK

The National Patient Safety Agency’s Safer Practice Notice 24 (NPSA SPN24) challenged all UK hospitals to produce printed patient wristbands from their patient administration systems (PAS) by the summer of 2009.

Furthermore, NHS policy is for all hospitals to adopt the GS1 coding standard and the Neonatal Screening Programme required hospitals to have GS1 128 barcoded baby heel-prick labels by April 2010.

Yet there are many reasons why not all NHS trusts have implemented printed wristbands. The myriad of patient administration systems (PAS) in situ can be a decade or more old. Any alterations to these systems would involve time investments suppliers simply don’t want to make on old systems, and financial investment by hospitals.

The timing is difficult too. Many trusts are in the process of moving to a spine-compliant PAS that could well have a wristband solution built in. Attempting to comply before these moves have taken place may be perceived as spending good money on an interim solution.

There are even more choices to make. Should you spend money on changing the old PAS to do something it was never designed to do and write it off when the new PAS is installed, or spend money on a bespoke wristband printing solution with extra printers and network cabling. Alternatively, you could spend money on a barcode-printing middleware solution that produces all sorts of barcodes out of existing networked printers.

But which wristband consumable do the patients and clinical staff prefer? The challenge is to find something that will tick all the boxes of suitability, agile flexibility and multi-purpose use in a changing environment.  

How to choose?
The choice of the clinical staff and patients was of paramount importance. In our case, their choice was based on suitability, comfort and durability of the product.

The NHS Re:Source hub in Nottingham provided Kettering General with a number of wristband suppliers who demonstrated their wares to staff at an open day. The consensus was that staff preferred ‘Laserband’.

‘Laserband’ passed handwritten trials on newborns and their mothers in the labour ward – proving the downtime procedure at the same time. In order to be able to produce wristbands and heel-prick labels from the NHS Numbers for Babies (NN4B) system, from Kettering’s ICIS PAS or a new spine-compliant PAS such as Lorenzo, Laserband recommended FDI as the middleware provider they had worked with previously in similar situations.

Initial proof of concept
The initial focus of work was the GS1 1D barcoded heel-prick labels which needed to print out of the NN4B system by April 2010. It was decided at the outset that process improvement was paramount to reduce unnecessary work.

As both neonatal wristbands and heel-prick labels were a form of barcode label, Kettering would produce them in one process, on one sheet, out of NN4B within 30 minutes of the baby being born. No further hardware or cabling would be purchased. The barcodes would be printed out of existing laser printers.

Laserband developed a new product with Kettering for use by the NHS, containing both the neonatal heel-prick label and the wristbands on one sheet. The perforated sheet enables the heel-prick labels to be separated from the wristbands and placed in the back of the red baby book.

This means that the wristband is produced at the first possible opportunity, when the baby is first registered onto NN4B and allocated their unique NHS Number – within 30 minutes of birth.

The heel-prick label output from NN4B was sent to the FDI server. FDI formatted the data using sophisticated text compression and font sizing, then routed the output to a specified printer with a GS1 1-D barcode on the heel-prick label and a 2-D datamatrix label on the wristbands.

This was proof of concept that output from a national system could be used to produce any style of barcode label and that they could also be logically routed and printed. The GS1 heel-prick label barcodes passed the National Newborn Screening Laboratory testing with over 80% reflectance. All of the 1-D and 2-D barcodes scan first time every time, which proves that high-quality barcode printing is more than achievable out of standard laser printers (Dell 1720dn).

Printing GS1 wristbands across the trust
The next technical challenge was to find a way of transferring the knowledge gained from setting up the NN4B barcode labels to printing wristbands from ICIS PAS. What was needed was an output from ICIS that was common to all clinical areas that contained enough of the patient demographic to positively ID the patient.

People and process are critical to the success of IT, so the process for printing wristbands needed to be familiar to staff. The answer proved to be printing the addressograph label.  

Some of the essential elements for logical routing of the outputs and the NHS Number were not part of the addressograph label output. Once FDI received the addressograph data, then the further data was retrieved from the ICIS tables. The printed wristbands were technically trialled on the surgical assessment unit, which also tested the acceptability of the new business process.

All of the specialised formatting and logical routing for wristband printing is contained within the FDI server. When the PAS is swapped out, the wristbands will be up and running after minimal configuration on the new PAS system.   

Safety in design
The NHS Number only prints on the wristband when it is traced and verified. If it is unavailable, the PAS ID can be used. Apart from critical areas such as A&E and operating theatres, printing of wristbands is possible only when a patient has been admitted on the PAS. This is to prevent printing in advance, which is one of the main safety considerations.

Where we are December 2010
Two members of staff delivered training to key users on the wards and departments over a period of three weeks in November 2010. The key clinical users then cascaded the training to the rest of the staff in their department.

This time-frame was sufficient to allow for follow-up visits and any troubleshooting. The training included information about NHS Number adoption, positive patient ID and the NPSA SPN 24.

In a small number of departments some hard-pressed nurses have found the idea of taking on this task unthinkable. But this has been the exception rather than the rule.

Most nursing and administration staff who are used to using ICIS PAS  have taken printing wristbands in their stride, because the basic process and system used for wristband label production is very similar to the method used for printing addressograph labels.

Inpatient GS1 2-D Datamatrix barcoded wristbands are now live across the whole KGHFT site.

Newborn wristbands and heel-prick labels are printed out of NN4B within 30 minutes of a baby being born (live since March 2010). Adult, paediatric and neonatal bands – with no heel-prick label – are being printed out of ICIS PAS (live since November 2010).

Initial benefits
One of the first benefits is very simple – all of the wristbands are legible.

Furthermore, anecdotal evidence from both the National Newborn Screening Programme and from community midwives has identified a significant reduction of repeat neonatal heel-prick testing due to the introduction of GS1 128 barcode labelling of the specimens.

But there are many other benefits, such as:

The National Newborn Screening Laboratory has reduced the previous time taken for manual data entry for each specimen to a matter of seconds by using GS1 128 barcode technology
The time taken to handwrite neonatal 
heel-prick label forms in the community has been reduced to the time taken to stick two labels on the form
The time taken to handwrite baby wristbands has been reduced to one click of a button at the end of the existing registration process.
The GS1 2-D datamatrix barcodes scan as a comma-delimited string and contain hospital identifier, traced and verified NHS Number, PAS ID, last name, first name, date of birth. This can be used by a multitude of applications in future using barcode enabled personal digital computers (PDAs or ‘palmtops’), personal and notepad computers
Initial estimates show that wristband printing out of ICIS PAS takes 10 to 15 seconds.

Potential future pilot studies

  • Printing pathology phlebotomy labels at the bedside:
    • Phlebotomist transcription time will be saved, errors will be reduced

Electronic patient record duplication will be reduced in the pathology system, improving pathology delta checking and result viewing on the ward feed.
Printing demographic labels and headers on demand:
    • Repeated hand transcription of demographics by staff is inefficient and wastes clinicians’ time. It also is one of the main causes of errors due to misread handwriting or omission of key data such as the NHS Number
The use of pre-printed labels for request forms and patient note headers bring their own well-known challenges.
  • Matching drugs to patients:
    • Drug checking
    • Drug dispensing.
Matching procedures to patients; for example:
    • Surgery
    • Radiology
    • Endoscopy.

A personal view of the future
Compliance with the NPSA guidelines could be seen as the end of the project. I see it as first step towards the use of automatic identification and data capture (AIDC) and robotics in the clinical areas.

Pathology department automation, robotics and barcode technology has been in use for 25 years and has reached a high level of sophistication. More recently, pharmacy department robotics and AIDC are becoming commonplace, with all of the service improvements and patient safety benefits they bring.

Barcoded wristbands are the foundation required for the introduction of these technologies into the clinical workspace.

The IT itself is not important; what is important is the process change and benefits to staff and patients that will be enabled. Re-engineering processes around the new AIDC capability will allow service transformation, capacity building and patient safety benefits to be delivered.   

One of the main challenges to service improvement is to identify where processes are not optimal and bring them into focus in the minds of others.

Changing the way ‘things have always been done’ is difficult when there is no imperative for change. But getting staff to engage with systems and process changes to deliver efficiency is easier to justify in times of recession.

The NHS is already at a point where staff cannot take on more tasks or work any faster. The challenge now is to re-engineer and straighten out the work people are asked to do, removing duplication and waste and thereby building capacity. Operational change to remove tasks that add no value to the delivery of healthcare or patient experience would be popular with staff, save time for clinicians and would be safer for the patient.

Combining the introduction of barcoded wristbands with AIDC in areas such as sterile services, appliance register, bed management, pathology and pharmacy opens up the possibility for IT-enabled process redesign to make all of these services patient centred.