Technicians at Gundersen Health System brought their education, experience, and teamwork to bear on a major construction project that brings a historic institution into the 21st century
?Ask anyone in the midst of a major construction project about the process, and you’ll likely hear groans and complaints. Funding issues aside, conceiving, designing, constructing, and completing such an undertaking requires a team of professionals who collaborate and share the same goals, philosophy, and work ethic. At Gundersen Health System in La Crosse, Wisconsin, the clinical engineering department served as one of the major contributors to the success of the hospital’s Legacy Building project.
Gundersen first opened its doors in 1902 as Lutheran Hospital, and for the next 9 decades it set many precedents for medical care and patient safety. In 1995, Gundersen Clinic and Lutheran Hospital-La Crosse joined forces to become Gundersen Lutheran, then, in 2013, Gundersen Health System.
Today, the 325-bed, major tertiary teaching hospital has expanded to include 41 clinics and three critical access hospitals, with some 700 medical, dental, and associate staff and 6,500 employees. It is ranked as one of the 100 best medical facilities in the country.
A century of growth, however, took a toll on the physical plant. Certain wings of the existing hospital were in dire need of updating. The cost of bringing these areas up to code would require a sizeable financial investment. The decision to invest in new construction made more sense and would offer patients a better experience in a state-of-the-art environment.
Thus began the planning for the construction of a new 500,000-square-foot critical care hospital, the Legacy Building, on Gundersen’s main campus. While the project required input and assistance from external contractors and internal personnel, the new facility design relied heavily on the expertise of its Information Systems (IS) clinical engineering department.
Integration with IS
Clinical engineering at Gundersen stood as a separate department until 1999, when it merged with IS. In July 2009, Tom Wiese, CBET, who had risen through the ranks in the clinical engineering department since joining the organization in 1988, became director of IS Technical Services. The marriage of the two departments was relatively seamless, as clinical engineering had been dabbling in the network side for a few years already. “There was not a lot of ‘we/they’ with clinical engineering and information systems,” Wiese says. “We work across all teams pretty well. It’s a cohesive group with not much of a boundary.”
Clinical engineering has responsibility for support and maintenance of imaging, dialysis, medical, and nonmedical equipment, and also has a strong hybrid background in information systems and health technology management, according to Ryan Motl, manager, IS Clinical Engineering. He reports that the department had been involved with medical server support, such as various PACS and vitals data-collection servers. However, over the last 10 years, as Gundersen transitioned from physical servers to VMware-based servers and a more comprehensive electronic medical record (EMR), the department has taken on more of an application support role. “One of the nice parts of being an IS department is that we have access to tools, tips, and people that other biomedical departments might not,” Motl points out. “We’re one family and typically more efficient that way.”
The department comprises 17 technicians with various levels of education and experience in different medical specialty areas. It also offers technical consultation, server support, project planning/management, and capital planning services.
While the department embraces teamwork and cross training, each technician may have specific responsibilities. For example, the dialysis specialists support 110 machines across seven dialysis centers, while the imaging specialists handle a full suite of services, including radiography, ultrasound, mammography, and computerized tomography (CT) at multiple campuses. The radiation oncology specialist supports two linear accelerators, their associated software and servers, a CT simulator, and other equipment.
The Ground Floor
Following Gundersen’s decision to construct the Legacy Building, Motl was invited, in 2009, to represent clinical engineering on the design committee for the project. As part of a seven-member core team that included personnel from purchasing, IS, constructional engineering, operations planning, and others, he had the opportunity to participate in the design and implementation of major and minor medical equipment. “Clinical engineering was invited to the table pretty much right after planning began, since the project included a large amount of major medical equipment. Upper leadership recognized that they needed a voice for medical equipment from the beginning, when architects were taking the shell design and creating spaces at a room-by-room level,” Motl explains.
Relative to the size of the hospital, Gundersen is equipment intensive, due to the number of specialties it houses. “This is not typical for a hospital of this size,” Motl says. The new facility has installed new imaging, catheter, interventional radiology, hybrid operating room (OR), and integrated OR platforms for which the clinical engineering department is responsible. It also has new technologies for its group to learn, such as a distributed antenna system that handles telemetry, cell phone, and other frequencies.
Throughout the planning stages, clinical engineering had to be vigilant about modifications to the design, Motl recalls: “We accommodated many changes when staff realized which changes they needed and what would or would not work for them.” Several members of the clinical engineering group were assigned segments to bring from plan to reality. They worked on the floor with construction workers and vendors. “They had to guide what was on paper to becoming the real hospital,” Motl says. “They did all this without us having to contract out work. They managed to maintain their usual responsibilities, while working on the new building implementation.”
Clinical engineering participated in the decision-making process when it came to equipment purchase as well. “If it made sense, we moved equipment from the old hospital to the new, rather than short circuit the equipment life. We were trying to keep costs as reasonable as possible,” Motl says. “However, we are also part of the capital acquisition process, and were able to work with departments to extend the life of their existing equipment in the old space. This meant that they could move into the new hospital with new equipment. For instance, through careful capital planning, we were able to move in with all new patient monitoring in place, without having to dispose of equipment that had significant life left in it.”
Motl’s team also does a significant amount of contract analysis. “If it makes sense economically to do maintenance in-house, we will get the training and do it. If it’s not economically feasible, we may go with contract services,” he says. For instance, the cost to have Siemens oversee a CT in one of the regional clinics was reasonable, so training one of Gundersen’s technicians and taking the risk in-house would have been fiscally irresponsible. On the other hand, the return on investment to train technicians to service two other CTs in-house was more feasible. Economics aside, in their analysis, the team at Gundersen will also factor in their potential to provide quicker and better service than the vendors in many situations.
Linking Old and New
David Houge, CBET, imaging specialist for equipment throughout the health system, has been at Gundersen since 1989 and has “more name tags than you can imagine.” He says, “I’ve been director, lead technician, technical systems administrator, and now am imaging equipment specialist.” And with the building project, he assumed yet another role: liaison.
Houge became involved when it was time to make decisions on vendors, serving as the link between the hospital and construction, engineers, and the vendors. “After the dreaming and planning stage, it was our turn. The techs went on field trips to the companies to look at the equipment,” he notes. The construction of the imaging platform products required the purchase of new GE magnetic resonance imaging (MRI) machines—a 3T and a 1.5T—and proved to be one of the most exciting and challenging activities Houge experienced during the project. Getting the magnet into the new building required a precise strategy, as well as a couple of riggers and cranes. Houge explains that the 3T weighs 18,000 pounds and the 1.5T, slightly less. “We’re talking about eight to ten tons of steel and copper,” he says.
The magnet arrived at the construction site on a flatbed in a hybernative state, according to Houge. “The magnet is losing helium when being transported. You don’t want to disrupt the coiling and shield mechanisms inside the magnet,” he points out. “We then hooked the magnet up to a crane and used a winch to take it across the railroad tracks.” Once the magnet was just inside the building, the construction workers slid it 30 feet down the hallway to the room where it now resides. “We kept it in a chilled state to maintain stability for several months, while the rest of construction took place,” Houge says, adding that 2 months before going online, the vendor “ramped up” the magnet, requiring a careful approach to maintaining safety in the MRI area.
The War Room
Clinical engineering specialist Gary L. Webb addressed the finer details in the fall of 2013 when the project was nearing completion. “I looked at where monitors would go, how many jacks we would need in the rooms, and what other pieces of equipment we needed,” he says.
His familiarity with telemetry positioned him well for assisting with the telemetry installation and conversion. Gundersen had decided to switch from Philips to GE house-wide for telemetry in its inpatient spaces. This meant converting or installing nearly one million square feet of telemetry to create a seamless landscape between the old and new buildings. Significant planning and work with the end users was needed for success. “GE uses frequency hopping that helps to avoid interference problems, which we are excited about. I worked with the vendor on the antenna installation and testing of the system,” he says.
BMET Tyler Kussman, who started working at Gundersen in 2012 after preparations for the new building were well under way, collaborated with Webb and the vendor on monitoring installations and the telemetry conversion. As the implementation date moved closer, he helped set up the GE monitors in the emergency department and coordinated the wire cable run. “I made sure we had enough data ports for the GE network and that the telemetry would work. I set up the monitors and made sure they were talking to the central station,” Kussman adds.
One of the bigger parts of the project involved configuring the “war room,” located within the new critical care unit. The room comprises two patient monitoring pods—each with monitoring capability of up to 60 patients, video observation, remote connections to regional facilities, and other equipment such as printers and EMR PCs. These monitors can oversee patient vital signs in the critical care, emergency services, PACU, preop, and inpatient rooms with telemetry. “If they see something, such as rhythm changes or a lead that falls off a patient, they call the nurse,” Kussman explains. When the rooms are fully booked, there could be as many as 90 patients to monitor.
One of the most challenging parts of the new construction project for Kussman was devising the layout for the GE monitors and their central PCs. “I had to work with a raceway from the IT closet behind the war room. This required many custom cable arrangements in order to reach both workstations with the signals they needed,” he says.
Not only was clinical engineering responsible for planning support of the medical equipment, but the department also needed to plan for new, nontraditional items. One example would be the RFID and nurse call systems. “We now have a high-tech nurse call with RFID integration that needs support. We have thousands of active RFID tags to manage, as well as having assumed the support role of nurse call from facilities operations,” Motl says.
Additionally, devising a better work process for the new building required some creative thinking. For example, in the old hospital, noninvasive blood pressure units were rolled around on portable stands. But in the new building, to help nurses with workflow, clinical engineering put the units in every room. “We added close to 100 Dinamap units overall.” Motl reports. “It’s part of a natural equipment growth when better workflows rely on technology.”
While Gundersen was in the process of creating a state-of-the art medical facility, it also aimed to maintain its excellent track record for environmental awareness. Four wind turbines, nearly 100 geothermal wells under the parking lot, methane from a nearby landfill, solar panels, manure digesters, and wood waste generate energy for heating and cooling, making the health system nearly energy-independent. Clinical engineering embraces this same philosophy.
For example, the cooling system for MRI equipment and CT scanners are designed to conserve resources. “We recycle cooling water back to the power plant. An isolated water loop goes through the CT and MRI cooling cabinets to a heat exchanger. At that point, the heat goes back to the power plant and is captured for hot water needs,” Houge says. He notes that typically, an MRI has its own chiller system that creates cooling privately and exhausts heat to the outside. But at Gundersen, the machines capture heat and reuse it, optimizing efficiency and saving energy.
Employing environmentally aware practices is good not only for the planet, but also for the health system’s efficient operation. The machines carry a hefty price tag—nuclear medicine scanners can run about $500,000 each, while the MRI scanners cost about $3 million for the pair, according to Houge. “We’re looking at very expensive machines. When they are not working, there’s mass disruption in the operation of a hospital,” he reports.
So when something goes wrong with this equipment, quick response is critical. At one time, the cooling water in the MR equipment was connected directly to the whole house environment cooling system, which meant that chilled water for patients’ rooms and the operating room circulated through the MRI scanner. “This water was not clean enough and contained a lot of bacteria,” Houge says. Even when the cooling system is chemically treated, normal debris tends to plug up filters. So a month after the system was installed, the contractors built an independent loop for the chilling system that uses heat exchangers to separate whole house chilled water from the machine, and more closely control water temperatures. Working with mechanical engineers, Houge watched over the needs of the equipment as this new system was designed.
In addition, the nuclear medicine equipment must be calibrated periodically to develop a uniform image. “It’s a big lumbering machine that has to be greased and [have its] filters cleaned. I do what I call ‘predictive maintenance’ on the machines to catch any potential problems,” Houge says.
On move day, January 19, 2014, a staff of hundreds, including volunteers, operations planners, and every member of the clinical engineering team, arrived as early as 4 am and made the transition relatively painless. “We did mock operations for weeks on end before the real thing,” Motl notes. The time spent running through scenarios helped to synchronize the patient move and ensure that all equipment was properly installed and ready for use. The result is a highly efficient critical care facility with 15 integrated surgical suites, and a full surgical theatre with bidirectional video and audio between the suites. Still to come are three more integrated surgical suites and a hybrid operating room with a robotic C-arm.
The emergency services department tripled in size, and the facility has all private patient rooms. There are also new operating rooms with specialized technology and improved medical, surgical, and critical care units.
Motl notes that Gundersen plans to remodel and reuse portions of the old building for office space or other outpatient needs.
Wiese praises his staff for the role they played in bringing such a massive project to fruition. “People were doing multiple jobs,” he says. “We did not hire interim personnel. We’re patient-focused here, and that’s one thing that helped. We all went above and beyond to hit the target.”
In the midst of this massive undertaking, each member of Gundersen’s clinical engineering team managed to continue providing service to the customer, while contributing significantly to the successful relocation of patients and installation of equipment at a new site. The key, Kussman says, was teamwork: “We’re all in this boat when it gets crazy. This makes our work less stressful and more successful.” 24×7
Phyllis Hanlon is a contributor to 24×7. For more information, contact editorial director John Bethune at [email protected]com.