Can the Use of One-Way Can the Use of One-Way Communication Using Alphanumeric Communication Using Alphanumeric

Paging Lead to Problems in Paging Lead to Problems in Patient Care and Communication?Patient Care and Communication?

Sasa Espino BA, Diane Cox MD,Sasa Espino BA, Diane Cox MD,Brian Kaplan MDBrian Kaplan MD

Department of SurgeryDepartment of SurgeryMedical College of Virginia Medical College of Virginia

Hospitals, Hospitals,

Virginia Commonwealth University, Virginia Commonwealth University, Richmond VARichmond VA

APDS MARCH 24, 2011APDS MARCH 24, 2011

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DisclosuresDisclosures

NONENONE

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BackgroundBackground

• Paging - mainstay of communication in Paging - mainstay of communication in most medical centersmost medical centers

• Residents are often paged while Residents are often paged while geographically separated from their geographically separated from their patientspatients

• Pages have the potential to be Pages have the potential to be disruptive to residents’ daily disruptive to residents’ daily activities, including work rounds, activities, including work rounds, conferences, and sleepconferences, and sleep

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Background - Evolution of Background - Evolution of CommunicationCommunication

Verbal communicationVerbal communication– Direct person-to-person contactDirect person-to-person contact

PagingPaging– NumericNumeric– Voice/toneVoice/tone– AlphanumericAlphanumeric

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What we have nowWhat we have now

One-way alphanumeric paging systemOne-way alphanumeric paging system– Simple personal telecommunications deviceSimple personal telecommunications device– Telepage operators vs internet-basedTelepage operators vs internet-based

BenefitsBenefits– Increased physician and nurse Increased physician and nurse satisfactionsatisfaction

– Decreased disruption to pt care, Decreased disruption to pt care, educational activitieseducational activities

– Decreased frequent paging of residentsDecreased frequent paging of residents– Improved physician and nursing workflowImproved physician and nursing workflow

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Implementation and Evaluation Implementation and Evaluation of an Alphanumeric Paging of an Alphanumeric Paging

System on a Resident Inpatient System on a Resident Inpatient Teaching ServiceTeaching Service

Aim: Implement an alphanumeric paging Aim: Implement an alphanumeric paging system on the General Internal Medicine system on the General Internal Medicine inpatient wardsinpatient wards

Measured proportion pages sent as text, Measured proportion pages sent as text, source of pages, content of pages, pages source of pages, content of pages, pages that disrupted educational activities, that disrupted educational activities, satisfaction w paging systemsatisfaction w paging system

Intervention included equipping residents w Intervention included equipping residents w alphanumeric pagers and increasing use of alphanumeric pagers and increasing use of internet-based system to send text pagesinternet-based system to send text pages

Wong et al. J Hosp Med 2009 4(8):E34.

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Results, Wong et al.Results, Wong et al.

Pages that Disrupted Scheduled Educational Rounds

0

20

40

60

80

100

120

140

Total # pagesreceived during

rounds

Pages requiringimmediate call

back

Numeric pages* Text pages*

Nov-05 Nov-06 Jan-08

Wong et al. J Hosp Med 2009 4(8):E34.*Total pages sent from Medicine ward or other physician

88

Aim: To see if alphanumeric pages improved Aim: To see if alphanumeric pages improved work environment in a large academic work environment in a large academic medical centermedical center

Pre and Postintervention surveysPre and Postintervention surveys Intervention included implementation of Intervention included implementation of alphanumeric pages and detailed alphanumeric pages and detailed instruction on the use of text pages by instruction on the use of text pages by all usersall users

Alphanumeric Paging in Alphanumeric Paging in an Academic Hospital an Academic Hospital

SettingSetting

Nguyen et al. Am J Surg 2005 191:561.

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Results, Nguyen et al.Results, Nguyen et al.

Nguyen et al. Am J Surg 2005 191:561.

Resident Paging Logs

0100200300400500600700800900

1000

Total # of pages Interrupted pt care Required a call back

Preintervention (%)Postintervention (%)

Nurses: % answering "strongly agree" or "agree"

0

10

20

30

40

50

60

70

80

90

100

Saves time Decreases frustration Improves patient care

PreinterventionPostintervention

1010

Why the Crisis?Why the Crisis?

Potential for Potential for patient harmpatient harm– Missed pagesMissed pages– Unclear textUnclear text

Use as numeric Use as numeric pagingpaging

Potential HIPAA Potential HIPAA violationsviolations

Limited workstationsLimited workstations

QuickTime™ and a decompressor

are needed to see this picture.

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One-Way Communication One-Way Communication at VCUat VCU

Aim: Determine whether the use Aim: Determine whether the use of alphanumeric pagers may lead of alphanumeric pagers may lead to problems in patient care to problems in patient care and/or communication or and/or communication or provides any benefit over provides any benefit over numeric pagingnumeric paging

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MethodMethod IRB approval obtainedIRB approval obtained Study setting: 779-bed academic medical centerStudy setting: 779-bed academic medical center Study population: residents on General Surgery, Study population: residents on General Surgery, Trauma Surgery, and Surgical ICU servicesTrauma Surgery, and Surgical ICU services

Pages collected over 3-month periodPages collected over 3-month period Resident name and pager numbers were blindedResident name and pager numbers were blinded 52,384 total pages52,384 total pages

– Pages categorized according to:Pages categorized according to: Reason for pageReason for page Type of follow-up requiredType of follow-up required Potential HIPAA violationsPotential HIPAA violations

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ResultsResults

Content of Content of PagePage

Number (%)Number (%) ExampleExample

Callback numberCallback number 11,884 (22.6)11,884 (22.6) x81234x81234

Callback name and Callback name and numbernumber

6,198 (11.8)6,198 (11.8) *Resident* x81234*Resident* x81234

Change in pt statusChange in pt status 1273 (2.4)1273 (2.4) Possible pneumothorax on CT pt s/p VATSPossible pneumothorax on CT pt s/p VATS

Test resultTest result 1037 (2.0)1037 (2.0) US done on Pt X. Free fluid present, not US done on Pt X. Free fluid present, not there yesterdaythere yesterday

Consult requestConsult request 249 (0.48)249 (0.48) Pls call Team 1 regarding consult on Pt X w Pls call Team 1 regarding consult on Pt X w port-a-cath swelling and erythemaport-a-cath swelling and erythema

Medication requestMedication request 411 (0.78)411 (0.78) Pt X - can he have PO dose of Benadryl for Pt X - can he have PO dose of Benadryl for sleep?sleep?

Trauma callTrauma call 10,312 (19.7)10,312 (19.7) 2222 Echo ETA 5 minutes2222 Echo ETA 5 minutes

Team updateTeam update 1803 (3.4)1803 (3.4) 8a rounds on Main Hosp 9. Have vitals ready8a rounds on Main Hosp 9. Have vitals ready

Paperwork requestPaperwork request 127 (0.24)127 (0.24) When you have time, pls consent Pt X for When you have time, pls consent Pt X for toe amputationtoe amputation

Non pt-care relatedNon pt-care related 124 (0.24)124 (0.24) Food in team room when you’re done w roundsFood in team room when you’re done w rounds

OtherOther 19,354 (36.9)19,354 (36.9) *Includes error messages, unclear text *Includes error messages, unclear text pages, request for call to outside numberpages, request for call to outside numberExample: 804-555-1212 Home Health regarding Example: 804-555-1212 Home Health regarding Pt X medication ordersPt X medication orders

TotalTotal 52,384 (100)52,384 (100)

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ResultsResults

Content of Content of PagePage

Number (%)Number (%) ExampleExample

Callback numberCallback number 11,884 11,884 (22.6)(22.6)

x81234x81234

Callback name Callback name and numberand number

6,198 (11.8)6,198 (11.8) *Resident* x81234*Resident* x81234

Change in pt Change in pt statusstatus

1273 (2.4)1273 (2.4) Possible pneumothorax on CT pt Possible pneumothorax on CT pt s/p VATSs/p VATS

Test resultTest result 1037 (2.0)1037 (2.0) US done on Pt X. Free fluid US done on Pt X. Free fluid present, not there yesterdaypresent, not there yesterday

Consult requestConsult request 249 (0.48)249 (0.48) Pls cal Team 1 regarding Pls cal Team 1 regarding consult on Pt X w port-a-cath consult on Pt X w port-a-cath swelling and erythemaswelling and erythema

Medication Medication requestrequest

411 (0.78)411 (0.78) Pt X - can he have PO dose of Pt X - can he have PO dose of Benadryl for sleep?Benadryl for sleep?

20,653 pages (39.4% of total) have potential to result in patient harm

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ResultsResults

Content of Page

23%

12%65%

Callback number

Callback numberand name

InformationTransfer

Use as numeric Use as numeric pagingpaging

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ResultsResults

Potential HIPAA violationsPotential HIPAA violations

– 2636 (5.0% of the total pages)2636 (5.0% of the total pages)

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Improving CommunicationImproving Communication

EducationEducation Reply message templatesReply message templates Smartphones for residentsSmartphones for residents Elements for optimal Elements for optimal implementation of alphanumeric implementation of alphanumeric paging*paging*– Web-based paging systemWeb-based paging system– Two-way communicationTwo-way communication– Safe, secure paging server Safe, secure paging server

*Wong et al. J Hosp Med 2009 4:E34

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Next StepsNext Steps

Future research:Future research:

– Potential objective Potential objective

impact of two-way impact of two-way

communication on patient communication on patient

safety and reducing safety and reducing

medical errorsmedical errors

– Most effective way to Most effective way to

educate physicians and educate physicians and

nurses regarding nurses regarding

appropriate use of text appropriate use of text

pagingpaging

QuickTime™ and a decompressor

are needed to see this picture.

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ConclusionConclusion

Effective communication is essential to safe and Effective communication is essential to safe and optimal patient careoptimal patient care

One-way alphanumeric paging can lead to errors in One-way alphanumeric paging can lead to errors in communication, disruptions to patient care and communication, disruptions to patient care and physician workflowphysician workflow

Biggest concern: inability of sender to Biggest concern: inability of sender to immediately know if recipient has received the immediately know if recipient has received the pagepage

Potential for incomplete or no transfer of Potential for incomplete or no transfer of important patient care information, possibly important patient care information, possibly resulting in patient harmresulting in patient harm

We have identified opportunities for improvement We have identified opportunities for improvement in education and call attention to the potential in education and call attention to the potential benefits of using two-way communicationbenefits of using two-way communication

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LimitationsLimitations

Limited to study of pages sent Limited to study of pages sent residents on 3 surgical residents on 3 surgical servicesservices

Limited time span of 3 monthsLimited time span of 3 months Retrospective studyRetrospective study

– No paging logs collectedNo paging logs collected

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Questions?Questions?