1. Can the Use of One-Way Communication Using Alphanumeric Paging Lead to Problems in Patient Care and Communication? Sasa Espino BA, Diane Cox MD, Brian Kaplan MD Department of Surgery Medical College of Virginia Hospitals, Virginia Commonwealth University, Richmond VA APDS MARCH 24, 2011

2. 2 Disclosures NONE NONE

3. 3 Background Paging - mainstay of communication in most medical centers Paging - mainstay of communication in most medical centers Residents are often paged while geographically separated from their patients Residents are often paged while geographically separated from their patients Pages have the potential to be disruptive to residents’ daily activities, including work rounds, conferences, and sleep Pages have the potential to be disruptive to residents’ daily activities, including work rounds, conferences, and sleep

4. 4 Background - Evolution of Communication Verbal communication Verbal communication –Direct person-to-person contact Paging Paging –Numeric –Voice/tone –Alphanumeric

5. 5 What we have now One-way alphanumeric paging system One-way alphanumeric paging system –Simple personal telecommunications device –Telepage operators vs internet-based Benefits Benefits –Increased physician and nurse satisfaction –Decreased disruption to pt care, educational activities –Decreased frequent paging of residents –Improved physician and nursing workflow

6. 6 Implementation and Evaluation of an Alphanumeric Paging System on a Resident Inpatient Teaching Service Aim: Implement an alphanumeric paging system on the General Internal Medicine inpatient wards Aim: Implement an alphanumeric paging system on the General Internal Medicine inpatient wards Measured proportion pages sent as text, source of pages, content of pages, pages that disrupted educational activities, satisfaction w paging system Measured proportion pages sent as text, source of pages, content of pages, pages that disrupted educational activities, satisfaction w paging system Intervention included equipping residents w alphanumeric pagers and increasing use of internet-based system to send text pages Intervention included equipping residents w alphanumeric pagers and increasing use of internet-based system to send text pages Wong et al. J Hosp Med 2009 4(8):E34.

7. 7 Results, Wong et al. Wong et al. J Hosp Med 2009 4(8):E34.*Total pages sent from Medicine ward or other physician

8. 8 Aim: To see if alphanumeric pages improved work environment in a large academic medical center Aim: To see if alphanumeric pages improved work environment in a large academic medical center Pre and Postintervention surveys Pre and Postintervention surveys Intervention included implementation of alphanumeric pages and detailed instruction on the use of text pages by all users Intervention included implementation of alphanumeric pages and detailed instruction on the use of text pages by all users Alphanumeric Paging in an Academic Hospital Setting Nguyen et al. Am J Surg 2005 191:561.

9. 9 Results, Nguyen et al. Nguyen et al. Am J Surg 2005 191:561.

10. 10 Why the Crisis? Potential for patient harm Potential for patient harm –Missed pages –Unclear text Use as numeric paging Use as numeric paging Potential HIPAA violations Potential HIPAA violations Limited workstations Limited workstations

11. 11 One-Way Communication at VCU Aim: Determine whether the use of alphanumeric pagers may lead to problems in patient care and/or communication or provides any benefit over numeric paging Aim: Determine whether the use of alphanumeric pagers may lead to problems in patient care and/or communication or provides any benefit over numeric paging

12. 12 Method IRB approval obtained IRB approval obtained Study setting: 779-bed academic medical center Study setting: 779-bed academic medical center Study population: residents on General Surgery, Trauma Surgery, and Surgical ICU services Study population: residents on General Surgery, Trauma Surgery, and Surgical ICU services Pages collected over 3-month period Pages collected over 3-month period Resident name and pager numbers were blinded Resident name and pager numbers were blinded 52,384 total pages 52,384 total pages –Pages categorized according to:  Reason for page  Type of follow-up required  Potential HIPAA violations

13. 13 Results Content of Page Number (%) Example Callback number 11,884 (22.6) x81234 Callback name and number 6,198 (11.8) *Resident* x81234 Change in pt status 1273 (2.4) Possible pneumothorax on CT pt s/p VATS Test result 1037 (2.0) US done on Pt X. Free fluid present, not there yesterday Consult request 249 (0.48) Pls call Team 1 regarding consult on Pt X w port-a-cath swelling and erythema Medication request 411 (0.78) Pt X - can he have PO dose of Benadryl for sleep? Trauma call 10,312 (19.7) 2222 Echo ETA 5 minutes Team update 1803 (3.4) 8a rounds on Main Hosp 9. Have vitals ready Paperwork request 127 (0.24) When you have time, pls consent Pt X for toe amputation Non pt-care related 124 (0.24) Food in team room when you’re done w rounds Other 19,354 (36.9) *Includes error messages, unclear text pages, request for call to outside number Example: 804-555-1212 Home Health regarding Pt X medication orders Total 52,384 (100)

14. 14 Results Content of Page Number (%) Example Callback number 11,884 (22.6) x81234 Callback name and number 6,198 (11.8) *Resident* x81234 Change in pt status 1273 (2.4) Possible pneumothorax on CT pt s/p VATS Test result 1037 (2.0) US done on Pt X. Free fluid present, not there yesterday Consult request 249 (0.48) Pls cal Team 1 regarding consult on Pt X w port-a-cath swelling and erythema Medication request 411 (0.78) Pt X - can he have PO dose of Benadryl for sleep?  20,653 pages (39.4% of total) have potential to result in patient harm

15. 15 Results Use as numeric paging Use as numeric paging

16. 16 Results Potential HIPAA violations Potential HIPAA violations –2636 (5.0% of the total pages)

17. 17 Improving Communication Education Education Reply message templates Reply message templates Smartphones for residents Smartphones for residents Elements for optimal implementation of alphanumeric paging* Elements for optimal implementation of alphanumeric paging* –Web-based paging system –Two-way communication –Safe, secure paging server *Wong et al. J Hosp Med 2009 4:E34

18. 18 Next Steps Future research: Future research: –Potential objective impact of two-way communication on patient safety and reducing medical errors –Most effective way to educate physicians and nurses regarding appropriate use of text paging

19. 19 Conclusion Effective communication is essential to safe and optimal patient care Effective communication is essential to safe and optimal patient care One-way alphanumeric paging can lead to errors in communication, disruptions to patient care and physician workflow One-way alphanumeric paging can lead to errors in communication, disruptions to patient care and physician workflow Biggest concern: inability of sender to immediately know if recipient has received the page Biggest concern: inability of sender to immediately know if recipient has received the page Potential for incomplete or no transfer of important patient care information, possibly resulting in patient harm Potential for incomplete or no transfer of important patient care information, possibly resulting in patient harm We have identified opportunities for improvement in education and call attention to the potential benefits of using two-way communication We have identified opportunities for improvement in education and call attention to the potential benefits of using two-way communication

20. 20 Limitations Limited to study of pages sent residents on 3 surgical services Limited to study of pages sent residents on 3 surgical services Limited time span of 3 months Limited time span of 3 months Retrospective study Retrospective study –No paging logs collected

21. 21 Questions?