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| Journal of the New Zealand Medical Association,
31-March-2006, Vol 119 No 1231
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|
Appropriate use of pagers in a New Zealand tertiary
hospital
Rajesh Patel, Keryn Reilly, Andrew Old, Gill Naden, Stephen
Child
One of a house officer’s main roles is the evaluation
and management of medical problems on the ward. Never is this role more
pressured than after-hours, when the number of doctors on duty may drop by a
ratio of 6 or 7 to 1. Due to the increased patient load, it is necessary for
on-call house officers to prioritise and it is neither appropriate nor safe for
house officers to deal with administrative or minor tasks at the expense of more
urgent medical problems.
The reality however, is that house officers are frequently
called to sort out problems that are not urgent. A high call-frequency results
in inefficiency, stress, and decreased availability to deal with genuinely
urgent situations.
Several studies have examined the effect of
“interruptions” on appropriate task management. Outside the medical
area, these studies have looked at the psychological effects of interruptions;1
while within the environment of patient care, the effects on training2 and
errors3,4 have been studied. Results from these studies suggest that the work
environment of house officers is crucial to the safety of patients in teaching
hospitals. Specifically, they suggest that reducing the number of unnecessary
calls and delaying non-urgent calls would result in less disruption to patient
care and a decrease in medical errors.
Auckland City Hospital is a 570-bed adult inpatient hospital
and is part of Auckland District Health Board, the largest public healthcare
provider in New Zealand. Auckland District Health Board provides regional
services for approximately 415,000 people along with some national specialty
services. There are more than 7500 staff including approximately 500 junior
doctors and nearly 3000 nurses.5
While text messaging and non-urgent job lists are utilised
in some areas, their use is patchy and calling a pager remains the most common
method of communication from nurses to house officers.
This study looked at the quality of calls made to on-call
house officers across different specialities at Auckland City Hospital.
MethodsAll on-call house officers are supplied with a Telecom New
Zealand Ltd-operated electronic alphanumeric pager, which is capable of
recording phone numbers as well as receiving text messages.
Fourteen house officers (either first, second, or third year
postgraduation) from General Medicine, Medical Specialities, General Surgery,
and Orthopaedics were involved in the study which ran for 3 months from June to
August 2004. Evening (1600–2200) and night (2200–0800) shifts were
kept separate, and the study aimed to categorise 100 calls in each time period
for each service.
Calls were categorised according to their perceived
appropriateness and urgency. The definitions of “appropriate” and
“urgent” were agreed upon in advance following focus group
discussions held with house officers, medical consultants, and nursing staff.
The three categories were:
The benchmark
time of 1 hour for an ‘urgent’ call was based on a similar study by
Katz and Schroeder.6 It also seemed reasonable that house officers should be
circulating through their wards at approximately 1-hour intervals to attend to
routine jobs thereby removing the need to be paged for such jobs.
To maximise consistency, house officers involved in data
recording had training sessions on how to categorise the calls they received,
plus regular meetings were held throughout the study.
The medical services we studied consisted of nine wards
including General and Medical Specialities (Oncology, Haematology,
Gastroenterology, Renal, Respiratory, and Infectious Diseases). This nine wards
were covered by two on-call house officers. Surgical services consisted of six
wards covering Orthopaedics, Urology, Vascular and General Surgery, and were
similarly covered by two on-call house officers.
Auckland City Hospital has a phlebotomy and intravenous (IV)
cannulation service which operates from 1600–2300 Monday to Friday as well
as 1000–2200 Saturday, Sunday, and public holidays. However, with only a
single staff member they are frequently overloaded.
ResultsA total of 844 calls were received and categorised; 256
(30%) were deemed appropriate and urgent (Category 1); 445 (53%) were
appropriate but did not need an urgent response (Category 2); and 143 (17%) were
inappropriate (Category 3) (Table 1).
Table 1. Calls made to on-call house officers’
pagers at Auckland City Hospital (June–August 2004)
*Including changes in
blood pressure, heart rate, respiratory rate, or fever; ↑Increased;
↓Decreased.
The absolute numbers of calls are shown in Table 1 along
with the reason for the call. Charting of fluids was the most common reason
identified for surgical calls (15%), while ‘changes to vital signs’
(8.6%) was the most common reason for medical calls. It is interesting to note
that across all three categories, ‘other’ calls accounted for 31%
and 32% of calls for medicine and surgery respectively, thus highlighting the
breadth of issues that lead to ward staff paging house officers (Table 1).
Interesting differences between medical and surgical
services were also observed. While the percentage of appropriate and urgent
calls (30%) was comparable, the percentage of calls which were inappropriate was
markedly different, with the medical services having twice as many inappropriate
calls (23% vs 11%) (Table 1, Figure 1).
Figure 1. Appropriateness of calls to pagers compared:
medical versus surgical services
 DiscussionFrequent interruptions have been shown to have a profound
psychological impact, causing distraction and forgetfulness, resulting in both
increased production of errors and compromised patient care.3 Frequent paging
also directly interrupts patient care and is an important cause of workplace
stress.1–4,7,8
When an extension number is received on a pager, the house
officer has no way of prioritising the interruption without dialling the
extension to speak with the person making the call. While systems exist to
identify emergency calls (e.g. cardiac arrest), as yet there is no way of
distinguishing between routine and more urgent calls received on a standard
pager. Previously it has been suggested that if calls were able to be designated
as such it would allow house officers to prioritise those calls and therefore
improve the service they were able to provide.4
A parallel study performed at our institution looking at the
average time between calls found that on an evening shift; surgical on-call
house officers had an average of just 16 minutes between each call, whilst in
medical services, the average was 23 minutes.9
Looking more closely at our results, the potential for
improvement is immediately obvious. The most common reason for calls in surgical
services was re-charting of IV fluids (15%); while in medical services,
re-charting of medications (7%) was second only to changes in vital signs. Both
of these tasks could be foreseen and dealt with by the patient’s primary
team during normal hours. Indeed, if we combine the reasons of re-charting
fluids or medications with charting regular insulin/warfarin, we can see that
approximately 18% of calls made in medical services and 25% made in surgical
services could be avoided by better team management during normal hours. Even if
these tasks were not attended to during the day, they are prime candidates for
notification via less disruptive means such as job sheets or text
messaging.
This situation is not unique to New Zealand. Similarly to
our findings, a study conducted at the University of California6 found that just
34% of calls required a response within 1 hour and resulted in a change in
patient care, while 26% of calls were deemed unnecessary as they neither
resulted in a change in clinical management nor were clinically indicated.
Furthermore, they found that the majority of calls (65%)
were received while interns (house officers) were engaged in patient care, hence
they concluded that reducing the number of unnecessary calls and postponing
non-urgent ones could result in a 42% decrease in disruptions, with a resulting
increase in time for patient care or rest for the interns.
Similar results were also observed in a Canadian study of
overnight calls where 19% of calls interrupted direct patient contact, with the
most common calls being for prescribing of medications (42%), patient assessment
(25%), and reporting of laboratory results (18%). Thirty-nine percent of the
calls in that study did not lead to a change in management.8
A 1992 study by Blum et al in paediatric residents found
that almost 50% of calls interrupted patient care, 24% interrupted ward rounds
or teaching conferences, 34% changed management, and 25% were
“unimportant.”7
A different way of looking at the issue is to observe what
junior doctors spend their time doing when on call. One study, looking at
overnight calls, found that residents spent about 70% more time on charting and
documentation than they did in direct patient care.10 This is consistent with
our study that found a significant proportion of calls were related to
documentation (Table 1).
While it is encouraging that 83% of calls in our study were
appropriate, only 36% of those calls required an urgent response from the house
officer. These urgent calls were appropriately sent as an extension number
requesting that the house officer immediately phone back to the caller. The
remaining 64% of calls could have been sent either as a text-page or added to a
job list held on the ward. Although our study didn’t measure what house
officers were doing when paged, evidence from similar studies suggests that
anything up to 65% of calls may interrupt patient care.6,8
Reducing interruptions would clearly help in reducing stress
levels while at the same time improving efficiency and enhancing house
officers’ ability to make appropriate and timely decisions.
The authors acknowledge that the definitions of what
constitute an ‘appropriate’ and ‘urgent’ call are
arbitrary, and were dependent on subjective application by the house officers at
the time the call was recorded. However, the definitions were agreed in
consultation with house officers, medical consultants, and nurses; and house
officers were educated in their use. Therefore we consider that the definitions
appropriately describe the situation at Auckland City Hospital.
Internationally, various interventions have been trialed in
an attempt to relieve the ‘pager burden.’ One that was shown to be
effective was based on an English surgical service and involved delegation of
paging duties to the nurse in charge and establishment of ‘task
boards’ on the house officers’ wards. Inappropriate calls fell from
a rate of 58% pre-intervention to just 15% following implementation. There was
also a fall in the number of calls that interrupted patient care from 46% to
28%.11 Important in the success of this innovation was that the policy had
buy-in from both medical and nursing staff and, encouragingly, the results were
reproducible when trialed on a medical service. Such a system would produce
similar benefits in the New Zealand setting we believe.
Advances in technology are likely to provide further options
in the future. Examples such as multifunction mobile phones that are already
widely used in Japan.12 and “smart pagers” capable of integration
directly with hospital information systems,13,14 have the potential to decrease
the number of calls made to house officers. In fact, proper use of readily
available technologies, such as intranet-based paging, has already been shown to
decrease costs and improve efficiency.15
Of concern when considering a reduction in paging to house
officers, is the observation that nurses’ and house officers’
perceptions of urgency differ markedly. One study found that only 45% of calls
judged by nurses to be an emergency resulted in assessment of the patient by the
‘physician,’ whereas 43% of calls that had been judged
‘routine,’ resulted in the same assessment.16
Indeed, any move to reduce inappropriate calls may mean that
appropriate calls are also reduced, with the potential for poor patient
outcomes. Hence, this observation lends strength to suggestions that more
integration of nursing and medical education has the potential to bolster mutual
respect and understanding and improve communication.
Further study into house officers’ response times to
calls (along with more research into nurse perception of calls to house officers
to investigate factors that make calls to house officers more or less likely to
be made) is needed.
Finally, disagreement between medical and nursing staff on
appropriate use of the house officer pager is a frequent source of friction and
ill-feeling. The nurse-physician relationship and its direct effect on patient
care has been widely studied,17 and it is in everyone’s interests (nurses,
doctors, but most importantly patients) to do everything possible to ensure as
harmonious and constructive a relationship as possible.
Author information:
Rajesh Patel, House Officer; Keryn Reilly, House Officer; Andrew Old,
Public Health Medicine Registrar; Gill Naden, Manager, Clinical Education and
Training Unit; Stephen Child, Director of Clinical Training, Auckland District
Health Board, Auckland
Correspondence: Dr
Stephen Child, Director of Clinical Training, Auckland District Health Board,
Private Bag 92024, Auckland. Fax: (09) 623 6421; email: Stephenc@adhb.govt.nz
References:
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