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| Journal of the New Zealand Medical Association,
31-March-2006, Vol 119 No 1231
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Frequency of calls to “on-call” house officer
pagers at Auckland City Hospital, New Zealand
Tin Chiu, Andrew Old, Gill Naden, Stephen Child
On-call junior doctors play a pivotal role in the provision
of healthcare in the hospital setting. This role takes on increased importance
during the after-hours period when it represents the medical frontline for the
evaluation and management of ill patients. Hospitals worldwide have noted
increasing patient demands, decreasing lengths of stay, and increasing staff
shortages, with the result being that the workload for individual junior doctors
has increased over time.1
In most cases, on-call junior doctors carry an alphanumeric
pager which can be used by other staff to alert them to tasks requiring their
attention.
There is increasing concern that the high frequency of calls
may inhibit junior doctors from performing their duties efficiently and safely,
and may also have a detrimental effect on morale, with subsequent flow-on
effects on junior doctor recruitment. In an effort to combat this perceived
“pager abuse”, some hospitals have developed paging policies in an
effort to increase the efficiency of the process, while others have developed
alternate communication systems such as text paging capability or on-call cell
phones.
Auckland City Hospital is the largest tertiary teaching
hospital in New Zealand, and employs approximately one-quarter of all junior
doctor staff in the country. In this study, we investigated the frequency of
calls to the on-call pagers of four departments during different time periods in
the week.
MethodsAuckland 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.2
All on-call junior doctors at Auckland City Hospital
are supplied with an electronic GSL Instant-Link 4 line alphanumeric pager
operated by Telecom New Zealand Ltd. These pagers are capable of recording
numbers as well as receiving text messages. In most cases, they have a memory
capacity of 32 calls and a range of 50 kilometres from a transmitter. All calls
to these pagers are distributed through a central computer transmission system
that is capable of recording the time and origin of calls.
For this study, we identified seven on-call pagers that
were responsible for covering a range of surgical and medical specialties during
the after-hours period (1600–0800) at Auckland City Hospital. Paging data
for a 4-month period from April to August 2004 was recorded and analysed. Pagers
were split into two groups, with the pagers covering General Surgery, Vascular
Surgery, Orthopaedics, Urology, Neurosurgery, Otorhinolaryngology (ORL), and
Neurology* grouped together as the surgical specialty pagers and those covering
the services of Renal, Haematology, Oncology, Respiratory, Geriatrics, and
General Medicine grouped together as the medical specialty pagers (see Table
1).
*Neurology was included under
surgical services as the after-hours house officer covers neurosurgery, ORL and
neurology.
Table 1. Beds available at Auckland City Hospital by
specialty
*Neurology is covered by
the same House Officer as Neurosurgery and ORL.
The number of calls to each pager were analysed in the
following periods:
Once
categorised, the mean time between each call in each time period was calculated,
and comparison made between surgical and medical pagers. Calls per hour are
reported as mean values with 95% confidence intervals. Differences across the
surgical and medical groups were compared using an unpaired t-test and based on
the mean number of calls per hour per month per pager.
Confidence intervals were calculated assuming a Poisson
distribution and all statistical analysis was performed using STATA 7.0
statistical software (Stata Corporation, Texas Station, Texas, USA).
ResultsDuring the 4-month study period, a total of 25,389 pages
were recorded and analysed. These data are presented as the mean frequency of
calls to each pager in the different periods outlined above (see Table 2).
Table 2. Minutes between calls; mean and (95% CI)
The highest pager frequency rate of 6.9 minutes between
calls was recorded on Friday 6 August 2004, during the 1600–2200 time
period in general surgery. The lowest pager frequency of one call in 5 hours was
identified on the pager covering the services of geriatric medicine and medical
outliers on Tuesday 25 May 2004 during the 2200–0800 overnight shift (See
Table 3).
Table 3. Frequency of pages by specialty
Haem=Haematology;
Onco=Oncology; Gastro=Gastroenterology; Resp=Respiratory
It is noteworthy that analysis of paging frequency data
alongside hospital admission data for the same period showed no correlation
between the number of admissions and the frequency of pager calls.
When looking at the number of calls per hour, surgical teams
experience more calls during the weekday evenings (p=0.002), weekday nights
(p=0.005), weekend days (p=0.04), and weekend nights (p=0.03) compared with
medical services (See Figure 1). This is despite those house officers covering a
lesser number of patients (see Table 1).
In line with the reduced staffing ratios during the night
shifts, the frequency of calls was similarly reduced, with approximately one
call every 35 to 52 minutes. Comparison of weekday pager frequency (see Figure
2) revealed a consistent pattern of variation. Calls to surgical pagers
increased in frequency as the week progressed whereas the medical pagers showed
a reduction in frequency. Data from the Auckland Hospital database shows that
the number of admissions usually decreases during the course of the week from a
high on Monday to a low on Saturdays.
Figure 1. Mean number of calls per hour by shift and
specialty group
 Figure 2. Mean number of calls per hour by day and
specialty group
 DiscussionIn this study, we analysed the pager frequency of seven
on-call house officer pagers in our hospital, during the 4-month period from
April to August 2004.
Our study revealed differences in call frequency between the
medical and surgical pagers as well as expected differences during different
shifts. While this information is useful for our hospital, its direct value to
other organisations is potentially limited due to the confounding effects of
variations in staffing ratios, patient volumes and patient acuity. For example,
at Auckland City Hospital, 1.5% of medical admissions were elective whereas
39.9% of surgical admissions were elective during the study period.3
Most importantly, our research has very closely analysed the
pager frequency for the seven pagers studied. Peak frequencies as high as one
page every 7 minutes in both surgical and medical services is concerning.
Indeed, multiple studies have shown that interruptions in work activity increase
the processing time of task completion and increase the error rate when staff
commence subsequent tasks.4 In addition, interruptions and distractions have
been shown to increase employee stress with multiple flow-on effects to patient
safety.4–7 Indeed, job stress is already a significant issue among junior
doctors due to a wide ranging set of factors.8
Other studies have looked at pager frequencies in hospitals
but it is difficult to draw direct comparisons due to differences in rostering
practices and patient loads as mentioned above. Despite these limitations, our
results appear similar to a study conducted among medical junior doctors in an
urban tertiary hospital in the United States, which showed a mean medical pager
call frequency of 12 minutes per call compared to our mean frequency of 23
minutes.9 A similar comparison with Lurie et al10 performed in three urban
teaching hospitals showed a night time interruption rate ranging from
40–86 minutes which covers the mean of 50 minutes found in our study.
In addition, our study revealed wide variation in the
frequency of calls to on-call house officer pagers, both by time and by
specialty. It is well known that some hospital services are busier than others
after hours, but the differences in work type mean that the call frequency alone
does not accurately describe the workload.
For example, junior doctors working in ward-based or
emergency areas can be extremely busy in one location and therefore not receive
calls due to their constant attendance.
In addition, the reason for the call is important when
assessing workload. For instance, a study performed at Auckland City Hospital
looking at the quality of calls made to on-call house officers found that just
30% of after-hours calls were clinically indicated and required a response
within 1 hour. A further 53% of calls were deemed clinically appropriate, but
did not require a response within an hour and 17% of calls were considered
inappropriate.11
Indirectly however, pager frequency can be a useful marker
of job acuity and consequent junior doctor stress levels. Ideally, the
after-hours workload should be shared to reduce excessive call frequency, with a
reduction in the associated risks to patients and staff.
We believe that all hospitals should monitor pager
frequencies as a surrogate marker of junior doctor workload and stress levels.
While it is difficult to set a minimum safe call-frequency level, support
systems should be developed for individual junior doctors as well as back-up
roster systems for those that show consistently high call frequency.
Strategies to decrease the number of unnecessary calls to
on-call pagers should also be developed, and (where necessary) a review of
junior doctor staffing numbers should be instituted to ensure appropriate and
manageable workloads.
At Auckland City Hospital, we will continue to monitor our
call frequencies on a monthly basis; we have also developed a House Officer
– Nurse Communication Policy. We hope that these developments will reduce
call frequencies in our institution, with subsequent improvements in patient
care and junior doctor morale.
Author information:
Tin Chiu, House Officer; Andrew Old, Public Health Medicine Registrar; Gill
Naden, Manager, Clinical Education & 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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