- Email: [email protected]
Hospital text paging communication as a surgical quality improvement initiative
j o u r n a l o f s u r g i c a l r e s e a r c h 1 j u n e 2 0 1 7 ( 2 1 3 ) 8 4 e8 9
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Association for Academic Surgery
Hospital text paging communication as a surgical quality improvement initiative Jeremy Hill, BA,a,1 Matthew Janko, MD,a,1 Kelsey F. Angell, MD,a Kathy Day, RN, MSN, OCN,a Michael G. Noujaim, BS,b Jennifer Kalil, MD,a and Scott R. Steele, MDc,* a
Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio b Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts c Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
article info
abstract
Article history:
Background: Studies on medicine wards have shown that numeric pages can be disruptive
Received 1 December 2016
of workflow and patient care. We created a quality improvement program among surgical
Received in revised form
ward nurses and residents and hypothesized that a text-based, urgency-stratified initiative
2 January 2017
would improve communication at no detriment to patient care.
Accepted 14 February 2017
Methods: Surgery residents recorded preintervention data for 1 mo including number of total
Available online 21 February 2017
pages, text pages, and numeric pages received from surgical floors. Nurses and residents completed surveys to assess preintervention satisfaction with communication, responsive-
Keywords:
ness, and workflow. Nurses were then instructed to use text paging for nonurgent issues.
Pager
Paging data were again recorded for 1 mo, surveys repeated, and patient safety and satis-
Text paging
faction data collected. Primary endpoints evaluated included patient safety and satisfaction
Quality improvement
data. Secondary endpoints included communication satisfaction of nurses and residents.
Communication
Results: After text paging implementation, 40.1% of nonurgent pages sent from nurses to
Surgery
resident physicians were alphanumeric texts versus only 17.9% before implementation (P < 0.0001). There was a 19.5% reduction in the number of nonurgent numeric pages sent (P < 0.0001). Overall, 70% of nurses responded postintervention that text paging was the preferred method of contacting a physician and that the text paging initiative improved efficiency. After implementation, 62% of nurses thought that overall communication with clinicians improved. In addition, there was no change in patient safety issues or patient satisfaction. Conclusions: Our text paging initiative for all nonurgent pages from nurses to residents improved physicianenurse workflow and communication on the surgical ward with no decrease in patient satisfaction or safety. ª 2017 Elsevier Inc. All rights reserved.
* Corresponding author. Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Avenue/A30, Fort Lewis, Cleveland, OH 44195. Tel.: þ1 216 444 4715; fax: þ1 216 445 8627. E-mail address: [email protected] (S.R. Steele). 1 Co-first authors contributed equally to the article. 0022-4804/$ e see front matter ª 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2017.02.008
85
hill et al surgical text paging safety
Introduction The Joint Commission identifies communication failures as one of the most common causes of sentinel events.1 These communication failures are often the result of poor or inadequate responsiveness to outdated technology.2,3 Beyond catastrophic consequences, previous studies have reported that residents receive a staggering amount of pages each day that interrupts educational activities and patient care.2-4 These near constant interruptions distract providers from patient care and lead to an increased number of potentially avoidable errors and decreased patient satisfaction with the care they receive.2-4 In a recent study, traditional numeric paging was reported as the preferred method of communication for none (0%) of the surgical residents surveyed, and only 1.3% reported it as their primary communication method.3 Recent literature has proposed possibilities beyond pagers for in-hospital communication,4 although reports focusing on communication on surgical wards are essentially nonexistent. There is a need for further clinical evaluation of the efficacy and reliability of different types of communications between healthcare providers.5 As technology has evolved, text messaging has become the preferred method of communication, and a study in the workplace that found more than 71% of residents preferred text messages at work because of efficiency, with more than 79% because of ease of use.6 Although text messaging is easy and efficient, the same study reports that patient information is frequently shared that is not secure and could be in violation of the privileged health information component of the Hospital Information Privacy Act of 1996.6 Other studies have evaluated secure smartphone text messaging applications to avoid such potential violations of privacy, finding higher satisfaction in perceived effectiveness in communicating thoughts and integration of patient care into daily workflow.7
These messaging applications come at a considerable cost to healthcare organizations though and should be weighed against cheaper alternatives. The purpose of this present study was to evaluate a free online text paging service on an existing pager network to assess nursing and resident satisfaction of a text-based communication system and the effects on patient care and satisfaction on the surgical ward. We hypothesized that a text-based, urgency-stratified initiative would improve resident physician and nurse workflow and satisfaction, would not affect physician responsiveness to urgent communications, and would not increase major adverse events on a surgical ward.
Material and methods The Institutional Review Board at the Center for Clinical Research and Technology at University Hospitals Cleveland Medical Center reviewed and approved this study. This study was a caseecontrol study in which intern or junior surgery residents covering service pagers for either day or night 12-h shifts recorded preintervention data for 1 mo before the beginning of the text paging trial. These data included average patient census, number of urgent and nonurgent pages received from surgical floors, number of text and traditional call-back pages from surgical floors, total number of pages received, and major adverse patient care events (Fig. 1). Also during this preintervention period, surgical nurses and residents completed preintervention surveys to assess satisfaction with communication, responsiveness to pages, interruptions in educational activities, and overall efficiency of workflow. The surveys were tested for validity by administering them to residents and nursing staff not involved in the study, before implementation, ensuring there were no questions about the survey and that target data would be collected.
Service
Average Patient Census
Shifts Worked
Total number of pages
Average pages per shift
Holden/General GI Surgery
8.8
10
44
4.4
Transplant Surgery
16.7
12
140
11.7
Colorectal Surgery
16.1
9
125
13.9
Vascular Surgery
11.8
10
50
5
Acute Care Surgery
12.3
8
113
14.1
Surgical Oncology/HPB
9.1
10
47
4.7
Fig. 1 e Pages by service. (Color version of figure is available online.)
86
j o u r n a l o f s u r g i c a l r e s e a r c h 1 j u n e 2 0 1 7 ( 2 1 3 ) 8 4 e8 9
Surgical nurses were then instructed to use text paging to communicate with residents for nonurgent issues using a standardized tiered text paging protocol. Notes, flyers, nurse managers, and word of mouth were all used to encourage participation in the intervention during the intervention period. The text pages were sent via the online text paging Web site www.spok.com that is secure and complies with Hospital Information Privacy Act requirements. Pages were stratified into one of three levels of urgency and tagged with the appropriate labeldFYI, advise, or 911/urgent. Urgent patient care issues continued to be communicated with traditional numeric callback pages. Urgent concerns were defined as change in mental status, escalation of care alerts, chest pain or shortness of breath, telemetry changes, significant increase in pain, increase in oxygen needs, and any other issue the nursing staff felt warranted urgent communication. General guidelines for each tier of communication were provided to guide nursing communication. Each page also included a call back number so that telephone communication could occur as needed. Nurses and residents had preexisting access to and use of text paging, and in addition, there was a 1-wk text paging training period without data collection to ensure participants were comfortable with the technology. Question and answer sessions were held periodically with nursing staff and leadership to address any concerns and troubleshoot the paging protocols. Paging data were recorded for 1 mo after implementation of text paging initiative and postintervention surveys were repeated with residents and nursing staff. Statistical analysis using chi-squared and Student’s t-tests were used to compare pre- and post-intervention results. The nurse manager obtained patient safety and satisfaction data from the surgical floor participating in the intervention for 2016 for pre- and post-intervention comparison. The patient satisfaction data were collected internally by the quality and safety department. The patient satisfaction scores reflect percentage of respondents that responded with the highest level of satisfaction, or “top box” rating, of the Likert scale questionnaire.
(P ¼ 0.318; Fig. 3A) or medication events (P ¼ 0.374). Breaking medication events down further, no significant differences were found in administration (P ¼ 0.749), dispensing (P ¼ 0.070), prescribing (P ¼ 0.374), or transcribing (no events pre- or post-intervention) of medications preintervention versus intervention periods. Total near misses, defined as an error of commission or omission that could have harmed the patient but harm did not occur, were also not significantly different (P ¼ 0.394; Fig. 3B). There were also no patient identification issues during the intervention period. The risk event findings are displayed in Table 2. Overall patient satisfaction data revealed no significant difference preintervention and postintervention (57.92% versus 57.69%, P ¼ 0.96; Fig. 4). Postintervention survey analysis revealed that 70% of responding nurses (n ¼ 13) believed the text paging initiative improved response time in triaging and responding to pages, whereas 30% responded that there was no change (Fig. 5A). Survey data also demonstrated the text paging initiative improved communication between nurses and responding residents. In all, 61.54% of surveyed nurses believed the text paging initiative improved communication compared with 23.08% who responded the initiative had not improved communication and 15.38% stating there had been no change (Fig. 5B). Seventy percent of nurses surveyed postimplementation responded that text paging was the preferred method for contacting a physician. Hundred percent of residents surveyed post text paging trial reported improved efficiency in triaging and responding to pages and overall improved communication with nursing after implementation of text paging and all responding residents indicated text paging as preferred to numeric paging.
Table 1 e Paging data before and during intervention on a surgical ward.
Surveys completed
Results
Intervention month
19
19
13 (68.4%)
13 (68.4%)
6 (31.6%)
6 (31.6%)
Role Registered nurse
All residents on service responded to pre- and post-surveys (n ¼ 6). Data were gathered from a total of 59 shifts. Before implementation of the text paging intervention, 76.2% of nonurgent pages were numeric pages, compared with 17.9% of nonurgent text pages. After implementation of the text paging intervention, 56.7% of nonurgent pages were numeric pages (difference of 19.5%, P < 0.0001), and 40.1% of nonurgent pages were text pages (difference of 22.2%, P < 0.0001; Table 1). Almost 40% of the 33 nurses working on the surgical floor responded to the postintervention survey (n ¼ 13). Patient safety data found no significant difference between the number of pre- and post-intervention patient escalation of care alerts (7.8 versus 3, P ¼ 0.10; Fig. 2A). There were fewer transfers to the intensive care unit during the intervention period (2 versus 0, P ¼ 0.02; Fig. 2B). There were no significant differences between preintervention and intervention periods in other safety matrices such as total risk events, defined as any event that did or could have caused patient harm
Preintervention
Surgical intern Number of surgical intern shifts during data collection
59
26
Total pages
235
127
Urgency Nonurgent Urgent
221 (94.0%)
123 (96.9%)
14 (6.0%)
4 (3.1%)
Type of page Text total Nonurgent Urgent
54 (42.5%)***
42 (17.9%)
51 (40.1%)***
2 (0.8%)
3 (2.4%)
Numeric total
191 (81.3%)
73 (57.5%)***
Nonurgent
179 (76.2%)
72 (56.7%)***
12 (5.1%)
1 (0.8%)*
Urgent ***
44 (18.7%)
*
P < 0.0001; P < 0.05.
87
hill et al surgical text paging safety
Paent Safety
Escalaon of Care Alerts
A
Transfers to ICU
B 4.5
16
4
14
3.5
12
3
10
2.5 8
2
6
1.5
4
1
2
0.5 0
0 Jan
Feb
Mar
Apr
May
Jan
Jun*
Feb
*Intervenon month
Mar
Apr
May
Jun*
*Intervenon month
Fig. 2 e Patient safety events. (Color version of figure is available online.)
Discussion Our text paging trial aimed to evaluate free online text paging on an existing pager network to assess nursing and resident satisfaction of a text-based communication system and the effects on patient care and satisfaction on the surgical ward. We found that the trial improved resident physician and nurse workflow and satisfaction (Fig. 5), did not affect physician responsiveness to urgent communications, did not increase major adverse events on a surgical ward (Figs. 2 and 3), and did not decrease patient satisfaction (Fig. 4). Few nurses or physicians are satisfied with numeric paging as the primary method of communication. Studies of in-hospital medical floors have shown that physicians prefer communicating by sending and receiving text communications.6 Text paging is becoming more popular in hospitals nationwide, with some hospitals even choosing to invest in secure text messaging smartphone applications.7 Associated costs and these patient safety and satisfaction measures are important matrices that must be considered as hospitals evaluate the future of their communication technologies.
Our trial focused on text paging within a surgical ward, only the third such study known to these authors. We used an existing free text paging Web site to implement this project given limitations in cost and technology. In addition, our innovative study included a new text paging intervention as well as measurements of objective data such as patient safety and satisfaction during the text paging initiative. One of our novel findings is that the text paging initiative did not increase adverse outcomes or cause a decline in patient satisfaction. Although providers appear satisfied and report greater efficiency, the effect on patient safety and satisfaction has been unexamined especially in settings where a hospital must transition from traditional numeric paging to a text-based messaging or paging system. Similar to previous publications, our trial of text paging showed improved satisfaction among both nursing and house staff.2-7 Partnering with nursing staff and leadership to implement this project was a critical point of our success. The text paging trial idea was brought to the nursing manager who encouraged text paging usage for nonurgent communication among nurses. The support and partnership with nursing administration made implementation of the trial easier and also allowed for enhanced communication in ways outside the
Risk Events
A
B
Total Risk Events
25
Near Misses
8 7
20
6 5
15
4 10
3 2
5
1 0
0 Jan
Feb
Mar
Apr
*Intervenon month
May
Jun*
Jan
Feb
Mar
Apr
May
*Intervenon month
Fig. 3 e Total and near miss events. (Color version of figure is available online.)
Jun*
88
j o u r n a l o f s u r g i c a l r e s e a r c h 1 j u n e 2 0 1 7 ( 2 1 3 ) 8 4 e8 9
Table 2 e Risk event data before and during text paging intervention. Jan
Feb
Mar
Apr
May
Jun*
P value
Total risk events
8
22
10
16
13
11
0.318
Medication events
0
3
2
4
0
1
0.374
Administering
0
0
1
3
0
1
0.749
Dispensing
0
1
1
1
0
0
0.070
Prescribing
0
2
0
0
0
0
0.374
Transcribing
0
0
0
0
0
0
e
Patient ID issues
0
0
0
0
0
0
e
Near misses
1
2
3
2
7
2
0.394
*
Text paging intervention month.
text paging trial. Beginning a dialog with nurses and residents regarding better ways to communicate with the goal of providing the best and safest patient care benefited those involved in the trial beyond what can be measured in our trial. Strengths of the study include the easy design generalizability and free cost of implementation. With no cost to the hospital, data could be gathered to assess the likelihood of success should larger scale communication changes be considered. A standardized paging algorithm and labels helped to avoid ambiguity in paging communication and allow residents to better triage page urgency. Although there was a substantial decrease in nonurgent numeric pages, they were not eliminated completely. Limitations of the study include the voluntary nature of the text paging trial with <50% of all pages being texted by the nursing staff on the surgical ward. Some nurses reported logistical difficulty accessing the text paging site. We also had a small number of nurses involved (33 on a single surgical floor), and a
short intervention period of 1 mo. Some nurses reported it was easier to numeric page than to log onto the computer, find the Web site, and send a text page, making it less likely for them to do so. Some nurses also indicated in formal feedback that they were more accustomed to numeric paging, and thus, more likely to use the traditional paging system. Also, numeric pages were not completely eliminated because nurses were instructed to use numeric paging for urgent or emergent communication. While the surgical floor nurses on general surgical floors were asked to text page, surgical residents receive pages from nursing staff that work on many different units of the hospital which may have demonstrated findings under representative of what a larger scale trial might have found. Future inquiry and studies should focus on longer duration trials and include standardized secure text messaging applications. In addition, future studies could quantify how other forms of communication, such as text paging or text messaging applications, affect response time from residents.
Overall Paent Sasfacon Highest sasfacon rang percentage
100.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Jan
Feb
Mar
Apr
May
Jun*
*Intervenon month Fig. 4 e Patient Satisfaction over 6 mo period. (Color version of figure is available online.)
89
hill et al surgical text paging safety
Nursing Opinions Following Text-Paging Intervenon
A
Efficiency in Page Response Time
B
Sasfacon with Communicaon
70% 61.54%
30% 23.08% 14.38%
0% Improved response Impaired response me me
No change
Improved communicaon
Impaired communicaon
No change
Fig. 5 e Efficiency and satisfaction after implementation. (Color version of figure is available online.)
Recording of the content of the text pages may also prove valuable, allowing for analysis so that text paging and text messaging communication can be optimized. The data collected will provide hospital administrators with support to justify the costs of technology updates desperately needed for hospital communications between healthcare providers. Improvements in communication technology may improve overall patient safety and satisfaction via decreases in work disruption and distractions, while continuing to improve provider and nurse satisfaction with communication and workflow.
Conclusions We successfully implemented a free universally available Web-based text paging initiative for nonurgent pages from nurses to residents that has improved physicianenurse workflow and communication on the surgical wards without an increase in adverse events or decrease in patient satisfaction.
Acknowledgment The authors would like to thank the nurses and residents at our institution who generously donated their time and effort to participate in this project. Authors’ contributions: J.H., M.J., K.F.A., K.D., M.G.N., and J.K. contributed to conception and design of study, acquisition of data, or analysis and interpretation of data; J.H., M.J., K.F.A., and S.R.S. contributed to final approval of the version to be submitted; J.H., M.J., K.F.A., K.D., M.J.N., S.R.S. responded to suggestions from reviewers and made further edits.
Disclosure The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.
references
1. The Joint Commission. Sentinel Event Data Root Causes by Event Type 2004e2013. Available at: http://www. jointcommission.org/assets/1/18/Root_Causes_by_Event_ Type_2004-2Q2013.pdf. 2. Smith AD, de Vos MS, Smink DS, Nguyen LL, Ashley SW. Text paging of surgery residents: efficacy, work intensity, and quality improvement. Surgery. 2016;159:930e937. 3. Plant MA, Fish JS. Resident use of the internet, e-mail, and personal electronics in the care of surgical patients. Teach Learn Med. 2015;27:215e223. 4. Khanna RR, Wachter RM, Blum M. Reimagining electronic clinical communication in the post-pager, smartphone era. JAMA. 2016;315:21e22. 5. Wu RC, Tran K, Lo V, et al. Effects of clinical communication interventions in hospitals: a systematic review of information and communication technology adoptions for improved communication between clinicians. Int J Med Inform. 2012;81:723e732. 6. Prochaska MT, Bird AN, Chadaga A, Arora VM. Resident use of text messaging for patient care: ease of use or breach of privacy? JMIR Med Inform. 2015;3:e37. 7. Przybylo JA, Wang A, Loftus P, Evans KH, Chu I, Shieh L. Smarter hospital communication: secure smartphone text messaging improves provider satisfaction and perception of efficacy, workflow. J Hosp Med. 2014;9:573e578.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Association for Academic Surgery
Hospital text paging communication as a surgical quality improvement initiative Jeremy Hill, BA,a,1 Matthew Janko, MD,a,1 Kelsey F. Angell, MD,a Kathy Day, RN, MSN, OCN,a Michael G. Noujaim, BS,b Jennifer Kalil, MD,a and Scott R. Steele, MDc,* a
Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio b Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts c Department of Colorectal Surgery, Cleveland Clinic, Cleveland, Ohio
article info
abstract
Article history:
Background: Studies on medicine wards have shown that numeric pages can be disruptive
Received 1 December 2016
of workflow and patient care. We created a quality improvement program among surgical
Received in revised form
ward nurses and residents and hypothesized that a text-based, urgency-stratified initiative
2 January 2017
would improve communication at no detriment to patient care.
Accepted 14 February 2017
Methods: Surgery residents recorded preintervention data for 1 mo including number of total
Available online 21 February 2017
pages, text pages, and numeric pages received from surgical floors. Nurses and residents completed surveys to assess preintervention satisfaction with communication, responsive-
Keywords:
ness, and workflow. Nurses were then instructed to use text paging for nonurgent issues.
Pager
Paging data were again recorded for 1 mo, surveys repeated, and patient safety and satis-
Text paging
faction data collected. Primary endpoints evaluated included patient safety and satisfaction
Quality improvement
data. Secondary endpoints included communication satisfaction of nurses and residents.
Communication
Results: After text paging implementation, 40.1% of nonurgent pages sent from nurses to
Surgery
resident physicians were alphanumeric texts versus only 17.9% before implementation (P < 0.0001). There was a 19.5% reduction in the number of nonurgent numeric pages sent (P < 0.0001). Overall, 70% of nurses responded postintervention that text paging was the preferred method of contacting a physician and that the text paging initiative improved efficiency. After implementation, 62% of nurses thought that overall communication with clinicians improved. In addition, there was no change in patient safety issues or patient satisfaction. Conclusions: Our text paging initiative for all nonurgent pages from nurses to residents improved physicianenurse workflow and communication on the surgical ward with no decrease in patient satisfaction or safety. ª 2017 Elsevier Inc. All rights reserved.
* Corresponding author. Department of Colorectal Surgery, Cleveland Clinic, 9500 Euclid Avenue/A30, Fort Lewis, Cleveland, OH 44195. Tel.: þ1 216 444 4715; fax: þ1 216 445 8627. E-mail address: [email protected] (S.R. Steele). 1 Co-first authors contributed equally to the article. 0022-4804/$ e see front matter ª 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2017.02.008
85
hill et al surgical text paging safety
Introduction The Joint Commission identifies communication failures as one of the most common causes of sentinel events.1 These communication failures are often the result of poor or inadequate responsiveness to outdated technology.2,3 Beyond catastrophic consequences, previous studies have reported that residents receive a staggering amount of pages each day that interrupts educational activities and patient care.2-4 These near constant interruptions distract providers from patient care and lead to an increased number of potentially avoidable errors and decreased patient satisfaction with the care they receive.2-4 In a recent study, traditional numeric paging was reported as the preferred method of communication for none (0%) of the surgical residents surveyed, and only 1.3% reported it as their primary communication method.3 Recent literature has proposed possibilities beyond pagers for in-hospital communication,4 although reports focusing on communication on surgical wards are essentially nonexistent. There is a need for further clinical evaluation of the efficacy and reliability of different types of communications between healthcare providers.5 As technology has evolved, text messaging has become the preferred method of communication, and a study in the workplace that found more than 71% of residents preferred text messages at work because of efficiency, with more than 79% because of ease of use.6 Although text messaging is easy and efficient, the same study reports that patient information is frequently shared that is not secure and could be in violation of the privileged health information component of the Hospital Information Privacy Act of 1996.6 Other studies have evaluated secure smartphone text messaging applications to avoid such potential violations of privacy, finding higher satisfaction in perceived effectiveness in communicating thoughts and integration of patient care into daily workflow.7
These messaging applications come at a considerable cost to healthcare organizations though and should be weighed against cheaper alternatives. The purpose of this present study was to evaluate a free online text paging service on an existing pager network to assess nursing and resident satisfaction of a text-based communication system and the effects on patient care and satisfaction on the surgical ward. We hypothesized that a text-based, urgency-stratified initiative would improve resident physician and nurse workflow and satisfaction, would not affect physician responsiveness to urgent communications, and would not increase major adverse events on a surgical ward.
Material and methods The Institutional Review Board at the Center for Clinical Research and Technology at University Hospitals Cleveland Medical Center reviewed and approved this study. This study was a caseecontrol study in which intern or junior surgery residents covering service pagers for either day or night 12-h shifts recorded preintervention data for 1 mo before the beginning of the text paging trial. These data included average patient census, number of urgent and nonurgent pages received from surgical floors, number of text and traditional call-back pages from surgical floors, total number of pages received, and major adverse patient care events (Fig. 1). Also during this preintervention period, surgical nurses and residents completed preintervention surveys to assess satisfaction with communication, responsiveness to pages, interruptions in educational activities, and overall efficiency of workflow. The surveys were tested for validity by administering them to residents and nursing staff not involved in the study, before implementation, ensuring there were no questions about the survey and that target data would be collected.
Service
Average Patient Census
Shifts Worked
Total number of pages
Average pages per shift
Holden/General GI Surgery
8.8
10
44
4.4
Transplant Surgery
16.7
12
140
11.7
Colorectal Surgery
16.1
9
125
13.9
Vascular Surgery
11.8
10
50
5
Acute Care Surgery
12.3
8
113
14.1
Surgical Oncology/HPB
9.1
10
47
4.7
Fig. 1 e Pages by service. (Color version of figure is available online.)
86
j o u r n a l o f s u r g i c a l r e s e a r c h 1 j u n e 2 0 1 7 ( 2 1 3 ) 8 4 e8 9
Surgical nurses were then instructed to use text paging to communicate with residents for nonurgent issues using a standardized tiered text paging protocol. Notes, flyers, nurse managers, and word of mouth were all used to encourage participation in the intervention during the intervention period. The text pages were sent via the online text paging Web site www.spok.com that is secure and complies with Hospital Information Privacy Act requirements. Pages were stratified into one of three levels of urgency and tagged with the appropriate labeldFYI, advise, or 911/urgent. Urgent patient care issues continued to be communicated with traditional numeric callback pages. Urgent concerns were defined as change in mental status, escalation of care alerts, chest pain or shortness of breath, telemetry changes, significant increase in pain, increase in oxygen needs, and any other issue the nursing staff felt warranted urgent communication. General guidelines for each tier of communication were provided to guide nursing communication. Each page also included a call back number so that telephone communication could occur as needed. Nurses and residents had preexisting access to and use of text paging, and in addition, there was a 1-wk text paging training period without data collection to ensure participants were comfortable with the technology. Question and answer sessions were held periodically with nursing staff and leadership to address any concerns and troubleshoot the paging protocols. Paging data were recorded for 1 mo after implementation of text paging initiative and postintervention surveys were repeated with residents and nursing staff. Statistical analysis using chi-squared and Student’s t-tests were used to compare pre- and post-intervention results. The nurse manager obtained patient safety and satisfaction data from the surgical floor participating in the intervention for 2016 for pre- and post-intervention comparison. The patient satisfaction data were collected internally by the quality and safety department. The patient satisfaction scores reflect percentage of respondents that responded with the highest level of satisfaction, or “top box” rating, of the Likert scale questionnaire.
(P ¼ 0.318; Fig. 3A) or medication events (P ¼ 0.374). Breaking medication events down further, no significant differences were found in administration (P ¼ 0.749), dispensing (P ¼ 0.070), prescribing (P ¼ 0.374), or transcribing (no events pre- or post-intervention) of medications preintervention versus intervention periods. Total near misses, defined as an error of commission or omission that could have harmed the patient but harm did not occur, were also not significantly different (P ¼ 0.394; Fig. 3B). There were also no patient identification issues during the intervention period. The risk event findings are displayed in Table 2. Overall patient satisfaction data revealed no significant difference preintervention and postintervention (57.92% versus 57.69%, P ¼ 0.96; Fig. 4). Postintervention survey analysis revealed that 70% of responding nurses (n ¼ 13) believed the text paging initiative improved response time in triaging and responding to pages, whereas 30% responded that there was no change (Fig. 5A). Survey data also demonstrated the text paging initiative improved communication between nurses and responding residents. In all, 61.54% of surveyed nurses believed the text paging initiative improved communication compared with 23.08% who responded the initiative had not improved communication and 15.38% stating there had been no change (Fig. 5B). Seventy percent of nurses surveyed postimplementation responded that text paging was the preferred method for contacting a physician. Hundred percent of residents surveyed post text paging trial reported improved efficiency in triaging and responding to pages and overall improved communication with nursing after implementation of text paging and all responding residents indicated text paging as preferred to numeric paging.
Table 1 e Paging data before and during intervention on a surgical ward.
Surveys completed
Results
Intervention month
19
19
13 (68.4%)
13 (68.4%)
6 (31.6%)
6 (31.6%)
Role Registered nurse
All residents on service responded to pre- and post-surveys (n ¼ 6). Data were gathered from a total of 59 shifts. Before implementation of the text paging intervention, 76.2% of nonurgent pages were numeric pages, compared with 17.9% of nonurgent text pages. After implementation of the text paging intervention, 56.7% of nonurgent pages were numeric pages (difference of 19.5%, P < 0.0001), and 40.1% of nonurgent pages were text pages (difference of 22.2%, P < 0.0001; Table 1). Almost 40% of the 33 nurses working on the surgical floor responded to the postintervention survey (n ¼ 13). Patient safety data found no significant difference between the number of pre- and post-intervention patient escalation of care alerts (7.8 versus 3, P ¼ 0.10; Fig. 2A). There were fewer transfers to the intensive care unit during the intervention period (2 versus 0, P ¼ 0.02; Fig. 2B). There were no significant differences between preintervention and intervention periods in other safety matrices such as total risk events, defined as any event that did or could have caused patient harm
Preintervention
Surgical intern Number of surgical intern shifts during data collection
59
26
Total pages
235
127
Urgency Nonurgent Urgent
221 (94.0%)
123 (96.9%)
14 (6.0%)
4 (3.1%)
Type of page Text total Nonurgent Urgent
54 (42.5%)***
42 (17.9%)
51 (40.1%)***
2 (0.8%)
3 (2.4%)
Numeric total
191 (81.3%)
73 (57.5%)***
Nonurgent
179 (76.2%)
72 (56.7%)***
12 (5.1%)
1 (0.8%)*
Urgent ***
44 (18.7%)
*
P < 0.0001; P < 0.05.
87
hill et al surgical text paging safety
Paent Safety
Escalaon of Care Alerts
A
Transfers to ICU
B 4.5
16
4
14
3.5
12
3
10
2.5 8
2
6
1.5
4
1
2
0.5 0
0 Jan
Feb
Mar
Apr
May
Jan
Jun*
Feb
*Intervenon month
Mar
Apr
May
Jun*
*Intervenon month
Fig. 2 e Patient safety events. (Color version of figure is available online.)
Discussion Our text paging trial aimed to evaluate free online text paging on an existing pager network to assess nursing and resident satisfaction of a text-based communication system and the effects on patient care and satisfaction on the surgical ward. We found that the trial improved resident physician and nurse workflow and satisfaction (Fig. 5), did not affect physician responsiveness to urgent communications, did not increase major adverse events on a surgical ward (Figs. 2 and 3), and did not decrease patient satisfaction (Fig. 4). Few nurses or physicians are satisfied with numeric paging as the primary method of communication. Studies of in-hospital medical floors have shown that physicians prefer communicating by sending and receiving text communications.6 Text paging is becoming more popular in hospitals nationwide, with some hospitals even choosing to invest in secure text messaging smartphone applications.7 Associated costs and these patient safety and satisfaction measures are important matrices that must be considered as hospitals evaluate the future of their communication technologies.
Our trial focused on text paging within a surgical ward, only the third such study known to these authors. We used an existing free text paging Web site to implement this project given limitations in cost and technology. In addition, our innovative study included a new text paging intervention as well as measurements of objective data such as patient safety and satisfaction during the text paging initiative. One of our novel findings is that the text paging initiative did not increase adverse outcomes or cause a decline in patient satisfaction. Although providers appear satisfied and report greater efficiency, the effect on patient safety and satisfaction has been unexamined especially in settings where a hospital must transition from traditional numeric paging to a text-based messaging or paging system. Similar to previous publications, our trial of text paging showed improved satisfaction among both nursing and house staff.2-7 Partnering with nursing staff and leadership to implement this project was a critical point of our success. The text paging trial idea was brought to the nursing manager who encouraged text paging usage for nonurgent communication among nurses. The support and partnership with nursing administration made implementation of the trial easier and also allowed for enhanced communication in ways outside the
Risk Events
A
B
Total Risk Events
25
Near Misses
8 7
20
6 5
15
4 10
3 2
5
1 0
0 Jan
Feb
Mar
Apr
*Intervenon month
May
Jun*
Jan
Feb
Mar
Apr
May
*Intervenon month
Fig. 3 e Total and near miss events. (Color version of figure is available online.)
Jun*
88
j o u r n a l o f s u r g i c a l r e s e a r c h 1 j u n e 2 0 1 7 ( 2 1 3 ) 8 4 e8 9
Table 2 e Risk event data before and during text paging intervention. Jan
Feb
Mar
Apr
May
Jun*
P value
Total risk events
8
22
10
16
13
11
0.318
Medication events
0
3
2
4
0
1
0.374
Administering
0
0
1
3
0
1
0.749
Dispensing
0
1
1
1
0
0
0.070
Prescribing
0
2
0
0
0
0
0.374
Transcribing
0
0
0
0
0
0
e
Patient ID issues
0
0
0
0
0
0
e
Near misses
1
2
3
2
7
2
0.394
*
Text paging intervention month.
text paging trial. Beginning a dialog with nurses and residents regarding better ways to communicate with the goal of providing the best and safest patient care benefited those involved in the trial beyond what can be measured in our trial. Strengths of the study include the easy design generalizability and free cost of implementation. With no cost to the hospital, data could be gathered to assess the likelihood of success should larger scale communication changes be considered. A standardized paging algorithm and labels helped to avoid ambiguity in paging communication and allow residents to better triage page urgency. Although there was a substantial decrease in nonurgent numeric pages, they were not eliminated completely. Limitations of the study include the voluntary nature of the text paging trial with <50% of all pages being texted by the nursing staff on the surgical ward. Some nurses reported logistical difficulty accessing the text paging site. We also had a small number of nurses involved (33 on a single surgical floor), and a
short intervention period of 1 mo. Some nurses reported it was easier to numeric page than to log onto the computer, find the Web site, and send a text page, making it less likely for them to do so. Some nurses also indicated in formal feedback that they were more accustomed to numeric paging, and thus, more likely to use the traditional paging system. Also, numeric pages were not completely eliminated because nurses were instructed to use numeric paging for urgent or emergent communication. While the surgical floor nurses on general surgical floors were asked to text page, surgical residents receive pages from nursing staff that work on many different units of the hospital which may have demonstrated findings under representative of what a larger scale trial might have found. Future inquiry and studies should focus on longer duration trials and include standardized secure text messaging applications. In addition, future studies could quantify how other forms of communication, such as text paging or text messaging applications, affect response time from residents.
Overall Paent Sasfacon Highest sasfacon rang percentage
100.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Jan
Feb
Mar
Apr
May
Jun*
*Intervenon month Fig. 4 e Patient Satisfaction over 6 mo period. (Color version of figure is available online.)
89
hill et al surgical text paging safety
Nursing Opinions Following Text-Paging Intervenon
A
Efficiency in Page Response Time
B
Sasfacon with Communicaon
70% 61.54%
30% 23.08% 14.38%
0% Improved response Impaired response me me
No change
Improved communicaon
Impaired communicaon
No change
Fig. 5 e Efficiency and satisfaction after implementation. (Color version of figure is available online.)
Recording of the content of the text pages may also prove valuable, allowing for analysis so that text paging and text messaging communication can be optimized. The data collected will provide hospital administrators with support to justify the costs of technology updates desperately needed for hospital communications between healthcare providers. Improvements in communication technology may improve overall patient safety and satisfaction via decreases in work disruption and distractions, while continuing to improve provider and nurse satisfaction with communication and workflow.
Conclusions We successfully implemented a free universally available Web-based text paging initiative for nonurgent pages from nurses to residents that has improved physicianenurse workflow and communication on the surgical wards without an increase in adverse events or decrease in patient satisfaction.
Acknowledgment The authors would like to thank the nurses and residents at our institution who generously donated their time and effort to participate in this project. Authors’ contributions: J.H., M.J., K.F.A., K.D., M.G.N., and J.K. contributed to conception and design of study, acquisition of data, or analysis and interpretation of data; J.H., M.J., K.F.A., and S.R.S. contributed to final approval of the version to be submitted; J.H., M.J., K.F.A., K.D., M.J.N., S.R.S. responded to suggestions from reviewers and made further edits.
Disclosure The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.
references
1. The Joint Commission. Sentinel Event Data Root Causes by Event Type 2004e2013. Available at: http://www. jointcommission.org/assets/1/18/Root_Causes_by_Event_ Type_2004-2Q2013.pdf. 2. Smith AD, de Vos MS, Smink DS, Nguyen LL, Ashley SW. Text paging of surgery residents: efficacy, work intensity, and quality improvement. Surgery. 2016;159:930e937. 3. Plant MA, Fish JS. Resident use of the internet, e-mail, and personal electronics in the care of surgical patients. Teach Learn Med. 2015;27:215e223. 4. Khanna RR, Wachter RM, Blum M. Reimagining electronic clinical communication in the post-pager, smartphone era. JAMA. 2016;315:21e22. 5. Wu RC, Tran K, Lo V, et al. Effects of clinical communication interventions in hospitals: a systematic review of information and communication technology adoptions for improved communication between clinicians. Int J Med Inform. 2012;81:723e732. 6. Prochaska MT, Bird AN, Chadaga A, Arora VM. Resident use of text messaging for patient care: ease of use or breach of privacy? JMIR Med Inform. 2015;3:e37. 7. Przybylo JA, Wang A, Loftus P, Evans KH, Chu I, Shieh L. Smarter hospital communication: secure smartphone text messaging improves provider satisfaction and perception of efficacy, workflow. J Hosp Med. 2014;9:573e578.