Efficiency and Interpretability of Text Paging Communication for Medical Inpatients: A Mixed-Methods Analysis

The Perceived Ease of Use and Perceived Usefulness of a Web-Based Interprofessional Communication and Collaboration Platform in the Hospital Setting: Interview Study With Health Care Providers

BACKGROUND

Hospitalized patients with complex care needs require an interprofessional team of health professionals working together to support their care in hospitals and during discharge planning. However, interprofessional communication and collaboration in inpatient settings are often fragmented and inefficient, leading to poor patient outcomes and provider frustration. Health information technology can potentially help improve team communication and collaboration; however, to date, evidence of its effectiveness is lacking. There are also concerns that current implementations might further fragment communication and increase the clinician burden without proven benefits.

OBJECTIVE

In this study, we aimed to generate transferrable lessons for future designers of health information technology tools that facilitate team communication and collaboration.

METHODS

A secondary analysis of the qualitative component of the mixed methods evaluation was performed. The electronic communication and collaboration platform was implemented in 2 general internal medicine wards in a large community teaching hospital in Mississauga, Ontario, Canada. Fifteen inpatient clinicians in those wards, including nurses, physicians, and allied health care providers, were recruited to participate in semistructured interviews about their experience with a co-designed electronic communication and collaboration tool. Data were analyzed using the Technology Acceptance Model, and themes related to the constructs of perceived ease of use (PEOU) and perceived usefulness (PU) were identified.

RESULTS

A secondary analysis guided by the Technology Acceptance Model highlighted important points. Intuitive design precluded training as a barrier to use, but lack of training may hinder participants' PEOU if features designed for efficiency are not discovered by users. Organized information was found to be useful for creating a comprehensive clinical picture of each patient and facilitating improved handovers. However, information needs to be both comprehensive and succinct, and information overload may negatively impact PEOU. The mixed paper and electronic practice environment also negatively impacted PEOU owing to unavoidable double documentation and the need for printing. Participants perceived the tool to be useful as it improved efficiency in information retrieval and documentation, improved the handover process, afforded another mode of communication when face-to-face communication was impractical, and improved shared awareness. The PU of this tool depends on its optimal use by all team members.

CONCLUSIONS

Electronic tools can support communication and collaboration among interprofessional teams caring for patients with complex needs. There are transferable lessons learned that can improve the PU and PEOU of future systems.

Completeness and quality of text paging for subspecialty consult requests

It is unclear whether previously developed frameworks for effective consultation apply to requests initiated by alphanumeric text page. We assessed a random sample of 210 text paged consult requests for communication of previously described 'essential elements' for effective consultation: reason for consult, level of urgency and requester contact information. Overall page quality was evaluated on a 5-point Likert scale. Over 90% of text paged consult requests included contact information and reason for consult; 14% indicated level of urgency. In ordinal logistic regression, reason for consult was most strongly associated with quality (OR 22.4; 95% CI 8.1 to 61.7), followed by callback number (OR 6.2; 95% CI 0.8 to 49.5), caller's name (OR 5.0; 95% CI 1.9 to 13.1) and level of urgency (OR 3.3; 95% CI 1.6 to 6.7). Results suggest that text paged consult requests often include most informational elements, and that urgency, often missing, may not be as 'essential' for text pages as it was once thought to be.

Improving Communication Between Nursing Staff and On-Call Residents via a Standardized Paging Protocol

OBJECTIVES

Clear and efficient communication between nursing staff and medical providers is an essential component of healthcare delivery. At McLean Hospital, there is an inconsistency in utilization of alphanumeric paging, with many individuals communicating primarily via numeric-only pages that can cause difficulty in triaging importance of pages and lead to disruptions in care. This quality improvement project sought to improve communication between nursing staff and residents by decreasing the number of difficult to triage pages sent to the psychiatrist-on-call at a stand-alone academic psychiatric hospital.

METHODS

Pages were analyzed during two discrete month-long periods before and after the implementation of a standardized paging protocol, which included an updated online template asking the individual sending the page to include specific information (urgency of page, identifying information of patient, contact information, and name of sender) and dissemination of information on its use.

RESULTS

The implementation of this protocol resulted in a statistically significant decrease in the percentage of pages that were difficult to triage (22.1 to 15.0%; p < 0.05). Examining specific units in the hospital revealed significant variation of change, with as much as 40% reduction to as large as an 11% increase in difficult to triage pages.

CONCLUSIONS

The decrease in the percentage of difficult to triage pages suggests that a standard paging protocol can improve delivery of patient care by minimizing interruptions with low-priority pages and may improve quality of communication between nursing staff and physicians on-call, ultimately improving quality of care provided and bettering the resident learning environment.

Beyond duty hours: leveraging large-scale paging data to monitor resident workload

Monitoring and managing resident workload is a cornerstone of policy in graduate medical education, and the duty hours metric is the backbone of current regulations. While the duty hours metric measures hours worked, it does not capture differences in intensity of work completed during those hours, which may independently contribute to fatigue and burnout. Few such metrics exist. Digital data streams generated during the usual course of hospital operations can serve as a novel source of insight into workload intensity by providing high-resolution, minute-by-minute data at the individual level; however, study and use of these data streams for workload monitoring has been limited to date. Paging data is one such data stream. In this work, we analyze over 500,000 pages-two full years of pages in an academic internal medicine residency program-to characterize paging patterns among housestaff. We demonstrate technical feasibility, validity, and utility of paging burden as a metric to provide insight into resident workload beyond duty hours alone, and illustrate a general framework for evaluation and incorporation of novel digital data streams into resident workload monitoring.

Using an electronic tool to improve teamwork and interprofessional communication to meet the needs of complex hospitalized patients: A mixed methods study

BACKGROUND

Teamwork and interprofessional communication are important in addressing the comprehensive care needs of complex hospitalized patients. The objective of this study is to evaluate the impact of an electronic interprofessional communication and collaboration platform on teamwork, communication, and adverse events in the hospital setting.

MATERIALS AND METHODS

In this mixed methods study, we used a quasi-experimental design in the quantitative component and deployed the electronic tool in a staged fashion to 2 hospital wards 3 months apart. We measured teamwork, communication, and adverse events with Relational Coordination survey, video recordings of team rounds, and retrospective chart review. We conducted qualitative semi-structured interviews with clinicians to understand the perceived impacts of the electronic tool and other contextual factors.

RESULTS

Teamwork sustainably improved (overall Relational Coordination score improved from 3.68 at baseline to 3.84 at three and six months after intervention, p = 0.03) on ward 1. A small change in face-to-face communication pattern during team rounds was observed (making plans increased from 22% to 24%, p = 0.004) at 3 months on ward 1 but was not sustained at 6 months. Teamwork and communication did not change after the intervention on ward 2. There was no meaningful change to adverse event rates on either ward. Clinicians reported generally positive views about the electronic tool's impact but described non-technology factors on each ward that affected teamwork and communication.

CONCLUSION

The impact of using an electronic tool to improve teamwork and communication in the hospital setting appears mixed, but can be positive in some settings. Improving teamwork and communication likely require both appropriate technology and addressing non-technology factors.

Improving Standardization of Paging Communication Using Quality Improvement Methodology

BACKGROUND AND OBJECTIVES

Paging is a primary mode of communication in hospitals, but message quality varies. With this project, we aimed to standardize paging, thus improving end user (EU) satisfaction, patient safety, and efficiency. Objectives were to increase the percent of pages containing 6 critical elements (CEs) (ie, the sender's first and last name, a 7-digit callback number, patient name, room number, and urgency indicator [information only, call, or come] to 90%); improve EU satisfaction to 80% rating paging communication as good or excellent; and decrease the frequency of safety events related to paging.

METHODS

This multidisciplinary, system-wide quality improvement study was conducted at our stand-alone academic children's hospital. CEs were determined by EU consensus. Outcome measures were inclusion of all 6 CEs, provider satisfaction, and frequency of safety events. Process measures were inclusion of individual CEs and appropriateness and timeliness of response to pages. Balancing measures included number of work-arounds (WAs). Interventions included education, engineering a platform with required fields, and optimization enhancements. Statistical process control charts (p-charts; XmR) were used to track the impact of interventions.

RESULTS

Special-cause improvement was noted in use of all 6 CEs (4.4%-79.7%) and individual CEs. EU satisfaction improved from 50% to 85% rating paging communication as good or excellent. Safety events related to paging remain infrequent. Specific WA use decreased by 60%.

CONCLUSIONS

System-wide use of required fields produced significant improvement in inclusion of all 6 CEs and EU satisfaction. WAs were curbed by improving the ease of CE incorporation. Required fields should be considered at institutions seeking improved paging communication.

A Matter of Urgency: Reducing Clinical Text Message Interruptions During Educational Sessions

BACKGROUND

Text messaging is increasingly replacing paging as a tool to reach physicians on medical wards. However, this phenomenon has resulted in high volumes of nonurgent messages that can disrupt the learning climate.

OBJECTIVE

Our objective was to reduce nonurgent educational interruptions to residents on general internal medicine.

DESIGN, SETTING, PATIENTS

This was a quality improvement project conducted at an academic hospital network. Measurements and interventions took place on 8 general internal medicine inpatient teaching teams.

INTERVENTION

Interventions included (1) refining the clinical communication process in collaboration with nursing leadership; (2) disseminating guidelines with posters at nursing stations; (3) introducing a noninterrupting option for message senders; (4) audit and feedback of messages; (5) adding an alert for message senders advising if a message would interrupt educational sessions; and (6) training and support to nurses and residents.

MEASUREMENTS

Interruptions (text messages, phone calls, emails) received by institution-supplied team smartphones were tracked during educational hours using statistical process control charts. A 1-month record of text message content was analyzed for urgency at baseline and following the interventions.

RESULTS

The interruption frequency decreased from a mean of 0.92 (95% CI, 0.88 to 0.97) to 0.59 (95% CI, 0.51 to0.67) messages per team per educational hour from January 2014 to December 2016. The proportion of nonurgent educational interruptions decreased from 223/273 (82%) messages over one month to 123/182 (68%; P < .01).

CONCLUSIONS

Creation of communication guidelines and modification of text message interface with feedback from end-users were associated with a reduction in nonurgent educational interruptions. Continuous audit and feedback may be necessary to minimize nonurgent messages that disrupt educational sessions.