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Klein R, Jackman S, Nelson J. A Single-resident Experience of Overnight Call Activity at a Multi-site Academic Health System. Urology 2024:S0090-4295(24)00336-4. [PMID: 38703953 DOI: 10.1016/j.urology.2024.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/29/2024] [Accepted: 04/24/2024] [Indexed: 05/06/2024]
Abstract
OBJECTIVE To characterize urology resident on-call activities overnight at a multi-site academic medical center and model the expected volume of clinical activity using inpatient beds, emergency room visits, and attendings covered. MATERIALS AND METHODS On-call activities for 70 13-hour overnight shifts spanning 5 nonconsecutive months between May 2022 and February 2023 were recorded. Clinical coverage included 5 academic hospitals encompassing 1761 staffed inpatient beds and an expected nightly volume of 255 Emergency Department (ED) visits. The time, source, and clinical features of every call were documented. RESULTS An average of 15 unique calls were received during each shift. Of these, 35% required an in-person evaluation and 12% required a bedside or operative procedure. Approximately a third of calls (36%) were received after midnight. An in-person evaluation occurred within the first hour of 53% of shifts and every shift required at least 1 evaluation. When normalized for inpatient bed volume, an average of 7 unique patient communications occurred per 1000 beds, leading to 2 in-person evaluations. When normalized for an expected number of overnight ED visits, an average of 1 new ED consultation occurred per 100 ED visits. CONCLUSION After-hours clinical coverage models vary significantly by specialty and institution, and coverage decisions must balance quality clinical care with safe provider workload. Patient needs were appropriately addressed by a single overnight on-call resident, providing a robust clinical experience. The volume of patient care activities in this experience supports the practice of a "night-float" resident with the clear expectation on-site care is required.
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Affiliation(s)
- Roger Klein
- UPMC Department of Urology, UPMC, Pittsburgh, PA.
| | | | - Joel Nelson
- UPMC Department of Urology, UPMC, Pittsburgh, PA
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Carr MM, Foreman AM, Friedel JE, O’Brien DC, Wirth O. Factors Affecting Medical Residents' Decisions to Work After Call. J Patient Saf 2024; 20:16-21. [PMID: 38116942 PMCID: PMC10753934 DOI: 10.1097/pts.0000000000001175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
BACKGROUND Accreditation Council for Graduate Medical Education (ACGME) work-hour restrictions (WHRs) are intended to improve patient safety by reducing resident fatigue. Compliance with ACGME WHRs is not universal. PURPOSE The purpose of this study was to identify factors that influence residents' decisions to take a postcall day (PCD) off according to ACGME WHRs. METHODS Residents (N = 433) at one university were emailed a link to a survey in 2019. The survey included demographic details and a Discrete Choice Experiment examining influences on resident decisions to take a PCD off. RESULTS One hundred seventy-five residents (40.4%) responded to the survey; 113 residents (26%) completed the survey. Positive feedback from attending physicians about taking PCDs off in the past had the greatest impact on respondents' decisions to take a PCD off, increasing the probability by 27.3%, followed by chief resident comments about the resident looking tired (16.6% increase), and having never heard their attendings comment about PCDs off as either positive or negative (13.9% increase). Factors that had the largest effect on decreasing the probability of taking a PCD were negative feedback about taking PCDs off (14.3% decrease), continuity of care concerns (10.8% decrease), and whether the resident was looking forward to an assignment (7.9% decrease). CONCLUSIONS The most important influencer of residents' decisions to take a PCD off was related to feedback from their attending physicians, suggesting that compliance with WHRs can be improved by focusing on the residency program's safety culture.
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Affiliation(s)
- Michele M. Carr
- Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, NY
| | - Anne M. Foreman
- Bioanalytics Branch, Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV
| | | | | | - Oliver Wirth
- Bioanalytics Branch, Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV
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Raines A, Ahn J, Cain M, Fernandez N, Joyner B, Kieran K, Shnorhavorian M, Merguerian P. Reducing post-operative caregiver after-hours phone calls to pediatric urology providers: A quality improvement study. J Pediatr Urol 2023; 19:539.e1-539.e7. [PMID: 37482473 DOI: 10.1016/j.jpurol.2023.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 06/14/2023] [Accepted: 06/28/2023] [Indexed: 07/25/2023]
Abstract
INTRODUCTION Caregiver phone calls are an important part of caring for pediatric patients. At our institution, residents respond to after-hours caregiver calls. While it is critical for families to be able to reach us for urgent concerns, the ease of access has led to overutilization with many phone calls not meeting the urgent nature that is intended for these calls. The primary aim of this quality improvement project was to decrease the number of non-urgent caregiver calls after-hours. Our secondary aim was to improve compliance with telephone encounter documentation and to standardize the documentation content. STUDY DESIGN We conducted a single institution, multiphase quality improvement project. This started with a preintervention phase which included evaluation of our current state, identifying that most calls were for post-operative patients and that our discharge instructions inadequately detailed when caregivers should call. Notes were also inconsistently documented with no standard format. In the first PDSA cycle, launched on November 1, 2021, a standardized note template was created for documentation of caregiver telephone encounters. The PDSA cycle began on January 1, 2022 and included updates to our post-operative instructions with explicit guidance detailing when to call after-hours. Call data from September 2021 to February 2022 was reviewed including variables such as caller demographics, reason for call, and operative details. Primary outcomes were proportion of post-operative calls within 30 days and non-urgent calls. Secondary outcome was proportion of calls documented appropriately. Phases were categorized as current state (Sep/Oct 2021), PDSA cycle 1 (Nov/Dec 2021), PDSA cycle 2 (Jan/Feb 2022). RESULTS In our current state, the majority of the calls (66%) were for post-operative patients and 59% of all calls during this period were non-urgent. The proportion of post-operative phone calls stayed stable at 67% during PDSA cycle 1, but decreased to 38% with PDSA cycle 2 with implementation of updated post-operative instructions (Summary figure) (p < 0.001). The proportion of non-urgent calls was similar (current state - 68%, PDSA cycle 1 - 72%, PDSA cycle 2-73%, p = 0.39) (Summary figure). Call documentation was also similar with a documentation rate of 79% pre-intervention and 87% post-intervention (p = 0.21) (Summary figure). CONCLUSIONS With interventions focused on post-operative caregiver instructions, the number of post-operative phone calls decreased. Standardization of documentation was achieved. However, the overall call volume did not change, nor the proportion of non-urgent calls.
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Affiliation(s)
- Amanda Raines
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA.
| | - Jennifer Ahn
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
| | - Mark Cain
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
| | - Nicolas Fernandez
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
| | - Byron Joyner
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
| | - Kathleen Kieran
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
| | - Margarett Shnorhavorian
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
| | - Paul Merguerian
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
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Schröder A, Farhat WA, Bägli DJ, Lorenzo AJ, Koyle MA. Turning a new “page”: ways to decrease the number of pages after hours without compromising patient care. Can J Surg 2020; 63:E155-E160. [PMID: 32216252 DOI: 10.1503/cjs.009119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background Pages to house staff after hours, especially overnight, lead to interrupted sleep and fatigue the next day. Although some pages are urgent, others may not need an immediate response. In this study we aimed to identify unwarranted pages and to establish ways to reduce them. Methods Over 2 months, all pages to the Department of Pediatric Urology at the Hospital for Sick Children in Toronto, Canada, during call hours were documented, including the assessment of the responding physicians of their medical necessity. After analyzing the reasons for inappropriate pages, we took several steps to try to reduce them without impairing patient care. One year later, pages were tracked again to evaluate the efficacy of our interventions. Results In the initial measurement period, no calls from parents and approximately 50% of the in-hospital pages (15 of 36 pages from the wards, 27 of 49 pages from the emergency department, 17 of 31 pages requesting consultations, and 8 of 8 pages from the inhouse pharmacy and outside pharmacies) were considered medically urgent. The reasons for unwarranted pages were inconsistent parent teaching, lack of adequate triaging and prioritizing on the ward and lack of awareness of the structure of the on-call provisions among different services in the hospital. Several steps were taken to streamline the teaching of parents and nurses, standardize information, provide alternative means of communication within the hospital and restrict parents’ access by phone to the urologist on call. One year later, the number of pages had decreased by 70%. Conclusion Although physician coverage throughout the day and night is necessary for high-quality and safe patient care, communication with on-call physicians should be only for appropriate reasons. The provision of consistent teaching and alternative communication channels can improve patient care as well as decrease the number of after-hour pages.
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Affiliation(s)
- Annette Schröder
- From the Department of Urology and Pediatric Urology, University Medical Center, Johannes Gutenberg University of Mainz, Mainz, Germany (Schröder); and the Department of Urology, Hospital for Sick Children, Toronto, Ont. (Farhat, Bägli, Lorenzo, Koyle)
| | - Walid A. Farhat
- From the Department of Urology and Pediatric Urology, University Medical Center, Johannes Gutenberg University of Mainz, Mainz, Germany (Schröder); and the Department of Urology, Hospital for Sick Children, Toronto, Ont. (Farhat, Bägli, Lorenzo, Koyle)
| | - Darius J. Bägli
- From the Department of Urology and Pediatric Urology, University Medical Center, Johannes Gutenberg University of Mainz, Mainz, Germany (Schröder); and the Department of Urology, Hospital for Sick Children, Toronto, Ont. (Farhat, Bägli, Lorenzo, Koyle)
| | - Armando J. Lorenzo
- From the Department of Urology and Pediatric Urology, University Medical Center, Johannes Gutenberg University of Mainz, Mainz, Germany (Schröder); and the Department of Urology, Hospital for Sick Children, Toronto, Ont. (Farhat, Bägli, Lorenzo, Koyle)
| | - Martin A. Koyle
- From the Department of Urology and Pediatric Urology, University Medical Center, Johannes Gutenberg University of Mainz, Mainz, Germany (Schröder); and the Department of Urology, Hospital for Sick Children, Toronto, Ont. (Farhat, Bägli, Lorenzo, Koyle)
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Ludvigson AE. Impact of Volume and Type of Overnight Pages on Resident Sleep During Home Call. J Grad Med Educ 2018; 10:591-595. [PMID: 30386488 PMCID: PMC6194884 DOI: 10.4300/jgme-d-18-00174.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/24/2018] [Accepted: 07/18/2018] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Little research exists regarding factors that contribute to resident fatigue during home call. OBJECTIVE We objectively tracked the number and type of pages received, as well as residents' sleep time, during home call. We then examined the relationship between paging volume, resident sleep, and resident fatigue. METHODS A total of 4 of 4 urology residents (100%) at a single institution wore a FitBit Charge HR device from July 2015 to July 2016 to track sleep. Between January and July 2016, pages received by the on-call resident were counted as either floor (urology inpatient unit), clinic (after-hours answering service), or other. Postcall residents were defined as fatigued and excused at noon if they reported they were too tired to safely perform clinical duties. RESULTS Residents slept an average of 408 minutes per night while not on call, versus 368 minutes while on call but not fatigued, and 181 minutes while on call and fatigued (P < .05). The most senior resident received fewer pages per night on average than the most junior resident. Each page was associated with 4.71 fewer minutes asleep on average for all residents. Pages in the other category were associated with 7.74 fewer minutes asleep per page for all residents, but only the most junior resident had significantly less sleep, 9.02 minutes, per floor page. CONCLUSIONS Objective sleep data correlate with subjective assessment of resident fatigue and with volume and type of pages received. Senior residents spent less time awake per page and received fewer pages.
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Thériault B, Marceau-Grimard M, Blais AS, Fradet V, Moore K, Cloutier J. Urology residents on call: Investigating the workload and relevance of calls. Can Urol Assoc J 2018; 12:E71-E75. [PMID: 29381457 DOI: 10.5489/cuaj.4333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION On-call medical services assumed by residents represent many hours of hard work and no studies have documented what it really entails. As part of an effort to improve our on-call system, we examined phone calls received by residents on call. Our objectives were to evaluate the characteristics of phone calls received by residents on call (who, when, why, need to go to the hospital) and to determine residents' perception of these calls. We also looked into implementing strategies to reduce unnecessary calls. METHODS We prospectively collected information about calls using a standardized reporting form with the participation of all residents (10) from a single urology program over two periods of four weeks from November 2014 to March 2015. Residents answered pre- and post-collecting period questionnaires. RESULTS A total of 460 calls were recorded on 97 on-call days in two on-call lists. There was a mean of 3.5 (median 3, range 0-12) calls per weeknight and 7.7 (median 6, range 0-23) calls per weekend full day. Nintey-three calls (20%) led to the need for bedside evaluation and many of these were for new consultations (49%). The majority of calls originated from the clinical in-patient ward (49%) and emergency room (29%), and nurses (66%) and doctors (23%) most commonly initiated the calls. Calls between 11:00 pm and 8:00 am represented 13% of all calls. Most of the calls (77%) were perceived as relevant or very relevant. Most residents reported at least 80% of calls. CONCLUSIONS Although likely representing an underestimate of the reality, we provide a first effort in documenting the call burden of Canadian urology residents.
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Affiliation(s)
- Benoît Thériault
- Division of Urology, Department of Surgery, CHU de Québec-Université Laval, Quebec City, QC, Canada
| | - Maryse Marceau-Grimard
- Division of Urology, Department of Surgery, CHU de Québec-Université Laval, Quebec City, QC, Canada
| | - Anne-Sophie Blais
- Division of Urology, Department of Surgery, CHU de Québec-Université Laval, Quebec City, QC, Canada
| | - Vincent Fradet
- Division of Urology, Department of Surgery, CHU de Québec-Université Laval, Quebec City, QC, Canada
| | - Katherine Moore
- Division of Urology, Department of Surgery, CHU de Québec-Université Laval, Quebec City, QC, Canada
| | - Jonathan Cloutier
- Division of Urology, Department of Surgery, CHU de Québec-Université Laval, Quebec City, QC, Canada
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Lehmann AE, Kozin ED, Sethi RKV, Wong K, Lin BM, Gray ST, Cunningham MJ. Resident responses to after-hours otolaryngology patient phone calls: An overlooked aspect of residency training? Laryngoscope 2017; 128:E163-E170. [PMID: 28782193 DOI: 10.1002/lary.26784] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 06/05/2017] [Accepted: 06/08/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS Otolaryngology residents are often responsible for triaging after-hours patient calls. However, residents receive little training on this topic. Data are limited on the clinical content, reporting, and management of otolaryngology patient calls. This study aimed to characterize the patient concerns residents handle by phone and their subsequent management and reporting. STUDY DESIGN Retrospective review. METHODS Five hundred consecutive after-hours patient calls in a tertiary pediatric hospital were reviewed. Data collected included patient and caller demographics, clinical concerns, surgical history, recommendations, and subsequent emergency department (ED) visits. RESULTS On average, 3.7 calls occurred per shift, 2.8 on weekday and 5.9 on weekend shifts. Mean patient age was 6.6 years. Mothers (71%) called most frequently. The majority of calls were postoperative (64.2%). Of postoperative calls, most occurred within 3 days of surgery (52.3%). Most calls were for surgical site bleeding (19.9%). Residents recommended ED evaluation for 17.2% of calls, of which 20.9% returned to the primary institution ED. ED evaluation was recommended more frequently for postoperative patients (P = .040), particularly following adenotonsillectomy (51.2%) or surgical site bleeding (18.6%). With respect to documentation, 32.8% of medical record numbers were absent, 11.8% had name errors, and 2.2% of patients could not be identified. CONCLUSIONS This is the first study to analyze the management and reporting of patient calls by otolaryngology residents. A wide array of clinical concerns are triaged by phone conversations. The study has implications for both resident and patient education. LEVEL OF EVIDENCE 4. Laryngoscope, 128:E163-E170, 2018.
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Affiliation(s)
- Ashton E Lehmann
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.,Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Elliott D Kozin
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.,Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Rosh K V Sethi
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.,Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Kevin Wong
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Brian M Lin
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.,Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, U.S.A
| | - Stacey T Gray
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - Michael J Cunningham
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.,Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, Massachusetts, U.S.A
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