Where: Sunnybrook Health Sciences Centre, an academic teaching hospital affiliated with the University of Toronto that has 94 beds on its four general medicine wards.
The issue: Reducing the number of pages sent to the wrong physician.
A few years ago, general internist Brian Wong, MD, overheard a nurse complaining about a recent attempt to page a physician. “They tried paging over and over again to the intern or the resident that was supposed to be on call….No one returned the call and finally they escalated to either the senior resident or the staff physician,” Dr. Wong said.
At the time, the system at Sunnybrook was to write the on-call physician's pager number on a white board on the unit. “It turned out someone had written the pager number with the last two numbers switched around. The patient was fine, but you could imagine the potential for delay and the potential for harm,” he said.
Harm could also result if pages were sent to off-duty physicians. “It was this issue of not having the scheduling linked to the messaging,” said Dr. Wong. He and colleagues quantified the frequency of such incidents at Sunnybrook in early 2008 and found that 14% of all pages were sent to the wrong physician, according to results published in the June 8, 2009 Archives of Internal Medicine. “The next step was the quality improvement around reducing the problem,” he said.
How it works
“We landed on this idea: There should just be one person, a gatekeeper for the team that would receive the information and then triage it or deal with it,” said Dr. Wong. The concept of team-based paging was not unique, but the Sunnybrook group modified it by electronically linking the paging system to the resident schedule. A Web-based system would automatically direct pages to the on-duty physician. The paging nurse didn't even have to know which physician she was contacting.
The new system also made it simpler to change the designated page recipient when necessary. “If there was someone who was away or sick, that change would be instantaneous,” Dr. Wong said. “You could update the computer system and then across the institution it was automatically updated.”
The group measured the success of the change by comparing pages before, during and after implementation of the new system. Under the old paging system, general medicine pages were sent to the wrong doctor 14% of the time, about the same as on other wards of the hospital. After the change, only 3% of medicine pages were wrong, compared to 7% on the other wards.
The new system also pleased nurses. “It solved a real problem for them. It solved this issue of having to figure out from these various sources of data who was on call or who was available,” said Dr. Wong. According to results published online by BMJ Quality and Safety last November, nurses said the new system made it easier to contact the right physician and was less disruptive.
The new system was not without disadvantages, especially for the resident who was now assigned to receive all the pages for his team. “It was very disruptive for that resident,” said Dr. Wong. The new system also posed the risk that the resident, busy dealing with so many pages, might not promptly relay information received in a page to the appropriate person.
“We're pretty confident at least that for urgent things, that wasn't an issue, but maybe [it was] for the more nonurgent things,” said Dr. Wong. “We don't have a good way of measuring that.”
Despite these potential flaws, some residents expressed appreciation for the new system. “They liked having all the information come to them so they knew what was happening with everyone. In the old system, if a patient of the team was sick, and a page went to one of their medical students or junior residents, they might not really know that this was happening until the resident or a student told them,” Dr. Wong said.
The researchers are continuing to observe the effects of the paging system, in the hopes of catching any additional side effects. They are also still thinking about the overall issue that the system was designed to improve.
“The next step is to really understand the other aspects of communication between physicians and nurses,” Dr. Wong said. “One problem with these pages is you can't even acknowledge that you received the message….Is paging the only way that we can communicate some of these issues?” A study is currently under way at Sunnybrook and several other Toronto hospitals to compare more diverse models for hospital communication, he said.