Published in the January 2011 issue of Today’s Hospitalist
HOSPITALIST PROGRAMS KNOW they’d practice more efficiently if they could just identify the factors that slow down workflow. For one North Carolina group, dissecting work patterns revealed a major, unexpected culprit: their pagers. Instead of speeding up communications, pagers had become a costly drag on operations.
"When we looked at where we were consistently losing efficiency, it was the pager," notes Darren Sommer, DO, hospitalist medical director at Southeastern Regional Medical Center in Lumberton, N.C. Every time a floor nurse needed a hospitalist, he explains, the doctor would be paged “regardless of whether the need was urgent or merely routine.
When Dr. Sommer would get a page that a patient’s potassium level was 3.3, he says, "I’d have to stop what I was doing and call, when the issue could safely have been handled later." Nurses were likewise constantly interrupted when the hospitalist returned the page.
After doing the math, Dr. Sommer realized that fielding requests and responding via pages took about 15 minutes out of the day “per page. The majority of the time, he reports, "hospitalists were spending 10 minutes trying to respond to a minor issue “like a medication adjustment “that should have taken only 30 seconds to deal with."
BlackBerry to the rescue
To solve the problem, Dr. Sommer’s 20-hospitalist group opted for another form of technology, taking the plunge into smartphones. The group assumed that using e-mail and text messaging instead of pages for non-urgent requests would boost productivity.
Nurses now e-mail a patient’s demographics and the nature of the problem or need, and the hospitalist reviews the details and decides when to address the issue. "Routine issues can now be resolved during natural pauses in workflow," Dr. Sommer points out, "not when the typical interruption could adversely affect patient care."
After researching available devices, the group opted to go with the BlackBerry because of its business platform and compatibility with the hospital’s existing communication systems. The medical center purchased the devices for each hospitalist, and it made needed enhancements to avoid weak signals and dropped calls.
"I definitely recommend that groups make sure the hospital puts in an internal antenna and a repeater to ensure a continuous signal," Dr. Sommer advises. "Most hospitals are not friendly to cell phones." At present, only the physicians are using the BlackBerrys; nurses email from their unit computers or portable "computers on wheels."
Not for critical results
Today, a year into the new system, the group uses the BlackBerrys for the basics: reporting non-emergent status changes, asking a hospitalist to assess a patient, requesting or prescribing medications, receiving test and lab results, and addressing requests from the emergency department ” and increasingly, community physicians “for new admissions.
The e-mail and text systems are not to be used for any urgent, emergent or critical situation, such as codes or rapid response team requests. Hospitalists have to be called directly, for instance, with any critical results.
Initially, deciding how to incorporate the BlackBerrys into the workflow was a challenge. Nurses and hospitalists alike were reluctant to abandon pagers altogether and had to be convinced that e-mail and text messages would be more efficient and potentially safer. "I got lots of complaints about it at first," Dr. Sommer says, "but now we couldn’t imagine going back to pagers."
Because users had such varying degrees of computer literacy, the initial learning curve was steep. However, Web-based templates helped ease many of the concerns and streamline the process.
Templates also made it possible for the hospital to mandate particular information. Required data fields include hospitalist/nurse name, phone and e-mail contact. Care-focused templates must include the patient’s name, DOB, medical record number, room number, and key demographics such as admitting diagnosis.
In addition, the physician request form includes situation, background, assessment and recommendation(s) (SBAR) fields. Other templates have been developed for medication and admission requests, and both outsiders and insiders can use a basic hospitalist contact link to reach the hospitalist service.
All hospitalists have their own BlackBerry phone number, and one device “with a dedicated number “is specifically used by the hospitalist "admissionist" on duty. That number, which was publicized widely once the new system was launched, allows referring physicians to bypass the hospital switchboard and contact the admitting hospitalist directly. Dr. Sommer credits it for an uptick in the number of direct admissions.
Agreeing on response times
There was also discussion over how long providers had to respond to an e-mail or text. The new protocol calls for conducting all routine communication via BlackBerry email, while people receiving messages need to respond promptly; they’re required to respond within 30 minutes. (At that time, the provider will contact the hospitalist directly by phone.) When nurses don’t receive a reply within 10 minutes, they are supposed to re-send the message. According to Dr. Sommer, that took some getting used to.
"Our doctors know that if they don’t answer the e-mail, they’ll get a phone call and be interrupted anyway, so they might at as well answer sooner rather than later," he says. That became "the carrot and the stick," he adds, between what nurses needed and doctors wanted.
Some users prefer being contacted directly by phone, and they’d have to be reminded to use the new system. "Sometimes, nurses would get frustrated and just want to pick up the phone," says Dr. Sommer, "or hospitalists wanted to take shortcuts and not fill in the templates. It took a lot of education and re-education to get everyone to understand the importance of standardized communication." They weren’t helping themselves, he notes, if they traded pager interruptions for phone interruptions.
According to Dr. Sommer, the BlackBerrys definitely save the doctors and nurses time. The exchanges also help transcription, and now the hospital “with only one overhead pager “is much quieter.
As for safety, the BlackBerry automatically provides a transcript of e-mails and calls, which can reduce the potential for prescribing or filling errors. The device also helps eliminate heated "he-said, she-said" exchanges.
"If the ER doc says, ‘Mr. Smith needs to be admitted for pneumonia and I e-mailed an hour ago,’ and it turns out it was only 15 minutes, there’s a record of that," Dr. Sommer says. "Being able to look at information also helps us make better decisions."
In terms of practice administration, Dr. Sommer says that the BlackBerry has been a godsend. The group uses the device’s calendar function to send out meeting notices, and Dr. Sommer judiciously sends group e-mails on policy changes or other important issues.
"It is nice to be able to reach our hospitalists when I need them, not just when they’re on duty," he points out. "They’re all much more likely to respond via the BlackBerry than when they’re using hospital e-mail exclusively."
Bonnie Darves is a freelance health care writer based in Seattle.