Laura Fanucchi, MD, MPH

Injection drug use (IDU) is a major public health problem leading to increased morbidity, mortality, and healthcare expenditures.[1, 2, 3] Persons who inject drugs (PWID) are often hospitalized with severe infections, such as endocarditis,[4, 5] which typically require prolonged courses of intravenous (IV) antibiotics. Outpatient parenteral antibiotic therapy (OPAT) via a peripherally inserted central catheter (PICC) is the standard of care for continuing IV medications once patients are medically stable and ready for discharge.[6] PWID have been excluded from OPAT studies,[6] leaving little evidence to guide care.[7] Furthermore, likely due to fears of ongoing IDU, PWID are often kept in the hospital for the full duration of their antibiotic courses. This practice is costly and may not be optimal, especially considering that hospitalized PWID have high rates of discharges against medical advice.[8, 9]

In 2012, as part of a quality‐improvement effort focused on hospitalized PWID requiring long courses of IV antibiotics, UKHealthCare in Lexington, Kentucky, established a protocol for OPAT in PWID meeting specific criteria. As this protocol was not widely adopted, we sought to formally assess attitudes, practices, and mediating factors impacting the decision making about discharging PWID on OPAT to inform future efforts. This study was approved by the University of Kentucky (UK) Institutional Review Board.

METHODS

A 14‐item survey (see Supporting Information, Appendix, in the online version of this article) with multiple‐choice and open‐ended response items was developed based on the existing protocol, and themes were confirmed through semistructured interviews with 10 attending physicians in hospital medicine (HM) and infectious disease (ID). Questions were designed to elucidate the role that IDU played in the decision to discharge patients on OPAT, identify barriers to discharging PWID on OPAT, as well as elicit recommendations for requisite services or programs. The first question excluded providers not caring for patients requiring long‐term IV antibiotics. Questions that allowed for open‐ended responses were categorized thematically initially by 1 researcher (L.F.), then refined and confirmed by another team member (J.L.). The survey was distributed over email through Qualtrics (Provo, Utah) software to attending physicians in HM, ID, cardiology, and surgery at UK. Qualtrics software was used to generate descriptive statistics.

RESULTS

In January 2015, the survey was emailed to 66 physicians, and the response rate was 83%, with 91% reporting caring for patients requiring long‐term IV antibiotics. Of those, 41 (82%) completed all items; 66% of completers were in HM, 12% ID, 10% surgery, and 2% cardiology. Sixty percent were male and in practice an average of 7.2 years. Thirty‐nine (95%) use OPAT for patients without IDU, but only 12 (29%) would consider OPAT in PWID. If the patient has a remote history of IDU, then 33 (79%) would consider OPAT. There was no agreed‐upon definition of remote history of IDU (range, 2120 months; median, 12 months).

The most common physician‐identified barriers to discharging PWID on OPAT, as well as recommendations for services or processes to be in place to allow PWID to be discharged with OPAT, are listed in Table 1.

DISCUSSION

This survey illustrates the extremely complex barriers present when treating hospitalized PWID requiring long courses of IV antibiotics, and supports the anecdotal evidence that physicians often keep PWID in the hospital for weeks to administer IV antibiotics. The majority of our sample of physicians believe that the largest barriers to OPAT in PWID are socioeconomic factors and the potential risk of the patient misusing the PICC line. Although the overall response rate of our physician survey was robust,[10] our results reflect the opinions of HM and ID physicians at a single site. The low response rate among cardiologists in particular limits the generalizability of this survey. We suspect, however, that our results pertain to HM in other US hospitals, as nearly three‐fourths of 37 HM physicians surveyed at the University of California, Irvine were very concerned about PWIDs potentially misusing the PICC line, and approximately half reported they usually or always kept PWID in the hospital for prolonged treatment due to concern of substance use (personal and email communication: Lloyd Rucker, MD, unpublished data, November 6, 2015).

We were surprised that fewer than half of respondents identified substance use disorder (SUD) treatment as essential to the OPAT decision. The reasons that may explain this observation are likely multifactorial, and may include gaps in knowledge about and resources to provide evidence‐based addiction medicine. Further research is warranted to explore this observation, including the effect of enrollment into medication‐assisted treatment programs (eg, methadone, buprenorphine).

This survey suggests that although there is variability, OPAT may be an option in PWID, if outpatient follow‐up and ancillary services (ie, home health and possibly intensive case management) were well established. We believe the comorbid SUD must be also addressed. Based on the survey results and recommendations, we have begun relationships with community SUD treatment providers willing to monitor IV antibiotics with PICC lines, and dedicated additional case management staff to this population. We are evaluating these programs with the goal of contributing to an evidence base for this high‐risk population.

Injection drug use (IDU) is a major public health problem leading to increased morbidity, mortality, and healthcare expenditures.[1, 2, 3] Persons who inject drugs (PWID) are often hospitalized with severe infections, such as endocarditis,[4, 5] which typically require prolonged courses of intravenous (IV) antibiotics. Outpatient parenteral antibiotic therapy (OPAT) via a peripherally inserted central catheter (PICC) is the standard of care for continuing IV medications once patients are medically stable and ready for discharge.[6] PWID have been excluded from OPAT studies,[6] leaving little evidence to guide care.[7] Furthermore, likely due to fears of ongoing IDU, PWID are often kept in the hospital for the full duration of their antibiotic courses. This practice is costly and may not be optimal, especially considering that hospitalized PWID have high rates of discharges against medical advice.[8, 9]

In 2012, as part of a quality‐improvement effort focused on hospitalized PWID requiring long courses of IV antibiotics, UKHealthCare in Lexington, Kentucky, established a protocol for OPAT in PWID meeting specific criteria. As this protocol was not widely adopted, we sought to formally assess attitudes, practices, and mediating factors impacting the decision making about discharging PWID on OPAT to inform future efforts. This study was approved by the University of Kentucky (UK) Institutional Review Board.

METHODS

A 14‐item survey (see Supporting Information, Appendix, in the online version of this article) with multiple‐choice and open‐ended response items was developed based on the existing protocol, and themes were confirmed through semistructured interviews with 10 attending physicians in hospital medicine (HM) and infectious disease (ID). Questions were designed to elucidate the role that IDU played in the decision to discharge patients on OPAT, identify barriers to discharging PWID on OPAT, as well as elicit recommendations for requisite services or programs. The first question excluded providers not caring for patients requiring long‐term IV antibiotics. Questions that allowed for open‐ended responses were categorized thematically initially by 1 researcher (L.F.), then refined and confirmed by another team member (J.L.). The survey was distributed over email through Qualtrics (Provo, Utah) software to attending physicians in HM, ID, cardiology, and surgery at UK. Qualtrics software was used to generate descriptive statistics.

RESULTS

In January 2015, the survey was emailed to 66 physicians, and the response rate was 83%, with 91% reporting caring for patients requiring long‐term IV antibiotics. Of those, 41 (82%) completed all items; 66% of completers were in HM, 12% ID, 10% surgery, and 2% cardiology. Sixty percent were male and in practice an average of 7.2 years. Thirty‐nine (95%) use OPAT for patients without IDU, but only 12 (29%) would consider OPAT in PWID. If the patient has a remote history of IDU, then 33 (79%) would consider OPAT. There was no agreed‐upon definition of remote history of IDU (range, 2120 months; median, 12 months).

The most common physician‐identified barriers to discharging PWID on OPAT, as well as recommendations for services or processes to be in place to allow PWID to be discharged with OPAT, are listed in Table 1.

DISCUSSION

This survey illustrates the extremely complex barriers present when treating hospitalized PWID requiring long courses of IV antibiotics, and supports the anecdotal evidence that physicians often keep PWID in the hospital for weeks to administer IV antibiotics. The majority of our sample of physicians believe that the largest barriers to OPAT in PWID are socioeconomic factors and the potential risk of the patient misusing the PICC line. Although the overall response rate of our physician survey was robust,[10] our results reflect the opinions of HM and ID physicians at a single site. The low response rate among cardiologists in particular limits the generalizability of this survey. We suspect, however, that our results pertain to HM in other US hospitals, as nearly three‐fourths of 37 HM physicians surveyed at the University of California, Irvine were very concerned about PWIDs potentially misusing the PICC line, and approximately half reported they usually or always kept PWID in the hospital for prolonged treatment due to concern of substance use (personal and email communication: Lloyd Rucker, MD, unpublished data, November 6, 2015).

We were surprised that fewer than half of respondents identified substance use disorder (SUD) treatment as essential to the OPAT decision. The reasons that may explain this observation are likely multifactorial, and may include gaps in knowledge about and resources to provide evidence‐based addiction medicine. Further research is warranted to explore this observation, including the effect of enrollment into medication‐assisted treatment programs (eg, methadone, buprenorphine).

This survey suggests that although there is variability, OPAT may be an option in PWID, if outpatient follow‐up and ancillary services (ie, home health and possibly intensive case management) were well established. We believe the comorbid SUD must be also addressed. Based on the survey results and recommendations, we have begun relationships with community SUD treatment providers willing to monitor IV antibiotics with PICC lines, and dedicated additional case management staff to this population. We are evaluating these programs with the goal of contributing to an evidence base for this high‐risk population.

Injection drug use (IDU) is a major public health problem leading to increased morbidity, mortality, and healthcare expenditures.[1, 2, 3] Persons who inject drugs (PWID) are often hospitalized with severe infections, such as endocarditis,[4, 5] which typically require prolonged courses of intravenous (IV) antibiotics. Outpatient parenteral antibiotic therapy (OPAT) via a peripherally inserted central catheter (PICC) is the standard of care for continuing IV medications once patients are medically stable and ready for discharge.[6] PWID have been excluded from OPAT studies,[6] leaving little evidence to guide care.[7] Furthermore, likely due to fears of ongoing IDU, PWID are often kept in the hospital for the full duration of their antibiotic courses. This practice is costly and may not be optimal, especially considering that hospitalized PWID have high rates of discharges against medical advice.[8, 9]

In 2012, as part of a quality‐improvement effort focused on hospitalized PWID requiring long courses of IV antibiotics, UKHealthCare in Lexington, Kentucky, established a protocol for OPAT in PWID meeting specific criteria. As this protocol was not widely adopted, we sought to formally assess attitudes, practices, and mediating factors impacting the decision making about discharging PWID on OPAT to inform future efforts. This study was approved by the University of Kentucky (UK) Institutional Review Board.

METHODS

A 14‐item survey (see Supporting Information, Appendix, in the online version of this article) with multiple‐choice and open‐ended response items was developed based on the existing protocol, and themes were confirmed through semistructured interviews with 10 attending physicians in hospital medicine (HM) and infectious disease (ID). Questions were designed to elucidate the role that IDU played in the decision to discharge patients on OPAT, identify barriers to discharging PWID on OPAT, as well as elicit recommendations for requisite services or programs. The first question excluded providers not caring for patients requiring long‐term IV antibiotics. Questions that allowed for open‐ended responses were categorized thematically initially by 1 researcher (L.F.), then refined and confirmed by another team member (J.L.). The survey was distributed over email through Qualtrics (Provo, Utah) software to attending physicians in HM, ID, cardiology, and surgery at UK. Qualtrics software was used to generate descriptive statistics.

RESULTS

In January 2015, the survey was emailed to 66 physicians, and the response rate was 83%, with 91% reporting caring for patients requiring long‐term IV antibiotics. Of those, 41 (82%) completed all items; 66% of completers were in HM, 12% ID, 10% surgery, and 2% cardiology. Sixty percent were male and in practice an average of 7.2 years. Thirty‐nine (95%) use OPAT for patients without IDU, but only 12 (29%) would consider OPAT in PWID. If the patient has a remote history of IDU, then 33 (79%) would consider OPAT. There was no agreed‐upon definition of remote history of IDU (range, 2120 months; median, 12 months).

The most common physician‐identified barriers to discharging PWID on OPAT, as well as recommendations for services or processes to be in place to allow PWID to be discharged with OPAT, are listed in Table 1.

DISCUSSION

This survey illustrates the extremely complex barriers present when treating hospitalized PWID requiring long courses of IV antibiotics, and supports the anecdotal evidence that physicians often keep PWID in the hospital for weeks to administer IV antibiotics. The majority of our sample of physicians believe that the largest barriers to OPAT in PWID are socioeconomic factors and the potential risk of the patient misusing the PICC line. Although the overall response rate of our physician survey was robust,[10] our results reflect the opinions of HM and ID physicians at a single site. The low response rate among cardiologists in particular limits the generalizability of this survey. We suspect, however, that our results pertain to HM in other US hospitals, as nearly three‐fourths of 37 HM physicians surveyed at the University of California, Irvine were very concerned about PWIDs potentially misusing the PICC line, and approximately half reported they usually or always kept PWID in the hospital for prolonged treatment due to concern of substance use (personal and email communication: Lloyd Rucker, MD, unpublished data, November 6, 2015).

We were surprised that fewer than half of respondents identified substance use disorder (SUD) treatment as essential to the OPAT decision. The reasons that may explain this observation are likely multifactorial, and may include gaps in knowledge about and resources to provide evidence‐based addiction medicine. Further research is warranted to explore this observation, including the effect of enrollment into medication‐assisted treatment programs (eg, methadone, buprenorphine).

This survey suggests that although there is variability, OPAT may be an option in PWID, if outpatient follow‐up and ancillary services (ie, home health and possibly intensive case management) were well established. We believe the comorbid SUD must be also addressed. Based on the survey results and recommendations, we have begun relationships with community SUD treatment providers willing to monitor IV antibiotics with PICC lines, and dedicated additional case management staff to this population. We are evaluating these programs with the goal of contributing to an evidence base for this high‐risk population.

We acknowledge that our inability to measure in‐person interruptions is a limitation of our study. We maintain that while in‐person interruptions may increase in geographically localized patient care units, this form of direct face‐to‐face communication is more effective, efficient and decreases the latent errors inherent in alphanumeric paging.

Dr. Gandiga cites a study conducted in an emergency department where the vast majority of interruptions to attending physicians were in person from nurses or medical staff. We feel that this study cannot be extrapolated to medical floors, as the workflow and patient flow in an emergency department is very different than on a medical floor. The continuous throughput of patients in an emergency department would require ongoing and frequent communication between the different members of the care team. In addition, the physicians in that study were receiving an average of 1 page in 12 hours, compared to greater than 25 in 12 hours for our interns on a localized service, which illustrates the problem with comparing the emergency department to a localized medical floor.[1, 2]

We believe that the benefits of geographically localized care models, which include dramatic decreases in paging, improved efficiency, and greater agreement on the plan of care, outweigh the probable increases in in‐person interruptions. Additional study is indeed warranted to further clarify this discussion.

We acknowledge that our inability to measure in‐person interruptions is a limitation of our study. We maintain that while in‐person interruptions may increase in geographically localized patient care units, this form of direct face‐to‐face communication is more effective, efficient and decreases the latent errors inherent in alphanumeric paging.

Dr. Gandiga cites a study conducted in an emergency department where the vast majority of interruptions to attending physicians were in person from nurses or medical staff. We feel that this study cannot be extrapolated to medical floors, as the workflow and patient flow in an emergency department is very different than on a medical floor. The continuous throughput of patients in an emergency department would require ongoing and frequent communication between the different members of the care team. In addition, the physicians in that study were receiving an average of 1 page in 12 hours, compared to greater than 25 in 12 hours for our interns on a localized service, which illustrates the problem with comparing the emergency department to a localized medical floor.[1, 2]

We believe that the benefits of geographically localized care models, which include dramatic decreases in paging, improved efficiency, and greater agreement on the plan of care, outweigh the probable increases in in‐person interruptions. Additional study is indeed warranted to further clarify this discussion.

We acknowledge that our inability to measure in‐person interruptions is a limitation of our study. We maintain that while in‐person interruptions may increase in geographically localized patient care units, this form of direct face‐to‐face communication is more effective, efficient and decreases the latent errors inherent in alphanumeric paging.

Dr. Gandiga cites a study conducted in an emergency department where the vast majority of interruptions to attending physicians were in person from nurses or medical staff. We feel that this study cannot be extrapolated to medical floors, as the workflow and patient flow in an emergency department is very different than on a medical floor. The continuous throughput of patients in an emergency department would require ongoing and frequent communication between the different members of the care team. In addition, the physicians in that study were receiving an average of 1 page in 12 hours, compared to greater than 25 in 12 hours for our interns on a localized service, which illustrates the problem with comparing the emergency department to a localized medical floor.[1, 2]

We believe that the benefits of geographically localized care models, which include dramatic decreases in paging, improved efficiency, and greater agreement on the plan of care, outweigh the probable increases in in‐person interruptions. Additional study is indeed warranted to further clarify this discussion.

It's hard to imagine a busy urban hospital without its chorus of beepers.[1] This statement, the first sentence of an article published in 1988, rings (or beeps or buzzes) true to any resident physician today. At that time, pagers had replaced overhead paging, and provided a rapid method to contact physicians who were often scattered throughout the hospital. Still, it was an imperfect solution as the ubiquitous pager constantly interrupted patient care and other tasks, failed to prioritize information, and added to an already stressful working environment. Notably, interns were paged on average once per hour, and occasionally 5 or more times per hour, a frequency that was felt to be detrimental to patient care and to the working environment of resident physicians.[1]

Little has changed. Despite the instant, multidirectional communication platforms available today, alphanumeric paging remains a mainstay of communication between physicians and other members of the care team. Importantly, paging contributes to communication errors (eg, by failing to convey urgency, having incomplete information, or being missed entirely by coverage gaps),[2, 3] and interrupts resident workflow, thereby negatively affecting work efficiency and educational activities, and adding to perceived workload.[4, 5]

In this era of duty hour restrictions, there has been concern that residents experience increased workload due to having fewer hours to do the same amount of work.[6, 7] As such, the Accreditation Council of Graduate Medical Education emphasizes the quality of those hours, with a focus on several aspects of the resident working environment as key to improved educational and patient safety outcomes.[8, 9, 10]

Geographic localization of physicians to patient care units has been proposed as a means to improve communication and agreement on plans of care,[11, 12] and also to reduce resident workload by decreasing inefficiencies attributable to traveling throughout the hospital.[13] O'Leary, et al. (2009) found that when physicians were localized to 1 hospital unit, there was greater agreement between physicians and nurses on various aspects of care, such as planned tests and anticipated length of stay. In addition, members of the patient care team were better able to identify one another, and there was a perceived increase in face‐to‐face communication, and a perceived decrease in text paging.[11]

In consideration of these factors, in July 2011, at New YorkPresbyterian Hospital/Weill Cornell (NYPH/WC), an 800‐bed tertiary care teaching hospital in New York, New York, we geographically localized 2 internal medicine resident teams, and partially localized 2 additional teams. We investigated whether interns on teams that were geographically localized received fewer pages than interns on teams that were not localized. This study was reviewed by the institutional review board of Weill Cornell Medical College and met the requirements for exemption.

METHODS

We conducted a retrospective analysis of the number of pages received by interns during the day (7:00 _am to 7:00 _pm) on 5 general internal medicine teams during a 1‐month ward rotation between October 17, 2011 and November 13, 2011 at NYPH/WC. The general medicine teams were composed of 1 attending, 1 resident, and 2 interns each. Two teams were geographically localized to a 32‐bed unit (geographic localization model [GLM]). Two teams were partially localized to a 26‐bed unit, which included a respiratory care step‐down unit (partial localization model [PLM]). A fifth and final team admitted patients irrespective of their assigned bed location (standard model [SM]). Both the GLM and the PLM occasionally carried patients on other units to allow for overall census management and patient throughput. The total number of pages received by each intern over the study period was collected by retrospective analysis of electronic paging logs. Night pages (7 _pm7 _am) were excluded because of night float coverage. Weekend pages were excluded because data were inaccurate due to coverage for days off.

The daily number of admissions and daily census per team were recorded by physician assistants, who also assigned new patients to appropriate teams according to an admissions algorithm (see Supporting Figure 1 in the online version of this article). The percent of geographically localized patients on each team was estimated from the percentage of localized patients on the day of discharge averaged over the study period. For the SM team, percent localization was defined as the number of patients on the patient care unit that contained the team's work area.

Figure 1

Standard multivariate linear regression techniques were used to analyze the relationship between the number of pages received per intern and the type of team, controlling for the potential effect of total census and number of admissions. The regression model was used to determine adjusted marginal point estimates and 95% confidence intervals (CIs) for the average number of pages per intern per hour for each type of team. All statistical analyses were conducted using Stata version 12 (StataCorp, College Station, TX).

RESULTS

Over the 28‐day study period, a total of 6652 pages were received by 10 interns on 5 general internal medicine teams from 7 _am to 7 _pm Monday through Friday. The average daily census, average daily admissions, and percent of patients localized to patient care units for the individual teams are shown in Table 1. In univariate analysis, the mean daily pages per intern were not significantly different between the 2 teams within the GLM, nor between the 2 teams in the PLM, allowing them to be combined in multivariate analysis (data not shown). The number of pages received per intern per hour, adjusted for team census and number of admissions, was 2.2 (95% CI: 2.02.4) in the GLM, 2.8 (95% CI: 2.6‐3.0) in the PLM, and 3.9 (95% CI: 3.6‐4.2) in the SM (Table 1). All of these differences were statistically significant (P<0.001).

Figure 1 shows the pattern of daytime paging for each model. The GLM and PLM had a similar pattern, with an initial ramp up in the first 2 hours of the day, holding steady until approximately 4 _pm, and then decrease until 7 _pm. The SM had a steeper initial rise, and then continued to increase slowly until a peak at 4 _pm.

DISCUSSION

This study corroborates that of Singh et al. (2012), who found that geographic localization led to significantly fewer pages.[14] Our results strengthen the evidence by demonstrating that even modest differences between the percent of patients localized to a care unit led to a significant decrease in the number of pages, indicating a dose‐response effect. The paging frequency we measured is higher than described in Singh et al. (1.4 pages per hour for localized teams), yet our average census appears to be 4 patients higher, which may account for some of that difference. We also show that interns on teams whose patients are more widely scattered throughout the hospital may experience upward of 5 pages per hour, an interruption by pager every 12 minutes, all day long.

A pager interruption is not solely limited to a disruption by noxious sound or vibration. The page recipient must then read the page and respond accordingly, which may involve a phone call, placing an order, walking to another location, or other work tasks. Although some of these interruptions must be handled immediately, such as a clinically deteriorating patient, many are not urgent, and could wait until the physician's current task or thought process is complete. There is also the potentially risky assumption on the part of the sender that the message has been received and will be acted upon. Furthermore, frequent paging is a common interruption to physician workflow; interruptions contribute to increased perceived physician workload[4, 5] and are likely detrimental to patient safety.[15, 16]

The most common metrics used to measure resident workload are patient census and number of admissions,[13] but these metrics have provided a mixed and likely incomplete picture. Recent research suggests that other factors, such as work efficiency (including interruptions, time spent obtaining test results, and time in transit) and work intensity (such as the acuity and complexity of patients), contribute significantly to actual and perceived resident workload.[13]

Our analysis was a single‐site, retrospective study, which occurred over 1 month and was limited to internal medicine teams. Additionally, geographic localization logically should lead to increased face‐to‐face interruptions, which we were unable to measure with this project, but direct communication is more efficient and less prone to error, which would likely lead to fewer overall interruptions. Although we anticipate that our findings are applicable to geographically localized patient care units in other hospitals, further investigation is warranted.

The paging chorus has only grown louder over the last 25 years, with likely downstream effects on patient safety and resident education. To mitigate these effects, it is incumbent upon us to approach our training and patient care environments with a critical and creative lens, and to explore opportunities to decrease interruptions and streamline our communication systems.

It's hard to imagine a busy urban hospital without its chorus of beepers.[1] This statement, the first sentence of an article published in 1988, rings (or beeps or buzzes) true to any resident physician today. At that time, pagers had replaced overhead paging, and provided a rapid method to contact physicians who were often scattered throughout the hospital. Still, it was an imperfect solution as the ubiquitous pager constantly interrupted patient care and other tasks, failed to prioritize information, and added to an already stressful working environment. Notably, interns were paged on average once per hour, and occasionally 5 or more times per hour, a frequency that was felt to be detrimental to patient care and to the working environment of resident physicians.[1]

Little has changed. Despite the instant, multidirectional communication platforms available today, alphanumeric paging remains a mainstay of communication between physicians and other members of the care team. Importantly, paging contributes to communication errors (eg, by failing to convey urgency, having incomplete information, or being missed entirely by coverage gaps),[2, 3] and interrupts resident workflow, thereby negatively affecting work efficiency and educational activities, and adding to perceived workload.[4, 5]

In this era of duty hour restrictions, there has been concern that residents experience increased workload due to having fewer hours to do the same amount of work.[6, 7] As such, the Accreditation Council of Graduate Medical Education emphasizes the quality of those hours, with a focus on several aspects of the resident working environment as key to improved educational and patient safety outcomes.[8, 9, 10]

Geographic localization of physicians to patient care units has been proposed as a means to improve communication and agreement on plans of care,[11, 12] and also to reduce resident workload by decreasing inefficiencies attributable to traveling throughout the hospital.[13] O'Leary, et al. (2009) found that when physicians were localized to 1 hospital unit, there was greater agreement between physicians and nurses on various aspects of care, such as planned tests and anticipated length of stay. In addition, members of the patient care team were better able to identify one another, and there was a perceived increase in face‐to‐face communication, and a perceived decrease in text paging.[11]

In consideration of these factors, in July 2011, at New YorkPresbyterian Hospital/Weill Cornell (NYPH/WC), an 800‐bed tertiary care teaching hospital in New York, New York, we geographically localized 2 internal medicine resident teams, and partially localized 2 additional teams. We investigated whether interns on teams that were geographically localized received fewer pages than interns on teams that were not localized. This study was reviewed by the institutional review board of Weill Cornell Medical College and met the requirements for exemption.

METHODS

We conducted a retrospective analysis of the number of pages received by interns during the day (7:00 _am to 7:00 _pm) on 5 general internal medicine teams during a 1‐month ward rotation between October 17, 2011 and November 13, 2011 at NYPH/WC. The general medicine teams were composed of 1 attending, 1 resident, and 2 interns each. Two teams were geographically localized to a 32‐bed unit (geographic localization model [GLM]). Two teams were partially localized to a 26‐bed unit, which included a respiratory care step‐down unit (partial localization model [PLM]). A fifth and final team admitted patients irrespective of their assigned bed location (standard model [SM]). Both the GLM and the PLM occasionally carried patients on other units to allow for overall census management and patient throughput. The total number of pages received by each intern over the study period was collected by retrospective analysis of electronic paging logs. Night pages (7 _pm7 _am) were excluded because of night float coverage. Weekend pages were excluded because data were inaccurate due to coverage for days off.

The daily number of admissions and daily census per team were recorded by physician assistants, who also assigned new patients to appropriate teams according to an admissions algorithm (see Supporting Figure 1 in the online version of this article). The percent of geographically localized patients on each team was estimated from the percentage of localized patients on the day of discharge averaged over the study period. For the SM team, percent localization was defined as the number of patients on the patient care unit that contained the team's work area.

Figure 1

Standard multivariate linear regression techniques were used to analyze the relationship between the number of pages received per intern and the type of team, controlling for the potential effect of total census and number of admissions. The regression model was used to determine adjusted marginal point estimates and 95% confidence intervals (CIs) for the average number of pages per intern per hour for each type of team. All statistical analyses were conducted using Stata version 12 (StataCorp, College Station, TX).

RESULTS

Over the 28‐day study period, a total of 6652 pages were received by 10 interns on 5 general internal medicine teams from 7 _am to 7 _pm Monday through Friday. The average daily census, average daily admissions, and percent of patients localized to patient care units for the individual teams are shown in Table 1. In univariate analysis, the mean daily pages per intern were not significantly different between the 2 teams within the GLM, nor between the 2 teams in the PLM, allowing them to be combined in multivariate analysis (data not shown). The number of pages received per intern per hour, adjusted for team census and number of admissions, was 2.2 (95% CI: 2.02.4) in the GLM, 2.8 (95% CI: 2.6‐3.0) in the PLM, and 3.9 (95% CI: 3.6‐4.2) in the SM (Table 1). All of these differences were statistically significant (P<0.001).

Figure 1 shows the pattern of daytime paging for each model. The GLM and PLM had a similar pattern, with an initial ramp up in the first 2 hours of the day, holding steady until approximately 4 _pm, and then decrease until 7 _pm. The SM had a steeper initial rise, and then continued to increase slowly until a peak at 4 _pm.

DISCUSSION

This study corroborates that of Singh et al. (2012), who found that geographic localization led to significantly fewer pages.[14] Our results strengthen the evidence by demonstrating that even modest differences between the percent of patients localized to a care unit led to a significant decrease in the number of pages, indicating a dose‐response effect. The paging frequency we measured is higher than described in Singh et al. (1.4 pages per hour for localized teams), yet our average census appears to be 4 patients higher, which may account for some of that difference. We also show that interns on teams whose patients are more widely scattered throughout the hospital may experience upward of 5 pages per hour, an interruption by pager every 12 minutes, all day long.

A pager interruption is not solely limited to a disruption by noxious sound or vibration. The page recipient must then read the page and respond accordingly, which may involve a phone call, placing an order, walking to another location, or other work tasks. Although some of these interruptions must be handled immediately, such as a clinically deteriorating patient, many are not urgent, and could wait until the physician's current task or thought process is complete. There is also the potentially risky assumption on the part of the sender that the message has been received and will be acted upon. Furthermore, frequent paging is a common interruption to physician workflow; interruptions contribute to increased perceived physician workload[4, 5] and are likely detrimental to patient safety.[15, 16]

The most common metrics used to measure resident workload are patient census and number of admissions,[13] but these metrics have provided a mixed and likely incomplete picture. Recent research suggests that other factors, such as work efficiency (including interruptions, time spent obtaining test results, and time in transit) and work intensity (such as the acuity and complexity of patients), contribute significantly to actual and perceived resident workload.[13]

Our analysis was a single‐site, retrospective study, which occurred over 1 month and was limited to internal medicine teams. Additionally, geographic localization logically should lead to increased face‐to‐face interruptions, which we were unable to measure with this project, but direct communication is more efficient and less prone to error, which would likely lead to fewer overall interruptions. Although we anticipate that our findings are applicable to geographically localized patient care units in other hospitals, further investigation is warranted.

The paging chorus has only grown louder over the last 25 years, with likely downstream effects on patient safety and resident education. To mitigate these effects, it is incumbent upon us to approach our training and patient care environments with a critical and creative lens, and to explore opportunities to decrease interruptions and streamline our communication systems.

It's hard to imagine a busy urban hospital without its chorus of beepers.[1] This statement, the first sentence of an article published in 1988, rings (or beeps or buzzes) true to any resident physician today. At that time, pagers had replaced overhead paging, and provided a rapid method to contact physicians who were often scattered throughout the hospital. Still, it was an imperfect solution as the ubiquitous pager constantly interrupted patient care and other tasks, failed to prioritize information, and added to an already stressful working environment. Notably, interns were paged on average once per hour, and occasionally 5 or more times per hour, a frequency that was felt to be detrimental to patient care and to the working environment of resident physicians.[1]

Little has changed. Despite the instant, multidirectional communication platforms available today, alphanumeric paging remains a mainstay of communication between physicians and other members of the care team. Importantly, paging contributes to communication errors (eg, by failing to convey urgency, having incomplete information, or being missed entirely by coverage gaps),[2, 3] and interrupts resident workflow, thereby negatively affecting work efficiency and educational activities, and adding to perceived workload.[4, 5]

In this era of duty hour restrictions, there has been concern that residents experience increased workload due to having fewer hours to do the same amount of work.[6, 7] As such, the Accreditation Council of Graduate Medical Education emphasizes the quality of those hours, with a focus on several aspects of the resident working environment as key to improved educational and patient safety outcomes.[8, 9, 10]

Geographic localization of physicians to patient care units has been proposed as a means to improve communication and agreement on plans of care,[11, 12] and also to reduce resident workload by decreasing inefficiencies attributable to traveling throughout the hospital.[13] O'Leary, et al. (2009) found that when physicians were localized to 1 hospital unit, there was greater agreement between physicians and nurses on various aspects of care, such as planned tests and anticipated length of stay. In addition, members of the patient care team were better able to identify one another, and there was a perceived increase in face‐to‐face communication, and a perceived decrease in text paging.[11]

In consideration of these factors, in July 2011, at New YorkPresbyterian Hospital/Weill Cornell (NYPH/WC), an 800‐bed tertiary care teaching hospital in New York, New York, we geographically localized 2 internal medicine resident teams, and partially localized 2 additional teams. We investigated whether interns on teams that were geographically localized received fewer pages than interns on teams that were not localized. This study was reviewed by the institutional review board of Weill Cornell Medical College and met the requirements for exemption.

METHODS

We conducted a retrospective analysis of the number of pages received by interns during the day (7:00 _am to 7:00 _pm) on 5 general internal medicine teams during a 1‐month ward rotation between October 17, 2011 and November 13, 2011 at NYPH/WC. The general medicine teams were composed of 1 attending, 1 resident, and 2 interns each. Two teams were geographically localized to a 32‐bed unit (geographic localization model [GLM]). Two teams were partially localized to a 26‐bed unit, which included a respiratory care step‐down unit (partial localization model [PLM]). A fifth and final team admitted patients irrespective of their assigned bed location (standard model [SM]). Both the GLM and the PLM occasionally carried patients on other units to allow for overall census management and patient throughput. The total number of pages received by each intern over the study period was collected by retrospective analysis of electronic paging logs. Night pages (7 _pm7 _am) were excluded because of night float coverage. Weekend pages were excluded because data were inaccurate due to coverage for days off.

The daily number of admissions and daily census per team were recorded by physician assistants, who also assigned new patients to appropriate teams according to an admissions algorithm (see Supporting Figure 1 in the online version of this article). The percent of geographically localized patients on each team was estimated from the percentage of localized patients on the day of discharge averaged over the study period. For the SM team, percent localization was defined as the number of patients on the patient care unit that contained the team's work area.

Figure 1

Standard multivariate linear regression techniques were used to analyze the relationship between the number of pages received per intern and the type of team, controlling for the potential effect of total census and number of admissions. The regression model was used to determine adjusted marginal point estimates and 95% confidence intervals (CIs) for the average number of pages per intern per hour for each type of team. All statistical analyses were conducted using Stata version 12 (StataCorp, College Station, TX).

RESULTS

Over the 28‐day study period, a total of 6652 pages were received by 10 interns on 5 general internal medicine teams from 7 _am to 7 _pm Monday through Friday. The average daily census, average daily admissions, and percent of patients localized to patient care units for the individual teams are shown in Table 1. In univariate analysis, the mean daily pages per intern were not significantly different between the 2 teams within the GLM, nor between the 2 teams in the PLM, allowing them to be combined in multivariate analysis (data not shown). The number of pages received per intern per hour, adjusted for team census and number of admissions, was 2.2 (95% CI: 2.02.4) in the GLM, 2.8 (95% CI: 2.6‐3.0) in the PLM, and 3.9 (95% CI: 3.6‐4.2) in the SM (Table 1). All of these differences were statistically significant (P<0.001).

Figure 1 shows the pattern of daytime paging for each model. The GLM and PLM had a similar pattern, with an initial ramp up in the first 2 hours of the day, holding steady until approximately 4 _pm, and then decrease until 7 _pm. The SM had a steeper initial rise, and then continued to increase slowly until a peak at 4 _pm.

DISCUSSION

This study corroborates that of Singh et al. (2012), who found that geographic localization led to significantly fewer pages.[14] Our results strengthen the evidence by demonstrating that even modest differences between the percent of patients localized to a care unit led to a significant decrease in the number of pages, indicating a dose‐response effect. The paging frequency we measured is higher than described in Singh et al. (1.4 pages per hour for localized teams), yet our average census appears to be 4 patients higher, which may account for some of that difference. We also show that interns on teams whose patients are more widely scattered throughout the hospital may experience upward of 5 pages per hour, an interruption by pager every 12 minutes, all day long.

A pager interruption is not solely limited to a disruption by noxious sound or vibration. The page recipient must then read the page and respond accordingly, which may involve a phone call, placing an order, walking to another location, or other work tasks. Although some of these interruptions must be handled immediately, such as a clinically deteriorating patient, many are not urgent, and could wait until the physician's current task or thought process is complete. There is also the potentially risky assumption on the part of the sender that the message has been received and will be acted upon. Furthermore, frequent paging is a common interruption to physician workflow; interruptions contribute to increased perceived physician workload[4, 5] and are likely detrimental to patient safety.[15, 16]

The most common metrics used to measure resident workload are patient census and number of admissions,[13] but these metrics have provided a mixed and likely incomplete picture. Recent research suggests that other factors, such as work efficiency (including interruptions, time spent obtaining test results, and time in transit) and work intensity (such as the acuity and complexity of patients), contribute significantly to actual and perceived resident workload.[13]

Our analysis was a single‐site, retrospective study, which occurred over 1 month and was limited to internal medicine teams. Additionally, geographic localization logically should lead to increased face‐to‐face interruptions, which we were unable to measure with this project, but direct communication is more efficient and less prone to error, which would likely lead to fewer overall interruptions. Although we anticipate that our findings are applicable to geographically localized patient care units in other hospitals, further investigation is warranted.

The paging chorus has only grown louder over the last 25 years, with likely downstream effects on patient safety and resident education. To mitigate these effects, it is incumbent upon us to approach our training and patient care environments with a critical and creative lens, and to explore opportunities to decrease interruptions and streamline our communication systems.