The Case

A 57-year-old woman with a history of chronic obstructive pulmonary disease underwent hip surgery. Postoperatively, the patient was short of breath and remained in the postanesthesia care unit (PACU) for close monitoring of her respiratory and cardiac status while awaiting an intensive care unit (ICU) bed. When the patient suddenly lost a pulse, providers initiated cardiopulmonary resuscitation, which led to a return of spontaneous circulation.

As part of the evaluation for the patient's shortness of breath, providers ordered a chest radiograph, which showed a pneumothorax. But the radiologist, who knew that such a finding might require emergent treatment (usually a chest tube), found herself unable to find the correct ("first call") physician to page regarding this critical information. She was forced to call the PACU, find a nurse, and then have the nurse access the online physician scheduling system to determine who was currently the first call physician.

When the results were eventually communicated to the first call provider, needle thoracostomy was performed immediately and a chest tube was placed. The patient's shortness of breath resolved, and she was moved to the ICU after being stabilized. A follow-up chest radiograph showed resolution of the pneumothorax. Thus, while the delay in reaching the first call provider did not lead to long-term harm to the patient, it easily could have.

The Commentary

by Kiran Gupta, MD, MPH, and Raman Khanna, MD

Effective communication between care providers is essential for providing safe and high quality care to patients. It is well-established in the patient safety literature that poor communication—including delays, as this case highlights—is one of the most common contributors to medical error and preventable adverse events.(1-3) Delays in communicating important test results can lead to permanent disability or even death. They can also raise health care costs. One study estimated that inefficient communication costs hospitals in the United States more than $12 billion per year.(4)

In this case, the delayed communication surrounded the diagnosis of a pneumothorax, which can potentially be life-threatening. The radiologist identified the pneumothorax quickly but was unable to reach the appropriate clinician on the care team right away. This led to a delay in needle thoracostomy and chest tube placement—procedures necessary to stabilize the patient. Although the patient did well in the end, the delay could have been fatal.

Problems with identifying and paging the correct clinician for a particular patient are widespread. One study of two academic teaching hospitals demonstrated that, over the course of 2 months, 1409 out of a total of 10,190 pages (14%) were sent to the incorrect provider.(5) A review of pages sent to the wrong provider suggested that approximately 15% of these were emergent, requiring immediate action, and that about a third were urgent, requiring a response within an hour.

The first step in facilitating timely response from the correct provider for each patient requires accurate identification of both a patient's care team and the individual physician who is the primary responder, or "first call," for each patient, as well as a highly reliable way to reach that provider. Commercially available electronic health records (EHRs) may not provide adequate mechanisms for real-time identification of the members of a patient's care team (6) or may not readily link to the call schedule and paging systems. The radiologist in the case described above did not know how to access the call schedule to find out which care team and which resident were primarily responsible for the patient. The lack of direct links between call schedules, paging systems, care team lists, and the EHR results in a fragmented system, one in which it is often difficult to reach a patient's provider in the hospital quickly and efficiently.

Thus, in trying to fix the current state, systematic consideration must be given to how the paging system and the EHR interact. Pager numbers for a given service (e.g., Neurosurgery) would ideally remain static or else be identifiable in real time from within the EHR. (This contrasts with the traditional method, in which individuals hold their pagers permanently, and yet the EHR often offers limited guidance as to who the first call physician is.) Service pagers may either be physical pagers, handed from one provider to another at the time of shift change, or virtual pagers that may be forwarded via the paging system to the covering provider's pager. Once the primary service for the patient is displayed in a highly visible place on the EHR patient window (in the patient's header, in a floating window, or somewhere else that is easily visible), the patient, primary service, and primary service contact information can all be reliably linked and easily utilized to contact the correct provider.

Our hospital experienced challenges with regard to reaching the correct provider after it implemented a commercial EHR in 2012. At first, identifying a patient's primary inpatient care team (e.g., Medicine, Neurosurgery, Orthopedics, etc.) and first call provider (the provider on the care team responsible for direct care of the patient, who should receive all pages related to that patient's care) required walking to the patient's ward, identifying the patient's name on a whiteboard near the nurses' station, and looking at the board to determine first call provider's name and pager number. The whiteboard was updated manually and frequently not synchronized with the information in the patient's orders. Furthermore, those who might need to page a provider—for example, the radiologist described in the case—might not have easy access to the whiteboard.

To address the above problems, our hospital now requires that every patient have a "first call" (primary) team assigned and designated in the EHR. The first call team is assigned at the time of admission and can be changed if the patient transfers to another service. First call teams are required to have an associated service pager number. If a primary team is not assigned to a patient or more than one first call team has been assigned by mistake, a warning pops up, reminding the provider to assign a single primary team. Once a primary team is assigned to a patient, the primary team now appears prominently as "1st Call" in the EHR header for the patient, and the associated pager number is easily visible. Anyone wishing to reach the first call provider can click on 1st Call in the EHR header, which links to the paging system. At the time of shift change, the oncoming provider signs the virtual pager number assigned to a particular service (e.g., the pager number for Medicine A Intern 1) over to their personal pager number, which ensures that the 1st Call is going to the correct provider. This initiative has significantly improved workflow and helped to address inefficiencies associated with finding the correct provider to page. On average, more than 1000 messages are sent daily through this system. Initial feedback has been very positive because the new system integrates well into the existing workflow.

Designing an ideal system to reach the correct provider for an inpatient as quickly as possible remains challenging, largely because of the fragmented nature of information sources—call schedules, paging systems, team lists, and the EHR. Yet, identification of a patient's care team is critical to patient safety. Our hospital addressed this problem by customizing specific aspects of the EHR to require that every patient have an assigned first call team, linking the primary team and first call contact information to the patient's chart in the EHR, and developing functionality to page the first call provider directly from the EHR.

If the case of the patient described above were to take place at our hospital today, the radiologist would open the patient's record in the EHR, look at the 1st Call in the header for that patient, and click on the link. This action would generate a page to the patient's first call provider—the provider who has signed over the virtual pager for that service to their personal pager—directly from the EHR. The first call provider would receive notification about the pneumothorax in a timely manner and be able to act right away to ensure the best outcome for the patient.

Take-Home Points

• Inability to promptly and efficiently reach the first call provider for a patient contributes to medical error, preventable adverse events, and increased health care costs.
• Commercial EHRs may not provide out-of-the-box tools for real-time notification of a patient's care team.
• Commercial EHRs can be configured to deliver notifications to the patient's care team (if necessary via integration with an external application) and reduce the inefficiency of current first call procedures.

Kiran Gupta, MD, MPH Assistant Clinical Professor of Hospital Medicine, UCSF Assistant Medical Director for Patient Safety, UCSF Medical Center

Raman Khanna, MD Assistant Clinical Professor of Hospital Medicine, UCSF Physician Lead for Inpatient Informatics, UCSF Medical Center

References

1. Alvarez G, Coiera E. Interdisciplinary communication: an uncharted source of medical error? J Crit Care. 2006;21:236-242. [go to PubMed]

2. Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004;79:186-194. [go to PubMed]

3. Dalal AK, Schnipper JL. Care team identification in the electronic health record: a critical first step for patient-centered communication. J Hosp Med. 2016;11:381-385. [go to PubMed]

4. Agarwal R, Sands DZ, Schneider JD. Quantifying the economic impact of communication inefficiencies in U.S. hospitals. J Healthc Manag. 2010;55:265-281. [go to PubMed]

5. Wong BM, Quan S, Cheung CM, et al. Frequency and clinical importance of pages sent to the wrong physician. Arch Intern Med. 2009;169:1072-1073. [go to PubMed]

6. Vawdrey DK, Wilcox LG, Collins S, et al. Awareness of the care team in electronic health records. Appl Clin Inform. 2011;2:395-405. [go to PubMed]