Afterhours patient phone calls: a quality improvement study

Objective:

The objective was to determine the most common topic of patient phone calls received by on-call orthopedic residents at a single academic institution in order to identify areas of improvement for patient outcome and resident workload and wellbeing.

Design:

Patient phone calls over 82 shifts were documented from May 2020 to January 2021 by on-call orthopedic residents. The length, nature, and associated attending physician of each call were recorded, as well as whether the call resulted in an emergency department visit. The nature of each phone call was categorized into one of 12 categories.

Setting:

An urban, tertiary care academic institution in the Midwest, USA.

Participants:

All orthopedic residents on-call during this period logged the phone calls that they received and related relevant data.

Results:

Orthopedic surgery residents took an average of 8.6 patient phone calls (average 53.3 total minutes) per shift. The most common reasons for the phone calls were pain, prescription, and pharmacy concerns, which together represented over half of the calls. Twenty-one (4.1%) phone calls resulted in an emergency department visit.

Conclusion:

Concerns about pain and prescriptions were among the most common reasons for patient phone calls. This information points to opportunities for interventions that could help guide how postoperative pain is discussed with patients, including providing patients with reasonable expectations for pain control, function, and tools for better self-efficacy. This approach could not only enhance patient care but also decrease resident on-call workload and improve resident wellbeing.

Introduction

Highlights

• Most afterhours phone calls from patients were related to pain or prescriptions.

• Few patient phone calls required patients to be subsequently evaluated in the emergency department.

Burnout, described as a syndrome caused by work-related stress, encompasses the feelings of emotional exhaustion, depersonalization, and reduced feelings of personal accomplishment1. The recent coronavirus disease 2019 pandemic has exacerbated and further highlighted contributors to and issues posed by physician burnout2. Even prior to the coronavirus disease 2019 pandemic, burnout was reported to be experienced by 40–80% of residents, depending on specialty3. Focusing specifically on orthopedic residents, ~50% of residents report symptoms of burnout, especially those in their early years of training4. While multiple factors can contribute to burnout, clinical work volume4 and the on-call experience5 have been reported as the primary contributing factors. Improving the on-call experience is one intervention that has been shown to decrease resident-reported burnout4,5. Although much thought and effort in recent years has been given to decreasing work hours for residents, less has been done regarding improving resident workload6. Targeting specific factors that contribute to residents’ workload when on-call is a possible area of intervention to address wellbeing.

For programs in which an on-call resident is responsible for answering patient phone calls after business hours, this responsibility can significantly increase the workload during a shift. Studies have been done across many surgical specialties regarding the driving factors behind patient phone calls. Previous research evaluating patient phone calls for neurosurgery patients following spine surgery and orthopedic patients after trauma surgery identified the main reasons for calls as pain control and bathing/dressing/wound questions7,8. These studies recommended improving patient education prior to and during discharge to prevent potentially unnecessary postoperative calls and improve patient satisfaction7,8.

The current study was undertaken to determine the burden (number and length) of afterhours patient phone calls, as well as the focus of these calls, addressed by orthopedic surgery residents at a single academic institution. Compared to prior studies in this area, the patients in this study were treated by orthopedic faculty across the spectrum of subspecialties and with a variety of inpatient and outpatient procedures. The goal of this quality improvement study was to determine what type of intervention could be developed and implemented to reduce the number of patient phone calls to improve the resident on-call experience, while also optimizing patient care.

Materials and methods

The orthopedic on-call residents at a single urban academic orthopedic program under study take all patient phone calls outside of normal business hours for the 24 attending physicians. This includes all calls received after normal clinic hours and during weekends. All PGY-2 (4) and PGY-3 (4) residents collected data for this study. More senior residents (authors M.H. and T.C.) supervised the collection of data and were available to answer questions from the eight participating residents. From May 2020 to January 2021, residents recorded information from patient phone calls over 82 24 h call shifts in a pre-made Microsoft Excel (Microsoft Corporation) document. Residents recorded the following information: call length to the closest 5 min increment, date, focus of call, whether the call resulted in a visit to the institution’s emergency department (ED), and the attending associated with the patient. Twelve categories for the calls were created by the residents based on previous patient phone call experiences and those cited in existing literature and are listed in Table 1. Residents used their discretion to pick the single category that best described each patient phone call except when two distinct topics were discussed, and these were recorded accordingly.

Table 1.

Topics/themes of patient afterhours phone calls.

Pain

Prescriptions/pharmacy

Loss of sensation

Wound/incision

Drainage

Dressing

Splint/pins/external fixator

Peripheral nerve catheter

Surgery

Other

Case volume per attending was defined by reviewing three months of a physician’s operative schedule to determine the monthly average of surgeries during this time period. This was compared to the number of total number of phone calls from each attending’s patients received during the recording period to determine if a higher case volume was associated with an increased number of phone calls. In addition, to account for varying numbers of faculty in various subspecialties, the number of phone calls per attending in each subspecialty was calculated by dividing the total number of phone calls in each subspecialty by the number of surgeons practicing in that field.

The following statistics were calculated based on the collected data: average phone call min per shift, average call length, minimum and maximum time spent on calls during a shift, percentage of calls for each category, percentage of phone calls resulting in an ED visit, the number and percent of phone calls based on day of the week, call volume per subspecialty, call volume per attending per subspecialty, and call volume in comparison to surgical case volume for each attending.

This study received IRB approval as a quality improvement project. The authors have no conflicts of interest. The manuscript is compliant with the Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0), as it describes an initiative to improve healthcare, the problem and available knowledge are outlined, the project is described in sufficient detail that others could replicate this, the key findings are described and placed into context, and the impact and opportunity costs are noted in the Discussion.

Results

Five hundred ten patient phone calls regarding 553 topics/questions were recorded over 82 call shifts. The total min spent on patient phone calls over 82 shifts was 4370 minutes, for an average of 53.3 min per shift. The average phone call length was 8.6 min. The minimum time spent on patient phone calls in a shift was 5 min and the longest recorded time was 195 min. 42/510 (8.2%) phone calls covered two subjects. The top three most common subjects were questions regarding pain (223/553, 40.3%), prescription and pharmacy (86/553 15.6%), and wounds and incisions (56/553, 10.1%) (Table 2). 4.1% (21/510) of the phone calls recorded over this period resulted in a subsequent ED visit.

Table 2.

Patient phone call topics- by number and percentage.

Call subject	# of calls regarding subject	% of calls regarding subject (#/553)
Pain	223	40.3
Prescription/Pharmacy	86	15.6
Wound/Incision concern	56	10.1
Other	49	8.9
Trouble shooting wound vac/dressing	38	6.9
Fever	25	4.5
Surgery questions	21	3.8
Problems with splint/pins/fixation	18	3.3
Surgical site drainage	17	3.1
Loss of sensation	11	2.0
Peripheral nerve catheter (PNC)	7	1.3
Surgical or appointment scheduling	2	0.4

Most patient phone calls occurred on weekends, with 32% (163/510) of phone calls on Saturday, 20% (102/510) on Friday, and 14.9% (76/510) on Sunday. Sports medicine attendings had the highest volume of phone calls, with 135 of the 510 phone calls (26.5%) recorded during this period. This was followed by trauma with 98 calls (19.2%) and then hand with 94 calls (18.4%) (Table 3). Sport Medicine at this institution includes more physicians, which could increase the absolute number of afterhours calls. When assessing the average number of calls per faculty in each subspecialty area, foot and ankle had the highest volume per physician at 61 calls/attending, followed by trauma at 32.7 calls/attending, and hand at 23.5 calls/attending (Table 3) over this period of time.

Table 3.

Phone call breakdown by orthopedic subspecialities.

Subspecialty	Calls	Calls/Attending	Average procedures/month for busiest surgeon	# of calls for busiest surgeon
Arthroplasty	23 (4.5%)	23	36	23
Foot and ankle	61 (11.9%)	61	56.3	61
Hand/upper extremity	94 (18.4%)	23.5	54.7	41
MSK oncology	39 (7.6%)	13	36.3	14
Spine	55 (10.8%)	13.8	21.3	12
Sports	135 (26.5%)	22.5	53.7	49
Trauma	98 (19.2%)	32.7	80	43
Unknown	5 (1.0%)	–	–	–

As anticipated, when looking at the ratio of case volume to the number of phone calls per physician, the top 4 busiest surgeons had the 4 highest numbers of patient phone calls. Conversely, surgeons with the lowest case volumes had associated lower phone calls. However, the busiest surgeon at this institution (>20 more cases/month than any other attending) was a trauma surgeon and had only the third highest phone call volume.

Discussion

When identifying areas of potential improvement related to the on-call experience in this program, residents have reported patient phone calls as an area of significant work burden, noting it frequently impeded their ability to care for patients in need of more urgent attention in the ED. This type of burden also has the potential for increasing risk of burnout. In this study, we found that the most common reasons patients called afterhours were questions about pain and prescriptions/pharmacies. It is worth noting that most phone calls about prescriptions were regarding pain medication. If questions about prescriptions are considered to be primarily questions pain, then over 50% of patient phone calls were pain-related. Identifying pain as the most common topic of patient phone calls is a result similar to what has been identified in other studies focusing on specific patient populations. However, the percentage of calls related to pain in the current study is higher than that reported by Reid et al. 7 for patients undergoing spine surgery (27% of calls related to pain) or by Hadeed et al. 8 after surgery related to orthopedic trauma (22% of calls). This may reflect the inclusion of a broader array of orthopedic injuries and procedure in the current study.

The fact that the busiest surgeon in this department did not have the highest volume of patient phone calls supports the fact that attending surgeons and their clinic staff likely have different approaches to answering questions and counseling patients about the expected postoperative course. These variations may influence the number of patients calling afterhours with questions. When considering interventions to reduce the number of patient phone calls, targeting patient education regarding expected postoperative pain and ways to manage it, as well as enhancing patient self-efficacy, could be beneficial to both residents and patients.

Preprocedure and postprocedure patient counseling have been shown to improve patient understanding of their recovery process9–11. When evaluating interventions to improve patient understanding or health literacy, Tsahakis et al. 9 found significant improvement in understanding at a patient’s first postoperative visit when they were discharged with informational documents including text and pictures when compared to those who received only verbal instructions. Similarly, Cosic et al. 10 found improved patient understanding of their recovery process when provided a predischarge discussion with a hard printed copy. In addition, patient education has been shown to be beneficial in helping patients manage their pain after surgery, decrease use of opioids postoperatively, and better understand how and when to use opioids12,13.

One of the primary limitations of this study is that the data was restricted to what residents reported. Phone call length and topic were reported based on resident estimates and the best interpretation of the phone call. Additionally, in some instances there was overlap between subject categories (i.e. pain or pain medication) which could have led to variations in data. A strength of the study is that this is the first to analyze patient phone calls across an entire orthopedic department, rather than focusing on specific patient populations (e.g. those undergoing spine surgery or those undergoing treatment for trauma)7,8, a more common scenario faced by orthopedic residents. The current study also allowed comparisons among orthopedic subspecialties.

We plan to implement additional patient education that addresses the common questions patients have after surgery, as identified in this study, with a specific emphasis on pain management and the appropriate use of opioids. We will then repeat data collection with more detailed descriptions regarding what calls should be coded in which category and determine the usefulness of the patient education provided. An additional step to reduce resident work burden would include hiring an advanced practice provider to assist with calls during weekends, the days with the greatest call volume. The goal of these targeted interventions is to decrease the number of patient calls afterhours and the related call burden, thus improving resident wellbeing and simultaneously improving patient care.

Conclusion

Patient phone calls answered by on-call residents were identified as a significant burden in terms of workload, most noticeably over the weekend with Saturdays having the greatest number of phone calls. Over 50% of patient phone calls related to questions about pain and pain management. High surgeon case volume, but not subspecialty, was associated with a high number of postoperative phone calls, demonstrating the need for interventions to be standardized across the entire department.

Ethical approval

This study was approved by the University of Kansas IRB as a quality improvement project.

Sources of funding

No sources of funding.

Consent

NA.

Author contribution

G.T.: data analysis; M.H.: study design, writing of paper, and collection of data; T.C.: study design and collection of data; K.T.: study concept and writing of paper.

Conflicts of interest disclosure

None for any of the authors.

Research registration unique identifying number (UIN)

1. Name of the registry: NA.

2. Unique Identifying number or registration ID: NA.

3. Hyperlink to your specific registration (must be publicly accessible and will be checked): NA.

Guarantor

Kimberly Templeton, MD. E-mail: ktemplet@kumc.edu

Provenance and peer review

Not commissioned, externally peer reviewed.

Disclosure

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors report no proprietary or commercial interest in any concept discussed in this article.