Abstract
This mixed-methods analysis investigates text page message content among clinicians regarding patient care with particular focus on efficiency and safety.
Today, inpatient health care teams typically communicate via paging technology on dedicated, single-purpose devices despite the advancements in mobile communication technology. Text paging has been identified as inefficient and disruptive, and even with implementation of novel technology, concerns about communication quality and safety persist. We investigated text page message content and structure with particular focus on efficiency and safety.
Methods
We used a mixed-methods approach to analyze the content of text page messages generated at an academic tertiary care hospital on an internal medicine service. We included electronic messages relating to care of specific patients that were sent or received by physicians, nurses, students, and ancillary staff using a web-based text paging system allowing bidirectional messaging to dedicated devices.
We sampled 3 blocks of 200 electronic messages and used an iterative coding and memo process to develop an analysis of message themes and attributes using a modified case study approach. One investigator (A.L.) read, coded, and wrote memos based on sampled messages until reaching thematic saturation. Our team refined preliminary codes, and a second investigator (B.C.) used the codebook to code messages independently (unweighted Cohen κ score [κ = 0.81; z = 64; P < .001]).
This study was approved by the University of California, San Francisco institutional review board.
Results
Of 575 text-page messages relating to 217 unique patients, the majority of messages were sent by nonphysicians (448 of 575 [78%]) to physicians (433 of 575 [75%]). Descriptive attributes of the sample are presented in the Table. Our analysis revealed 3 overarching themes: lack of standardization, range of urgency, and communication gaps that arise due to messaging practices (Box).
Table. Descriptive Attributes of Sample of 575 Messages and 240 Topics.
| Characteristic | No. (%) |
|---|---|
| Messages | |
| Total | 575 |
| Unique senders, total | 110 |
| Case management | 31 (5) |
| Nursing | 284 (49) |
| Nursing assistant | 38 (7) |
| Pharmacy | 5 (1) |
| Physician | 127 (22) |
| Social work | 3 (1) |
| Other/untagged | 87 (15) |
| Unique recipients, total | 183 |
| Case management | 5 (1) |
| Nursing | 37 (6) |
| Nursing assistant | 5 (1) |
| Pharmacy | 0 |
| Physician | 433 (75) |
| Social work | 4 (1) |
| Other/untagged | 91 (15) |
| Topics | |
| Total | 240 |
| Unique patients, total | 217 |
| Messages per patient, mean (SD) | 2.6 (2.1) |
| Questions and direct action requests | 73 (30) |
| Clinical information | 31 (13) |
| Callback request | 27 (11) |
| Discharge information | 23 (10) |
| Consults | 19 (8) |
| Short communication | 17 (7) |
| Patient logistics | 17 (7) |
| Blank messages | 11 (5) |
| Care team logistics | 9 (4) |
| Procedure planning | 8 (3) |
| Care plan updates | 5 (2) |
Box. Themes and Example Messages.
-
Lack of standardization:
From: Nurse
To: Physician
-
Message: Advise: BP 160/109, T38.7 HR 120 92% PA. RR 27, Pain 6/10. Please call back. Thank you. [SENDER][EXT]
or
From: Nurse
To: Physician
Message: FYI bp 180/73. prn hydral given. temp 38.5 Low UO over last few hrs. Pt mentating the same, still pretty drowsy. 100% O2sat on RA. thanks
-
Urgency designation:
From: Nurse
To: Physician
-
Message: Advise; May I have a 24 h extension on patient’s IV?
or
From: Nurse
To: Physician
Message: Advise: BP 160/109, T38.7 HR 120 92% PA. RR 27, Pain 6/10. Please call back. Thank you. [SENDER][EXT]
-
Gaps in communicationa
From: Nurse
To: Physician
Message: FYI patient BP 165/76 (109) HR 88 irregular. Plan to recheck BP as he was sitting up breathing treatment. Can I give PO Hydralazine early [SENDER][EXT]
We observed little standardization across messages with the same content. For example, vital signs that are commonly communicated via pager could be noted as either absolute numbers or using descriptors such as “hypotensive” or “stable.” Frequently, messages contained incomplete vital signs (ie, heart rate without blood pressure). Few messages followed a standardized format such as “situation background advise recommendation” or a consult question format.
Most messages were nonurgent (534 of 575 [93%]) and did not include an indicator of response urgency (463 of 575 [81%]). The messages lacked consistent language to indicate urgency.
Often, lack of clarity in text page messages introduced potential for delays or lack of understanding among team members. For example, we found messages that began with a tag FYI (for your information) but then asked a question in the body of the message. We also found that a number of messages included uncommon abbreviations, odd syntax, or missing words.
Discussion
Text paging has significant limitations for real-time communication in acute-care settings. First, despite the relatively circumscribed range of content, we observed wide variation in message structure between topics or within a given topic. Second, we found the majority of pages lacked clear or consistent language to indicate the urgency of the communication or need to respond. Finally, some text pages lack clarity and thus could undermine patient safety. Unclear messages have the potential to adversely affect the quality of inpatient care.
This data should inform the development of guidelines on the use of text paging for effective, efficient communication among health care team members in inpatient settings. Interventions akin to those used for patient handoffs could be used to inform better paging practices. To improve communication, inpatient health care teams should receive training on optimal pager communication, and individual health care team members should receive feedback on text page communication. Looking ahead, technology-enabled solutions should test standardized, structured communication for high-frequency topics, as well as structured urgency flags for text paging communication to physicians.
Footnotes
Example of mixed-message correspondence known as “FYI with question,” in which the sender includes a question after presenting pertinent information.
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