Alphanumeric Paging in an Academic Military Hospital Setting

INTRODUCTION

An alphanumeric paging system has the potential to reduce interruptions in patient care, reduce disruption of educational conferences, and allow prioritization of pages; by so doing, the implementation of such a system can increase efficiency in the delivery of patient care, improve the physician-nurse working relationship, and facilitate house-staff education. Documenting that these benefits actually occur during the use of such a system can provide justification for the wider implementation of alphanumeric pagers in a cost-benefit analysis.

Alphanumeric pagers are currently in use in some but not all military hospitals. Demonstrating that these devices are associated with improvements in work efficiency and staff satisfaction could provide justification for the wider implementation of alphanumeric pagers throughout all military medical facilities.

Physicians rely on paging as a means of communication because they have multiple duties that often divide them physically between ICUs, wards, the emergency room, and clinic. Nursing relies on paging as a means to communicate with physicians, who are frequently unavailable for direct verbal communication. Paging behaviors have been previously found to be disruptive to patient care, work rounds, teaching conferences, and sleep.1-3 One study suggested that repeated interruptions, such as these, result in hospital staff inefficiency and increased medical errors.1 With traditional numeric pagers, only a callback number appears on the screen, and physicians are unable to determine the urgency of the page. They are therefore forced to respond to each page as potentially urgent, which can disrupt patient interactions, lectures, meetings, and more pressing matters such as clinical procedures or concurrent acute patient management.

A recent study performed at Stanford University with general surgery residents, faculty, and nurses demonstrated that alphanumeric paging reduced interruptions in patient care and improved physician work efficiency.4 To our knowledge, this is the only study that suggests that text-paging technology may reduce interruptions in patient care, enhance care delivery, and improve physician work efficiency and satisfaction in an academic hospital setting.

The present study was designed to provide evidence that these findings could be generalized beyond surgical programs, to include nonoperative specialties like internal medicine. Furthermore, to our knowledge, no study of this kind has been conducted in a military teaching facility. Although military medical facilities have many parallels to their civilian counterparts, this study also aimed to provide additional information on the applicability of this technology specifically to a military setting.

METHODS

Study Setting

Brooke Army Medical Center is a 200-bed academic medical center and level 1 trauma center that serves as a teaching facility for over 40 graduate medical education and other training programs. Nonintensive care internal medicine patients are located primarily on three wards. In addition, some internal medicine overflow is located on two other wards. Internetenabled computer stations are located in all patient rooms and throughout hospital floors.

Study Participants

For this study, internal medicine house-staff, faculty, and noncritical care nurses were invited to participate. Institutional research board approval was obtained before the initiation of the study. Informed consent was obtained from all individuals who completed the surveys. As per Department of Defense policy, there was no financial compensation and no coercion by the research group or chain of command.

Preintervention Surveys

One week before implementation of the alphanumeric pagers (while the numeric paging system was in place) preintervention surveys were distributed to all internal medicine residents, faculty, and nurses on internal medicine wards. Basic demographic data (to include age, gender, and job position) were collected without any personal identifiers. Respondents were asked to use a 5-point Likert scale to rate their perceptions of potential benefits of using a text-paging system in terms of how it might impact patient care and resident learning (1, strongly agree; 2, agree; 3, neither agree or disagree; 4, disagree; and 5, stongly disagree).

To evaluate efficiency of the paging system, respondents used a 3-point Likert scale to quantify the time spent sending a numeric page and waiting for a callback using time categories (<1 minute, 2-4 minutes, and >5 minutes), as well as the amount of time it took to locate the pager number and place a page. An 11 -point scale was used to gauge the percentage of pages sent/received that were work related, and the percentage that would require a callback to completely convey the message. The following categories were used: none, 1-10%, ll-20%,21-30%, and so on. Space was provided to write in comments or concerns relating to the replacement of the existing numeric-only paging system by an alphanumeric system.

The nursing investigator (J.M.) circulated the floors during various nursing shifts to distribute and collect completed surveys from nursing personnel. Likewise, the physician investigators (A.G. and L.N.) circulated through staff and residency offices to distribute and collect surveys.

Intervention 

A Web link was distributed to all internal medicine housestaff, faculty, and nursing to facilitate online alphanumeric paging. In addition, a Web link was placed in all patient rooms, on the electronic desktops of all internet-enabled computer stations throughout the hospital. The Web interface was very user friendly; it allowed the sender to click a link "send a message" where the physician's pager number could be typed. The user could then type an alphanumeric message of up to 240 characters.

During the transition to alphanumeric pagers, all internal medicine residents received an alphanumeric pager and a manufacturer's instruction manual. All points of hospital communication resources, such as the information desk or centralized pager lists, were changed as each resident exchanged his or her pager for one of the new alphanumeric devices. All pages could also be placed through the traditional direct telephone dial-in system or through overhead hospital paging as previously done. "Codes" (resuscitative emergencies) were handled through the overhead paging system as before, and as such were unaffected by our protocol.

Detailed instruction was given to the physicians by means of a dedicated internal medicine program lecture as well as a handout. Nursing staff was educated by means of in-service training, and detailed written instructions were posted on all nursing floors. Individual teaching sessions were also conducted with nurse managers on internal medicine floors. In the weeks after the initiation of the system, the investigating team provided informal teaching, and informal meetings were conducted to review the system's implementation and address any concerns.

Postintervention Surveys

One month after the transition from traditional numeric pagers to alphanumeric pagers, postintervention surveys were distributed to internal medicine residents, faculty, and ward nursing staff in the same fashion as before. The second survey, i.e., the postintervention survey, solicited the same data as the preintervention survey, with the exception that the time spent sending a page and waiting for a callback now pertained to alphanumeric pagers. Again, a comment section was provided.

Statistical Analysis

For each item in the preintervention and postintervention questionnaires, means were calculated and were compared using t tests and ?^sup 2^ statistics as appropriate. Statistical significance was accepted at the p< 0.05 level.

RESULTS

Summary Data

Participants in the preintervention survey included 26 physicians and 9 nursing staff. Participants in the postintervention survey included 14 physicians and 28 nursing staff. There were significant differences in the physician demographic data when the participants in the preintervention survey were compared to those in the postintervention survey. These included age (33 vs. 28 years of age in the pre- vs. the postintervention survey, respectively; p = 0.009) and gender (presurvey had 11 females, with no female participation in postintervention surveys). There were no significant differences in nursing demographic data for pre- and postintervention surveys.

Survey Data

Physician preintervention perceptions were positive in all categories (defined as a survey score of >2). All physicians answered "strongly agree" (corresponding to a survey score of 1) or "agree" (corresponding to a survey score of 2) to questions about the potential for text paging to "save time," "improve the delivery of care for patients," "minimize interruptions during lectures and other learning environments," and "decrease the amount of time waiting for a callback." Physician postintervention scores remained positive (corresponding to a score >2) in these areas; however, postintervention surveys did change with regard to delivery of care (average survey score of 1.65 vs. 2.07, p = 0.031) and minimizing interruptions (1.62 vs. 2.36,p = 0.013). Physician perceptions were significantly more positive with respect to time to locate the pager number (average survey score of 1.77 vs. 1.07, p = 0.001), and the percentage of pages requiring a callback (average percentage of 71-80% vs. 50-60%, p = 0.016). Perception of whether the text pager would "increase the amount of time it takes to place a page," did not change significantly pre or postintervention (3.3 vs. 3.6).

In terms of physician efficiency, responses to "the average amount of time it takes to locate the pager number and place a page" improved significantly (an average survey score of 1.77 vs. 1.07, p = 0.001). Perceived proportion of "pages requiring a callback to completely convey the message" fell from 71-80% of pages to 50-60% of pages (p = 0.016). The perceived time spent "sending a page and awaiting a callback," did not change significantly when pre and postintervention responses were compared (average remained 2-4 minutes).

Nursing preintervention surveys revealed that there was hesitation in transitioning to the new paging system, immediately manifest by low participation in the study. For nursing staff, the preintervention survey revealed a neutral response (defined as a survey score of 3) for all categories. Postintervention perceptions, however, were more positive, as was willingness on the part of the nursing staff to participate in the study. Significantly more respondents answered "strongly agree" or "agree" to questions about an alphanumeric paging system's potential to "save time" (an average survey score of 3.33 vs. 2.11, p = 0.025) and to "improve the delivery of care for patients" (3.44 vs. 2.39, p = 0.034). There were no significant differences among nurses in responses to whether the alphanumeric system would "increase the amount of time it takes place a page" (2.56 vs. 2.61), "minimize interruptions during lectures and other learning environments" (3.00 vs. 2.32), or "decrease the amount of time waiting for a callback" (3.00 vs. 2.18).

In terms of nursing efficiency, there were no statistically significant changes, although the perceived percentage of "pages requiring a callback to completely convey the message" fell from 91-100% to 61-70%.

Qualitative Feedback

Pre- and postintervention surveys included a space for respondents to write comments. Preintervention comments, both written and verbal, from nurses on the traditional numericpaging system reflected difficulties finding the correct person to page, determining whether a resident was working a particular shift, concerns about adopting an unfamiliar alphanumeric paging system, and concerns about not getting a page confirmation. Postintervention surveys demonstrated positive comments, with requests that other departments adopt the text paging system as well. The most commonly expressed postintervention concern was, again, that there was no confirmation to the sender that a page was received.

Physician preintervention surveys also expressed concerns of pages being delivered to them when they were not on duty in the hospital. However, none of these concerns were expressed postintervention.

DISCUSSION

Overall, both physicians and nursing staff had favorable perceptions of the alphanumeric paging system after its implementation. Physicians entered the study with positive attitudes toward alphanumeric paging technology, and these were sustained after its implementation. In the postintervention surveys, physician responses indicated a perceived improvement in delivery of patient care, in that alphanumeric paging saved time, minimized disruption of learning, and decreased the amount of time waiting for a callback. Efficiency was also perceived to improve as evidenced by a significant reduction in time to locate the pager number (as pager numbers would be stored in the computer's Internet browser after they were used), as well as a significant reduction in the perceived percentage of pages requiring a callback to completely convey the message. There was no significant difference in perceived time it took to place a page and wait for a callback between the numeric and alphanumeric paging systems.

Nurses had a less positive perception of alphanumeric paging technology during the implementation period. However, the postintervention survey reflected increased acceptance and positive responses. In particular, postintervention surveys revealed that nurses changed their opinion significantly from neutral in the preintervention phase to agreement that the alphanumeric system saved time and improved the delivery of patient care in the postintervention phase. Nurses also perceived a reduction in the number of pages requiring a callback, a finding that is consistent with physician perception.

One possible explanation for the different preimplementation responses is a difference in computer comfort between the two groups. It could be that nursing personnel were less familiar or less comfortable with using an Internet-based pager communication system. One confounding factor for the nursing staff was that the inpatient computer system was being upgraded during the implementation of the alphanumeric paging system. As such, there were random system problems that might have made nursing personnel less enthusiastic about changing their usual way of communication with physicians. Many nurses initially refused to use the alphanumeric paging system at all, until they received encouragement from their peers and supervisors.

Although this study did not use quantitative measures of the number of pages sent, received, or requiring a callback, the survey revealed satisfaction and acceptance of the alphanumeric system after implementation only 1 month later. It seems reasonable that responses would have been more favorable as more nurses continued to use the system over time, and as more hospital services transitioned toward the alphanumeric paging system.

Overall, these positive findings were in agreement with the Stanford study, which also found a significant change in nursing perception of patient care;4 however we also demonstrated a significant perceived benefit from the nursing staff in terms of time saved. Our study also is the first to evaluate an alphanumeric paging system in a nonsurgical specialty.

Drawbacks of the alphanumeric paging system were reflected in the commentary on the survey instrument. The fear of pages going unacknowledged was the largest concern. This fear was alleviated after it was explained that any text page that required a specific response should be followed by a request for a callback if it remained unacknowledged; if there was still no response from the resident being paged, a call to the supervising physician should be made. This is the same procedure that would be followed regardless of whether a numeric or an alphanumeric paging system is being used. Having one alphanumeric system in place throughout the hospital, as is our institution's intent, will ultimately allay these types of concerns, facilitate understanding of the technology, and simplify the process. Finally there is the issue of cost. At our institution there was a $5 per month increase in cost per pager. However, in our opinion this seems marginal in the context of potentially improved patient care and enhanced physician and nursing efficiency. Furthermore, as this technology progresses, the cost of alphanumeric pagers will decrease, and the price difference will be less significant.

CONCLUSION

This study found that both physicians and nursing staff had high satisfaction with the implementation of an alphanumeric paging system. Our results suggest that replacement of numeric pagers with an alphanumeric-paging system may improve delivery of patient care, minimize interruptions in learning, improve physician efficiency, and improve time management of both physicians and nursing staff in an internal medicine residency program at a military teaching hospital.

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