Interruptions as an unsafe consequence of clinical communications
Like any team-based activity, healthcare is more effective when different members of a care team communicate clearly and in a timely fashion. A pager-based communication system relies on the prompt call-back by the message recipient to obtain information to drive decisions. In some cases, the recipient may be performing cognitively challenging or emotionally intensive tasks that delay a rapid call back (e.g., medication administration, entering orders within an electronic medical record, speaking with a family about end-of-life care). When the recipient becomes the new sender, the new recipient may be preoccupied with their own task, further delaying the close of the intended communication loop.
Beyond communication delays, interruptions increase the risk of error. One study of over 13,000 interruptions by medical/surgical nurses found that 90% of the interruptions resulted in delays in treatment or loss of concentration or focus. Efforts to reduce interruptions with changes like “no interruption zones” rely on sustained staff engagement and may be ignored during a worker’s busiest moments, the very times when the behavior would be most effective at reducing patient harm. In a 2014 Patient Safety Network perspective, Dr. Suzanne Beyea suggests an increase in mindfulness to help reducing interruptions, but acknowledges the challenges of implementing this cultural shift in the clinical arena.
Updating technology without updating communication processes
Outside of healthcare, individuals with access to email and a smartphone with texting capability have shifted how they communicate from 20 years ago when landlines with voicemail were the only “real-time” communication modality. Some senders and recipients use these principles:
- Send routine messages by email.
- Send urgent messages by text.
- If a conversation is necessary, either call the recipient or send a text asking for a time to converse later in the day.
- Never leave a voicemail.
Senders sending texts or calling the recipient’s smartphone expect the recipient to issue an acknowledgement nearly immediately. People outside the sender-recipient dyad may find these communication rules distracting and, in some cases, inappropriate. Smartphone availability has even been linked to lower cognitive performance.
Over the last decade, healthcare workers have also migrated from older technology (pagers) to newer technology (HIPAA-compliant smartphone applications). Some smartphone apps can include higher-level communication functions like transmitting images and allowing for multi-party conversations. Using “pager-based” rules with secure smartphone apps reduces the value of the newer technology. In October 2016, the Office of the National Coordinator for Health Information Technology published a Safety Assurance Factors for electronic health record (EHR) Resilience (SAFER) guide to clinician communication. The guide suggests organizations implement comprehensive policies and training to facilitate appropriate use of messaging and limit unnecessary messaging. This post will describe what might be included in such a policy or procedure to reduce the risk of healthcare interruptions from electronic communications (e.g., reduced attention by the recipient, increased time to complete tasks started prior to interruption, higher risk of cognitive errors by the recipient).
Possible rules for smartphone-based patient-related communication
In the absence of any published literature on how users might adopt new communication tactics with technology, here are a few suggestions based on my experience within a group of hospitals including residents, nurses and attending physicians.
General suggestions for escalating a communication request to a recipient with a smartphone
- If the sender has a way to receive a secure text-based reply, send the communication request by secure text. This gives the recipient a chance to reply asynchronously without having to stop whatever they are doing to answer your message.
- If the request is non-urgent but 30 minutes have passed, send a second text. If still no response after an hour, call the recipient.
- If the request is urgent and the initial text has not answered within five minutes, call the recipient. If there is still no answer after another five minutes (10 minutes since initial text), contact the recipient’s supervisor. Some healthcare apps program an automatic escalation path so the recipient must stop the escalation instead having the sender manually escalate the message.
General suggestions for sending secure texts
- Informational messages should include an indicator that no callback or response is needed (“FYI” [For Your Information] or “NRN” [No Response Needed]).
- Messages that require an action without a communication response should include those details within the communication (“Please enter admission orders for Ms. Jones in 4S-212 as she has arrived on the floor”).
- Messages requiring a communication response should include the sender’s preferred method of reply and a deadline to reply (“Call 55-1212 by 10 AM” or “Respond back within [hospital app] before 3 PM today”).
General suggestions for handling phone calls or secure texts on a smartphone
- During a cognitively difficult or emotionally challenging task, click a button on the smartphone to silence the call or message. In many cases, the click can be done without pulling the device out of a pocket. Avoid looking at the message to stay focused on the current task. After the task is complete, respond to the call or message.
- To reduce the risk of missing messages, develop a behavioral checklist that includes reviewing your smartphone for messages you may have forgotten to address before moving to a new task.
- For tasks that involve interacting with others outside the intended communication, develop a script to acknowledge the interruption (“I’m sorry, but this person keeps calling me. Please allow me to address their question so I can then focus my full attention on our conversation.”)
Pitfalls to consider
Changing communication practices can be difficult in the best of circumstances. During high-risk healthcare interactions, users are likely to revert to communication methods that have worked in the past. Moving all members of the healthcare team to new methods of communicating may require reviewing communication expectations and providing feedback when communication could have been transmitted more effectively. Leaders should consider defining new performance metrics (e.g., “percent of non-urgent replies handled via secure text”) to highlight expected behaviors instead of rewarding users who interrupt themselves to answer messages promptly.
Unlike settings where workers are expected to check a single work-related email account as a supplement to smartphone texts, many inpatient healthcare workers practice across different settings without access to email over the course of their day. An inpatient electronic communication tool should consider a single method to track urgent and non-urgent messages with methods to help the user filter and address messages. Healthcare workers who need to perform a task interrupted for more than an hour may need to consider forwarding their messages to a colleague.
In an environment where users adopt smartphone-based technology behaviors at different rates, some users will become frustrated with those users who shift their behavior less rapidly. Methods to display a recipient’s communication history may reduce a sender’s dissatisfaction when a communication request is not addressed in a timely fashion. Depending on the “laggard’s” exposure to the specific clinical environment using new communication practices, peer pressure may help in shift individual practice patterns.
Technology will not overcome cultural or workflow challenges among team members. Inappropriate communications that may have occurred over the telephone are now tracked within a smartphone app. These transcripts can be reviewed by medical staff professionalism committees and plaintiff’s attorneys.
Savvy healthcare team members may adopt new technology to help improve patient-related communications quickly. Unlike technology focused on the individual that only requires one person to change their behavior, changes in communication technology require behavioral adjustments for the sender, recipient and individuals interacting with the recipient during the communication. Developing communication norms with mechanisms to monitor behavior can help move a group of healthcare workers toward using new communication technologies that are more efficient for team members and safer for patients.