Robert Wu, MD, MSc

Canada’s 17 medical schools and their affiliated teaching hospitals are instrumental in serving local communities and providing regional and national access to specialized therapies. Akin to many other countries, patients in Canadian teaching hospitals typically receive care from trainees supervised by attending physicians on teams that Canadians refer to as clinical teaching units (CTUs).¹ For more than 50 years, the CTU model has served trainees, attendings, and patients well.² The success of the CTU model has been dependent on several factors including the crucial balance between the number of trainees and volume of patients. However, Canadian teaching hospitals are increasingly challenged by an imbalance in the trainee-to-patient volume equilibrium spurred by increasing patient volumes and declining house staff availability. The challenges we are facing today in Canada are similar to those teaching hospitals in the United States have faced and adapted to over the last 15 years. Can we build a new, sustainable model of inpatient care through attending-directed inpatient services much as has happened in the US?

Canada’s population of 36 million people is growing by approximately 1% per year, largely driven by immigration.³ At the same time, Canada’s population is aging and becoming increasingly medically complex; the percentage of Canadians age 65 years and older is anticipated to rise from approximately 17% today to 25% in 2035.⁴ Canada’s healthcare system historically functioned with relatively few inpatient beds, encouraging efficiency particularly with respect to which patients require hospital admission and which do not.⁵ Although data suggest that the number of hospital admissions declined in Canada between 1980 and 1995, recent data documented that General Internal Medicine admissions increased by 32% between 2010 and 2015 and accounted for 24% of total hospital bed days.^6,7 The effects of population growth and aging on admission volumes might be mitigated to some extent by innovations in healthcare delivery such as improved access to primary care (largely family physicians in Canada). However, even with these innovations, a growing and aging population is likely to have a disproportionate effect on the types of undifferentiated illnesses that are typically admitted to General Internal Medicine in Canadian teaching hospitals.

Increasing volumes and complexity are occurring at the same time that residency training in Canada is undergoing an extraordinary shift, mirroring trends in other countries.⁸ CTUs in Canada typically have a census of 20 or more patients and are staffed by an attending, one senior resident, two to three junior residents, and medical students. Recognition that physician fatigue is associated with patient safety events and physician burnout has led to shorter resident shifts, though Canadian hospitals typically operate without concrete work hour limits or “hard” caps on team size.⁸ To fulfill accreditation standards set by the Royal College of Physicians and Surgeons of Canada, residency programs have required increases in formal teaching sessions during working hours, further reducing resident presence at the bedside. Many specialty training programs (eg, anesthesiology and ophthalmology) that traditionally required trainees to rotate through General Medicine have eliminated this requirement. Moreover, postgraduate training now requires additional time be spent in ambulatory and community hospital settings to better prepare residents for practice.⁹ There is little enthusiasm for increasing the number of residents, as postgraduate training spots increased by 85% between 2000 and 2013, before stabilizing in recent years.¹⁰

These factors are leading to a substantial decline in resident availability on CTUs, shifting increasing amounts of direct patient care to attending physicians in Canadian teaching hospitals across virtually all specialties. Unsurprisingly, increased rates of burnout and decreases in job satisfaction have been reported.¹¹ The Royal College has yet to impose hard caps on team size, but many see this on the horizon.

Canadian teaching hospitals currently find themselves facing a confluence of factors nearly identical to those faced by teaching hospitals in the United States during 2003 when the Accreditation Council for Graduate Medical Education instituted resident duty hour restrictions to address concerns over trainee wellness, shift length, and patient safety.⁸ Instantly, hundreds of US teaching hospitals faced uncertainty over who would provide patient care when residents were unavailable. Virtually all US teaching hospitals responded with a creativity and speed that we are unaccustomed to in academic medicine. Hospitals reallocated money to finance attending-directed services where patient care was provided directly by attending physicians often working without trainees¹² but frequently supported by nurse practitioners or physician assistants.¹³ Despite the differences between US and Canadian healthcare, 15 years later, we in Canada can and should learn from the US experience.¹⁴

Attending-directed services offer several advantages. First, attending-directed services offer patient outcomes including ICU transfer, mortality, readmissions, and satisfaction that are similar, if not modestly improved, when compared with traditional teaching services.¹⁵ Results also suggest potential reductions in hospital length of stay and diagnostic testing.¹⁶ Attending-directed services can enhance trainee education by insuring attending physician presence and oversight in-hospital 24-hours per day.¹⁷ Although not well studied, attending-directed services may reduce variation in CTU patient census so that excess volumes can be absorbed by attending-directed teams even with seasonal surges (eg, influenza). Recognizing that many specialties were experiencing the same challenges as General Medicine in 2003, attending-directed services in the US have been designed to care for a wide spectrum of patients drawn from an array of different specialties with evidence of improved outcomes.¹² Building attending-directed services in Canadian teaching hospitals may expand to include patients from multiple specialties and subspecialties (surgery, orthopedics, and cardiology) where patient volumes are increasing and resident coverage is increasingly scarce.

The challenges that accompany the implementation of attending-directed teams must be acknowledged. First, while attending-directed teams solve many problems for teaching hospitals, physician billings may not generate sufficient income to be self-sustaining and require additional financial support.¹⁸ Without investment from hospitals or government, attending-directed models cannot flourish in teaching hospitals. US hospitals typically provide substantial financial support ($50,000-$100,000 per physician) to hospitalist programs, but Canadian teaching hospitals have been reluctant to follow suit.

Second, attending-directed services require a sustainable workforce. In Canada, inpatient care is provided predominately by family physician hospitalists in community hospitals, whereas internists typically fulfill these roles in teaching hospitals.¹⁹ Family physician hospitalists are commonly represented by the Canadian Society for Hospital Medicine, which is the Canadian branch of the Society of Hospital Medicine. Hospital medicine in Canada is typically organized around physician training (family physician vs internist) rather than clinical focus (outpatient vs inpatient). Collaborative models of care that unite hospitalists from all training streams (family physician, internist, and pediatrics) are only just emerging in Canadian teaching hospitals. How these programs are developed will be critical to the successful growth of attending-directed services. Third, if attending-directed services expand in teaching hospitals, the physicians who staff these services must come from somewhere. Either the “production” of physicians will need to increase or physicians will migrate to attending-directed services from outpatient practice or from community hospitals.²⁰ Canadian teaching hospitals can also explore nurse practitioners and physician assistants, a previously underutilized resource. Though the costs of such programs can be significant,²¹ the payoff in safety, quality, and efficiency may be worth it—as demonstrated in the US system. Fourth, teaching hospitals and medical schools must create academic homes to support and mentor the physicians working on attending-directed services. Although physicians hired for attending-directed services primarily provide direct patient care, few will join academic medical centers solely for this purpose. Teaching hospitals and medical schools need to carefully consider job descriptions, mentoring, and career advancement opportunities as they build attending-directed services. Finally, the interactions between teaching and attending-directed services are complex. There is an inevitable learning curve as clinical operations and protocols are built and developed. For example, decisions need to be made about how patients are divided between services and whether nocturnists are responsible for teaching overnight residents.¹⁷ Successful programs have the potential to benefit hospitals, patients, learners, and faculty alike.

The risks associated with the status quo in Canada must also be addressed. Patient volumes and complexity in Canada are likely to continue to slowly increase, while the number of trainees in Canadian teaching hospitals will remain stable at best. Forcing more patients onto already overtaxed teaching services is likely to worsen hospital efficiency, patient outcomes, and educational experiences.²² Forcing additional patient care onto overstretched faculty will slowly erode the academic work (teaching and research) that has characterized excellence in Canadian medicine.

The changes we propose to overcome the challenges facing Canadian teaching hospitals are neither cheap nor easy (Table). We expect resistance on many fronts. Implementing them will likely require concerted advocacy from a diverse group of champions shining a bright spotlight on the sizable challenges Canadian teaching hospitals are confronting. We believe that each challenge maps to a discrete group of champions with discrete targets within hospital leadership, medical school administration, and government who will need to be engaged. In our opinion, organizing around these challenges offers the best opportunity to overcome the perpetual resistance around costs. Canadian teaching hospitals and their CTUs are under unprecedented pressure. Do we act boldly and embrace attending-directed models of care or continue tinkering at the margins?

 

Acknowledgments

The authors thank Chaim Bell for his advice and suggestions.

Disclosures

The authors have nothing to disclose.

Canada’s 17 medical schools and their affiliated teaching hospitals are instrumental in serving local communities and providing regional and national access to specialized therapies. Akin to many other countries, patients in Canadian teaching hospitals typically receive care from trainees supervised by attending physicians on teams that Canadians refer to as clinical teaching units (CTUs).¹ For more than 50 years, the CTU model has served trainees, attendings, and patients well.² The success of the CTU model has been dependent on several factors including the crucial balance between the number of trainees and volume of patients. However, Canadian teaching hospitals are increasingly challenged by an imbalance in the trainee-to-patient volume equilibrium spurred by increasing patient volumes and declining house staff availability. The challenges we are facing today in Canada are similar to those teaching hospitals in the United States have faced and adapted to over the last 15 years. Can we build a new, sustainable model of inpatient care through attending-directed inpatient services much as has happened in the US?

Canada’s population of 36 million people is growing by approximately 1% per year, largely driven by immigration.³ At the same time, Canada’s population is aging and becoming increasingly medically complex; the percentage of Canadians age 65 years and older is anticipated to rise from approximately 17% today to 25% in 2035.⁴ Canada’s healthcare system historically functioned with relatively few inpatient beds, encouraging efficiency particularly with respect to which patients require hospital admission and which do not.⁵ Although data suggest that the number of hospital admissions declined in Canada between 1980 and 1995, recent data documented that General Internal Medicine admissions increased by 32% between 2010 and 2015 and accounted for 24% of total hospital bed days.^6,7 The effects of population growth and aging on admission volumes might be mitigated to some extent by innovations in healthcare delivery such as improved access to primary care (largely family physicians in Canada). However, even with these innovations, a growing and aging population is likely to have a disproportionate effect on the types of undifferentiated illnesses that are typically admitted to General Internal Medicine in Canadian teaching hospitals.

Increasing volumes and complexity are occurring at the same time that residency training in Canada is undergoing an extraordinary shift, mirroring trends in other countries.⁸ CTUs in Canada typically have a census of 20 or more patients and are staffed by an attending, one senior resident, two to three junior residents, and medical students. Recognition that physician fatigue is associated with patient safety events and physician burnout has led to shorter resident shifts, though Canadian hospitals typically operate without concrete work hour limits or “hard” caps on team size.⁸ To fulfill accreditation standards set by the Royal College of Physicians and Surgeons of Canada, residency programs have required increases in formal teaching sessions during working hours, further reducing resident presence at the bedside. Many specialty training programs (eg, anesthesiology and ophthalmology) that traditionally required trainees to rotate through General Medicine have eliminated this requirement. Moreover, postgraduate training now requires additional time be spent in ambulatory and community hospital settings to better prepare residents for practice.⁹ There is little enthusiasm for increasing the number of residents, as postgraduate training spots increased by 85% between 2000 and 2013, before stabilizing in recent years.¹⁰

These factors are leading to a substantial decline in resident availability on CTUs, shifting increasing amounts of direct patient care to attending physicians in Canadian teaching hospitals across virtually all specialties. Unsurprisingly, increased rates of burnout and decreases in job satisfaction have been reported.¹¹ The Royal College has yet to impose hard caps on team size, but many see this on the horizon.

Canadian teaching hospitals currently find themselves facing a confluence of factors nearly identical to those faced by teaching hospitals in the United States during 2003 when the Accreditation Council for Graduate Medical Education instituted resident duty hour restrictions to address concerns over trainee wellness, shift length, and patient safety.⁸ Instantly, hundreds of US teaching hospitals faced uncertainty over who would provide patient care when residents were unavailable. Virtually all US teaching hospitals responded with a creativity and speed that we are unaccustomed to in academic medicine. Hospitals reallocated money to finance attending-directed services where patient care was provided directly by attending physicians often working without trainees¹² but frequently supported by nurse practitioners or physician assistants.¹³ Despite the differences between US and Canadian healthcare, 15 years later, we in Canada can and should learn from the US experience.¹⁴

Attending-directed services offer several advantages. First, attending-directed services offer patient outcomes including ICU transfer, mortality, readmissions, and satisfaction that are similar, if not modestly improved, when compared with traditional teaching services.¹⁵ Results also suggest potential reductions in hospital length of stay and diagnostic testing.¹⁶ Attending-directed services can enhance trainee education by insuring attending physician presence and oversight in-hospital 24-hours per day.¹⁷ Although not well studied, attending-directed services may reduce variation in CTU patient census so that excess volumes can be absorbed by attending-directed teams even with seasonal surges (eg, influenza). Recognizing that many specialties were experiencing the same challenges as General Medicine in 2003, attending-directed services in the US have been designed to care for a wide spectrum of patients drawn from an array of different specialties with evidence of improved outcomes.¹² Building attending-directed services in Canadian teaching hospitals may expand to include patients from multiple specialties and subspecialties (surgery, orthopedics, and cardiology) where patient volumes are increasing and resident coverage is increasingly scarce.

The challenges that accompany the implementation of attending-directed teams must be acknowledged. First, while attending-directed teams solve many problems for teaching hospitals, physician billings may not generate sufficient income to be self-sustaining and require additional financial support.¹⁸ Without investment from hospitals or government, attending-directed models cannot flourish in teaching hospitals. US hospitals typically provide substantial financial support ($50,000-$100,000 per physician) to hospitalist programs, but Canadian teaching hospitals have been reluctant to follow suit.

Second, attending-directed services require a sustainable workforce. In Canada, inpatient care is provided predominately by family physician hospitalists in community hospitals, whereas internists typically fulfill these roles in teaching hospitals.¹⁹ Family physician hospitalists are commonly represented by the Canadian Society for Hospital Medicine, which is the Canadian branch of the Society of Hospital Medicine. Hospital medicine in Canada is typically organized around physician training (family physician vs internist) rather than clinical focus (outpatient vs inpatient). Collaborative models of care that unite hospitalists from all training streams (family physician, internist, and pediatrics) are only just emerging in Canadian teaching hospitals. How these programs are developed will be critical to the successful growth of attending-directed services. Third, if attending-directed services expand in teaching hospitals, the physicians who staff these services must come from somewhere. Either the “production” of physicians will need to increase or physicians will migrate to attending-directed services from outpatient practice or from community hospitals.²⁰ Canadian teaching hospitals can also explore nurse practitioners and physician assistants, a previously underutilized resource. Though the costs of such programs can be significant,²¹ the payoff in safety, quality, and efficiency may be worth it—as demonstrated in the US system. Fourth, teaching hospitals and medical schools must create academic homes to support and mentor the physicians working on attending-directed services. Although physicians hired for attending-directed services primarily provide direct patient care, few will join academic medical centers solely for this purpose. Teaching hospitals and medical schools need to carefully consider job descriptions, mentoring, and career advancement opportunities as they build attending-directed services. Finally, the interactions between teaching and attending-directed services are complex. There is an inevitable learning curve as clinical operations and protocols are built and developed. For example, decisions need to be made about how patients are divided between services and whether nocturnists are responsible for teaching overnight residents.¹⁷ Successful programs have the potential to benefit hospitals, patients, learners, and faculty alike.

The risks associated with the status quo in Canada must also be addressed. Patient volumes and complexity in Canada are likely to continue to slowly increase, while the number of trainees in Canadian teaching hospitals will remain stable at best. Forcing more patients onto already overtaxed teaching services is likely to worsen hospital efficiency, patient outcomes, and educational experiences.²² Forcing additional patient care onto overstretched faculty will slowly erode the academic work (teaching and research) that has characterized excellence in Canadian medicine.

The changes we propose to overcome the challenges facing Canadian teaching hospitals are neither cheap nor easy (Table). We expect resistance on many fronts. Implementing them will likely require concerted advocacy from a diverse group of champions shining a bright spotlight on the sizable challenges Canadian teaching hospitals are confronting. We believe that each challenge maps to a discrete group of champions with discrete targets within hospital leadership, medical school administration, and government who will need to be engaged. In our opinion, organizing around these challenges offers the best opportunity to overcome the perpetual resistance around costs. Canadian teaching hospitals and their CTUs are under unprecedented pressure. Do we act boldly and embrace attending-directed models of care or continue tinkering at the margins?

 

Acknowledgments

The authors thank Chaim Bell for his advice and suggestions.

Disclosures

The authors have nothing to disclose.

Canada’s 17 medical schools and their affiliated teaching hospitals are instrumental in serving local communities and providing regional and national access to specialized therapies. Akin to many other countries, patients in Canadian teaching hospitals typically receive care from trainees supervised by attending physicians on teams that Canadians refer to as clinical teaching units (CTUs).¹ For more than 50 years, the CTU model has served trainees, attendings, and patients well.² The success of the CTU model has been dependent on several factors including the crucial balance between the number of trainees and volume of patients. However, Canadian teaching hospitals are increasingly challenged by an imbalance in the trainee-to-patient volume equilibrium spurred by increasing patient volumes and declining house staff availability. The challenges we are facing today in Canada are similar to those teaching hospitals in the United States have faced and adapted to over the last 15 years. Can we build a new, sustainable model of inpatient care through attending-directed inpatient services much as has happened in the US?

Canada’s population of 36 million people is growing by approximately 1% per year, largely driven by immigration.³ At the same time, Canada’s population is aging and becoming increasingly medically complex; the percentage of Canadians age 65 years and older is anticipated to rise from approximately 17% today to 25% in 2035.⁴ Canada’s healthcare system historically functioned with relatively few inpatient beds, encouraging efficiency particularly with respect to which patients require hospital admission and which do not.⁵ Although data suggest that the number of hospital admissions declined in Canada between 1980 and 1995, recent data documented that General Internal Medicine admissions increased by 32% between 2010 and 2015 and accounted for 24% of total hospital bed days.^6,7 The effects of population growth and aging on admission volumes might be mitigated to some extent by innovations in healthcare delivery such as improved access to primary care (largely family physicians in Canada). However, even with these innovations, a growing and aging population is likely to have a disproportionate effect on the types of undifferentiated illnesses that are typically admitted to General Internal Medicine in Canadian teaching hospitals.

Increasing volumes and complexity are occurring at the same time that residency training in Canada is undergoing an extraordinary shift, mirroring trends in other countries.⁸ CTUs in Canada typically have a census of 20 or more patients and are staffed by an attending, one senior resident, two to three junior residents, and medical students. Recognition that physician fatigue is associated with patient safety events and physician burnout has led to shorter resident shifts, though Canadian hospitals typically operate without concrete work hour limits or “hard” caps on team size.⁸ To fulfill accreditation standards set by the Royal College of Physicians and Surgeons of Canada, residency programs have required increases in formal teaching sessions during working hours, further reducing resident presence at the bedside. Many specialty training programs (eg, anesthesiology and ophthalmology) that traditionally required trainees to rotate through General Medicine have eliminated this requirement. Moreover, postgraduate training now requires additional time be spent in ambulatory and community hospital settings to better prepare residents for practice.⁹ There is little enthusiasm for increasing the number of residents, as postgraduate training spots increased by 85% between 2000 and 2013, before stabilizing in recent years.¹⁰

These factors are leading to a substantial decline in resident availability on CTUs, shifting increasing amounts of direct patient care to attending physicians in Canadian teaching hospitals across virtually all specialties. Unsurprisingly, increased rates of burnout and decreases in job satisfaction have been reported.¹¹ The Royal College has yet to impose hard caps on team size, but many see this on the horizon.

Canadian teaching hospitals currently find themselves facing a confluence of factors nearly identical to those faced by teaching hospitals in the United States during 2003 when the Accreditation Council for Graduate Medical Education instituted resident duty hour restrictions to address concerns over trainee wellness, shift length, and patient safety.⁸ Instantly, hundreds of US teaching hospitals faced uncertainty over who would provide patient care when residents were unavailable. Virtually all US teaching hospitals responded with a creativity and speed that we are unaccustomed to in academic medicine. Hospitals reallocated money to finance attending-directed services where patient care was provided directly by attending physicians often working without trainees¹² but frequently supported by nurse practitioners or physician assistants.¹³ Despite the differences between US and Canadian healthcare, 15 years later, we in Canada can and should learn from the US experience.¹⁴

Attending-directed services offer several advantages. First, attending-directed services offer patient outcomes including ICU transfer, mortality, readmissions, and satisfaction that are similar, if not modestly improved, when compared with traditional teaching services.¹⁵ Results also suggest potential reductions in hospital length of stay and diagnostic testing.¹⁶ Attending-directed services can enhance trainee education by insuring attending physician presence and oversight in-hospital 24-hours per day.¹⁷ Although not well studied, attending-directed services may reduce variation in CTU patient census so that excess volumes can be absorbed by attending-directed teams even with seasonal surges (eg, influenza). Recognizing that many specialties were experiencing the same challenges as General Medicine in 2003, attending-directed services in the US have been designed to care for a wide spectrum of patients drawn from an array of different specialties with evidence of improved outcomes.¹² Building attending-directed services in Canadian teaching hospitals may expand to include patients from multiple specialties and subspecialties (surgery, orthopedics, and cardiology) where patient volumes are increasing and resident coverage is increasingly scarce.

The challenges that accompany the implementation of attending-directed teams must be acknowledged. First, while attending-directed teams solve many problems for teaching hospitals, physician billings may not generate sufficient income to be self-sustaining and require additional financial support.¹⁸ Without investment from hospitals or government, attending-directed models cannot flourish in teaching hospitals. US hospitals typically provide substantial financial support ($50,000-$100,000 per physician) to hospitalist programs, but Canadian teaching hospitals have been reluctant to follow suit.

Second, attending-directed services require a sustainable workforce. In Canada, inpatient care is provided predominately by family physician hospitalists in community hospitals, whereas internists typically fulfill these roles in teaching hospitals.¹⁹ Family physician hospitalists are commonly represented by the Canadian Society for Hospital Medicine, which is the Canadian branch of the Society of Hospital Medicine. Hospital medicine in Canada is typically organized around physician training (family physician vs internist) rather than clinical focus (outpatient vs inpatient). Collaborative models of care that unite hospitalists from all training streams (family physician, internist, and pediatrics) are only just emerging in Canadian teaching hospitals. How these programs are developed will be critical to the successful growth of attending-directed services. Third, if attending-directed services expand in teaching hospitals, the physicians who staff these services must come from somewhere. Either the “production” of physicians will need to increase or physicians will migrate to attending-directed services from outpatient practice or from community hospitals.²⁰ Canadian teaching hospitals can also explore nurse practitioners and physician assistants, a previously underutilized resource. Though the costs of such programs can be significant,²¹ the payoff in safety, quality, and efficiency may be worth it—as demonstrated in the US system. Fourth, teaching hospitals and medical schools must create academic homes to support and mentor the physicians working on attending-directed services. Although physicians hired for attending-directed services primarily provide direct patient care, few will join academic medical centers solely for this purpose. Teaching hospitals and medical schools need to carefully consider job descriptions, mentoring, and career advancement opportunities as they build attending-directed services. Finally, the interactions between teaching and attending-directed services are complex. There is an inevitable learning curve as clinical operations and protocols are built and developed. For example, decisions need to be made about how patients are divided between services and whether nocturnists are responsible for teaching overnight residents.¹⁷ Successful programs have the potential to benefit hospitals, patients, learners, and faculty alike.

The risks associated with the status quo in Canada must also be addressed. Patient volumes and complexity in Canada are likely to continue to slowly increase, while the number of trainees in Canadian teaching hospitals will remain stable at best. Forcing more patients onto already overtaxed teaching services is likely to worsen hospital efficiency, patient outcomes, and educational experiences.²² Forcing additional patient care onto overstretched faculty will slowly erode the academic work (teaching and research) that has characterized excellence in Canadian medicine.

The changes we propose to overcome the challenges facing Canadian teaching hospitals are neither cheap nor easy (Table). We expect resistance on many fronts. Implementing them will likely require concerted advocacy from a diverse group of champions shining a bright spotlight on the sizable challenges Canadian teaching hospitals are confronting. We believe that each challenge maps to a discrete group of champions with discrete targets within hospital leadership, medical school administration, and government who will need to be engaged. In our opinion, organizing around these challenges offers the best opportunity to overcome the perpetual resistance around costs. Canadian teaching hospitals and their CTUs are under unprecedented pressure. Do we act boldly and embrace attending-directed models of care or continue tinkering at the margins?

 

Acknowledgments

The authors thank Chaim Bell for his advice and suggestions.

Disclosures

The authors have nothing to disclose.

On general medical wards, effective interprofessional communication is essential for high-quality patient care. Hospitals increasingly adopt secure text-messaging systems for healthcare team members to communicate with physicians in lieu of paging.^1-3 Text messages facilitate bidirectional communication^4,5 and increase perceived efficiency^6-8 and are thus preferred over paging by nurses and trainees. However, this novel technology unintentionally causes high volumes of interruptions.^9,10 Compared to paging, sending text messages and calling smartphones are more convenient and encourage communication of issues in real time, regardless of urgency.¹¹ Interrupting messages are often perceived as nonurgent by physicians.^6,12 In particular, 73%-93% of pages or messages sent to physicians are found to be nonurgent.^13-17

Pages, text messages, or calls not only interrupt day-to-day tasks on the ward^{6,7,10,11,17,18} but also educational sessions,^18-21 which are essential to the clinical teaching unit (CTU). Interruptions reduce learning and retention²² and are disruptive to the medical learning climate.^18-20,23

Internal medicine CTUs at our large urban academic hospital network utilize a smartphone-based text messaging tool for interdisciplinary communication. Nonurgent interruptions are frequent during educational seminars, which occur at our institution between 8 AM and 9 AM and 12 PM and 1 PM on weekdays.^10,11,19 In a preliminary analysis at one hospital site, an average of three text messages (range 1-11), 2 calls (range 0-8), and 3 emails (range 0-13) interrupted each educational session. Physicians and nurses can disagree on the urgency of messages or calls for the purposes of patient care and workflow.^6,11,12,24 Nurses have expressed a desire for guidance regarding what constitutes an urgent clinical communication.⁶

This project aimed to reduce nonurgent text message interruptions during educational rounds. We hypothesized that improved decision support around clinical prioritization and reminders about educational hours could reduce unnecessary interruptions.

METHODS

This study was approved by the institution’s Research Ethics Board and conducted across 8 general medical CTU teams at an academic hospital network (Sites 1 and 2). Each CTU team provides 24-hour coverage of approximately 20–28 patients. The most responsible resident from each team carries an institution-provided smartphone, which receives secure texts, phone calls, and emails from nurses, social workers, physiotherapists, speech language pathologists, dieticians, pharmacists, and other physicians. Close collaboration with the platform developer permitted changes to be made to the system when needed. Prior to our interventions, a nurse could send a text message as either an “immediate interrupt” or a “delayed interrupt” message. Messages sent via the “delayed interrupt” option would be added to a queue and would eventually lead to an interrupting message if not replied to after a defined period. Direct phone calls were reserved for especially urgent or emergent communications.

Meetings were held with physicians and nursing managers at Site 1 (August 2014) and Site 2 (January 2015) to establish consensus on the communication process and determine clinical scenarios, regardless of time of day, that warrant a phone call, an “immediate interrupt” text, or a “delayed interrupt” text. In March 2015, resident feedback led to the addition of a third option to the sender interface. This option allowed messages to be sent as “For Your Information (FYI)” only, which would not lead to an interruption. “FYI” messages (for example, to notify that an ambulance had been booked for a patient), were instead placed in an electronic message board that could be viewed by the resident through the application. This change relied upon interdisciplinary trust and a commitment from residents to ensure that “FYI” messages were reviewed regularly.

Communication guidelines were transformed into poster format and displayed as a reference at nursing stations in July 2015 (Site 2) and February 2016 (Site 1; Figure 1). Nurse managers audited messages from nurses and provided feedback. In March 2016, a focused intervention was piloted across both sites to specifically limit nonurgent text messages during educational hours. First, educational hours were emphasized within the interface to make senders aware of their potential for interruption. In June 2016, the interface was further modified. Once the message application was opened during a defined educational time, an imbedded notification advised the sender to reevaluate the urgency of the communication and if appropriate, to delay sending the message until educational rounds were over or send an “FYI” message. This “alert” did not impede senders from sending a message through the system at any time (Figure 2A-D illustrates the evolution of the message interface).

Text interruptions (January 2014 to December 2016), phone calls (April 2015-December 2016), and emails (October 2014 to December 2016) received by team smartphones during educational hours were tracked. Total text messages sent over a 24-hour period and the type of message (“immediate interrupt,” “delayed interrupt,” and “FYI”) were also monitored. Calls were encouraged only in the case of emergent patient care matters, and monitoring calls would thus help identify whether senders bypass the message system due to deterioration in patient status or confusion surrounding the new message interface. Emails sent to team smartphones came from a variety of sources, including hospital administration, physicians, and patient flow coordinators who are not involved in direct patient care. Emails served as a “negative control” because of the predicted random variability in the email interruption frequency. Additional balancing measures included tracking Critical Care Outreach Team consultations and “Code Blue” (cardiac arrest) announcements over the same period to ensure that limiting educational interruptions did not result in increased deterioration of patient status.

Statistical process control charts (u charts) assessed the frequency of each type of educational interruption (text, call, or email) per team on a monthly basis. The total educational interruptions per month were divided by the number of educational hours per month to account for variation in educational hours each month (for example, during holidays when educational rounds do not take place). If call logs or email data were unavailable for individual teams or time periods, then the denominator was adjusted to reflect the number of teams and educational hours in the sample for that month.

Two 4-week samples of interrupting text messages received by the 8 teams during educational hours were deidentified, analyzed, and compared in terms of content and urgency. A preintervention sample (November 17 to December 14, 2014) was compared to a postintervention sample (November 14 to December 11, 2016). Messages from the 2014 and 2016 samples were randomized, deidentified for date and time, and analyzed for urgency by 3 independent adjudicators (2 senior residents and 1 staff physician) to avoid biasing the postintervention analysis toward improvement. Messages were classified as “urgent” if the adjudicator felt a response or action was required within 1 hour. Messages not meeting these criteria were classified as “nonurgent” or “indeterminate” if the urgency of the message could not be assessed because it required further context. Fleiss kappa statistic evaluated agreement among adjudicators. Individual urgency designations were compared for each message, and discrepant rankings were addressed through repeated joint assessments. Disagreements were resolved through discussion and comparison against communication guidelines. In addition, messages reporting a “critical lab,” requiring physician notification as per institutional policy, were reclassified as “urgent.” The proportion of “nonurgent” messages sent during educational hours was compared between baseline and post-intervention periods using the Chi-square test.

“FYI” messages sent from November 14 to December 11, 2016 were audited using the same adjudication process to determine if “FYI” designations were appropriate and did not contain urgent patient care communications.

 

RESULTS

Total text messages sent to team smartphones, the type of message the sender intended (“immediate interrupt,” “delayed interrupt,” or “FYI”), and total text interruptions received by the resident over the study period are illustrated in Figure 3. The introduction of the “FYI” message in March 2015 was associated with reduced text message interruptions, from a mean of 18.0 (95% CI, 17.2 to18.8) interrupting messages per team per day to 14.1 (95% CI, 13.6 to14.5) in March 2015 and 12.7 (95% CI, 12.2 to 13.2) after May 2016 (Supplemental Figure 1). The numbers of “delayed interrupt” and “FYI” messages increased over time.

Analysis of text interruptions during educational hours indicated 3 distinct phases (Figure 4). A mean of 0.92 (95% CI 0.88 to 0.97) text interruptions per team per educational hour was found during the first phase (January 2014 to July 2015). The message frequency decreased to a mean of 0.81 (95% CI, 0.77 to 0.84) messages per team per educational hour starting August 2015, following the implementation of the “FYI” message option for senders (March 2015) and dissemination of communication guidelines (July 2015). Finally, a further reduction to a mean of 0.59 (95% CI, 0.51 to 0.67) messages per team per educational hour began in June 2016 after the creation of the alert message that reminded senders of educational hours (March 2016, modified June 2016). Change in the interruption frequency was sustained over the following 6 months to the end of the observation period in December 2016.

Incoming phone call logs were available from April 2015 to December 2016, with a mean of 0.62 (95% CI, 0.56 to 0.67) calls per team per educational hour, which did not change over the study period (Supplementary Figure 2). The overall number of calls to team smartphones also did not change during the measurement period. Incoming email data were available from October 2014 to December 2016, with a mean of 0.94 (95% CI, 0.88 to 1.0) emails per team per educational hour, which did not change over the study period (Supplementary Figure 3). Internal medicine service discharges, “Code Blue” announcements, and Critical Care Outreach Team consultations remained stable over the measurement period.

Independent ranking of the combined 4-week samples of educational text interruptions from 2014 and 2016 revealed an initial 3-way agreement on 257/455 (56%) messages (Fleiss Kappa 0.298, fair agreement), which increased to 405/455 (89%) messages after the first joint assessment and reached full consensus after a third joint assessment that included classifying all messages that communicated institution-defined “critical lab” values as “urgent.”

Overall, 71 (16%) messages were classified as “urgent,” 346 (76%) as “nonurgent,” and 38 (8%) as “indeterminate.” After unblinding of the message date and time, 273 text messages were received during the baseline measurement period (November 17 to December 14, 2014) and 182 messages were received during the equivalent time period 2 years later (November 14 to December 11, 2016), consistent with the reduced volume of educational interruptions observed (Figure 4). A total of 426 (94%) messages were sent by nurses, and the remaining ones were sent by pharmacists (n = 20), ward clerks (n = 3), social workers (n = 4), speech language pathologist (n = 1), or device administrator (n = 1).

The proportion of “nonurgent” messages decreased from 223/273 (82%) in 2014 to 123/182 (68%) in 2016 (P ≤ .01). Although the absolute number of urgent messages remained similar (33 in 2014 and 38 in 2016), the proportion of “urgent” messages increased from 12% to 21% of the total messages received (P = .02). Seventeen (6%) messages had indeterminate frequency in 2014 compared to 21 (11.5%) in 2016 (NS).

An audit of consecutive “FYI” messages (November 14-December 11, 2016) revealed an initial agreement in 384/431 (89%), reaching full consensus after repeated joint assessments. A total of 406 (94%) “FYI” messages were appropriately sent, while 10 (2%) represented urgent communications that should have been sent as interruptions. In 15 (4%) cases, the appropriateness of the message was indeterminate.

DISCUSSION

Sequential interventions over a 36-month period were associated with reduced nonurgent text message interruptions during educational hours. A clinical communication process was formally defined to accurately match message urgency with communication modality. A “noninterrupt” option allowed nonurgent text messages to be posted to an electronic message board, rather than causing real-time interruption, thereby reducing the overall volume of interrupting text messages. Modifying the interface to alert potential senders to protected educational hours was associated with reductions in educational interruptions. Through a blinded analysis of the text message content between 2014 and 2016, we determined that nonurgent educational interruptions were significantly reduced, and the number of urgent communications remained constant. Reduced nonurgent interruptions have the potential to improve the learning climate on the medical teaching unit during protected educational hours.

 

At baseline, 82% of the sampled text messages sent during educational hours across both sites were considered nonurgent. The estimated proportion of urgent messages varies in the literature (5%-34%)^13-18 possibly due to center-specific methods of defining and measuring urgent messages. For example, different assessor training backgrounds, different numbers of assessors, and varying institutional policies are described.^13-17 We considered an urgent message to require a response or action within 1 hour or to represent an established “critical lab value” as per the institution. The high proportion of nonurgent interruptions found in this study and other works demonstrates the widespread nature of this problem within inpatient hospital settings; this phenomenon could potentially lead to unintended consequences on efficiency and medical education.

Few other initiatives have aimed to reduce interruptions to medical trainees during educational sessions. At one center, replacing numeric pagers with alphanumeric pagers decreased the need to return pages during educational sessions but did not decrease the overall number of pages.²¹ Another center implemented an inbox tool that reduced daytime nonurgent numeric pages.¹⁵ Similar to our center’s previous experience,¹¹ the total number of communications increased with the creation of the inbox tool.¹⁵ Unexpectedly, the introduction of an “FYI” option for senders in March 2015 did not increase the total number of messages.

Increasing use of text messages for communication between physicians and allied health professions has resulted in higher volumes of interruptions compared with conventional paging.^6,7,9 Excessive interruptions create a “crisis mode” work climate,¹⁰ which could compromise patient safety^25-27 and hamper trainees’ attainment of educational objectives.^18-20,23 During educational sessions, audible text, phone call, and email interruptions disrupt all learners in addition to the resident receiving the message. The creation of the “FYI” message option in March 2015 was associated with reduced overall daily interruptions, which may improve efficiency in residents’ clinical duties^17,18 and minimize multi-tasking that could lead to errors.²⁸ However, adding a real-time notification during educational hours (March 2016, modified June 2016) exerted the greatest impact specifically on educational interruptions. Engaging physicians in the creation and ongoing modification of instant-messaging interfaces can help customize technology to meet the needs of users.^15,29 Our work provides a strategy for improving communication between nurses and physicians in a teaching hospital setting, by achieving consensus on levels of urgency of different messages, providing a non-interrupting message option, and providing nurses with real-time information about educational hours.

Potential unintended consequences of the interventions require consideration. Discouraging interruptions may have reduced urgent patient care communications but were mitigated by enabling senders to ignore/override interruption warnings. We did not observe an increase in the number of overall calls to team devices, “Code Blues,” or critical care team consultations. However, we found that a very small (2%) but important group of “FYI” messages should have been sent as urgent interrupting messages, thereby underscoring the necessity for continuous feedback to senders on the clinical communication process.

Our study has limitations. Although educational interruptions can cause fragmented learning at our institution,¹⁹ the impact of reduced interruptions on the quality of educational sessions can only be inferred because we did not formally assess resident or staff physician perceptions on this outcome during the interventions. Moreover, we were unable to quantify interruptions received through personal smartphones, a frequent method of physician-physician communication.³⁰ Phone calls are the most intrusive of interruptions but were not the focus of interventions. Future work must consider documenting perceived appropriateness of calls in real time, similar to previous studies assessing paging urgency.^13,14,18 Biased ranking of message urgency was minimized by utilizing 3 independent adjudicators blinded to message date throughout the adjudication process and by applying established communication guidelines where available. Nevertheless, retrospective assessment of message urgency could be limited by a lack of clinical context, which may have been more apparent to the original sender and the recipient. Finally, at our center, a close relationship with the communication platform programmer made sequential modifications possible, while other institutions may have limited ability to make such changes. A different approach may be useful in some cases, such as modifying academic teaching times to limit interruptions.²³

In a large academic center, a high number of interrupting smartphone messages cause unnecessary distractions and reduce learning during educational hours. “Nonurgent” educational interruptions were reduced through successive improvement cycles, and ultimately by modifying the program interface to alert senders of educational hours. Further reduction in interruptions and sustainability may be achieved by studying phone call interruptions and by formalizing audit and feedback of sender’s adherence to standardized clinical communication methods.

ACKNOWLEDGMENT

Dr. Wu is supported by an award from the Mak Pak Chiu and Mak-Soo Lai Hing Chair in General Internal Medicine, University of Toronto. The authors would like to acknowledge Jason Uppal for his ongoing contribution to the improvement of clinical text message communications at our institution.

 

Disclosures

The authors have nothing to disclose.

On general medical wards, effective interprofessional communication is essential for high-quality patient care. Hospitals increasingly adopt secure text-messaging systems for healthcare team members to communicate with physicians in lieu of paging.^1-3 Text messages facilitate bidirectional communication^4,5 and increase perceived efficiency^6-8 and are thus preferred over paging by nurses and trainees. However, this novel technology unintentionally causes high volumes of interruptions.^9,10 Compared to paging, sending text messages and calling smartphones are more convenient and encourage communication of issues in real time, regardless of urgency.¹¹ Interrupting messages are often perceived as nonurgent by physicians.^6,12 In particular, 73%-93% of pages or messages sent to physicians are found to be nonurgent.^13-17

Pages, text messages, or calls not only interrupt day-to-day tasks on the ward^{6,7,10,11,17,18} but also educational sessions,^18-21 which are essential to the clinical teaching unit (CTU). Interruptions reduce learning and retention²² and are disruptive to the medical learning climate.^18-20,23

Internal medicine CTUs at our large urban academic hospital network utilize a smartphone-based text messaging tool for interdisciplinary communication. Nonurgent interruptions are frequent during educational seminars, which occur at our institution between 8 AM and 9 AM and 12 PM and 1 PM on weekdays.^10,11,19 In a preliminary analysis at one hospital site, an average of three text messages (range 1-11), 2 calls (range 0-8), and 3 emails (range 0-13) interrupted each educational session. Physicians and nurses can disagree on the urgency of messages or calls for the purposes of patient care and workflow.^6,11,12,24 Nurses have expressed a desire for guidance regarding what constitutes an urgent clinical communication.⁶

This project aimed to reduce nonurgent text message interruptions during educational rounds. We hypothesized that improved decision support around clinical prioritization and reminders about educational hours could reduce unnecessary interruptions.

METHODS

This study was approved by the institution’s Research Ethics Board and conducted across 8 general medical CTU teams at an academic hospital network (Sites 1 and 2). Each CTU team provides 24-hour coverage of approximately 20–28 patients. The most responsible resident from each team carries an institution-provided smartphone, which receives secure texts, phone calls, and emails from nurses, social workers, physiotherapists, speech language pathologists, dieticians, pharmacists, and other physicians. Close collaboration with the platform developer permitted changes to be made to the system when needed. Prior to our interventions, a nurse could send a text message as either an “immediate interrupt” or a “delayed interrupt” message. Messages sent via the “delayed interrupt” option would be added to a queue and would eventually lead to an interrupting message if not replied to after a defined period. Direct phone calls were reserved for especially urgent or emergent communications.

Meetings were held with physicians and nursing managers at Site 1 (August 2014) and Site 2 (January 2015) to establish consensus on the communication process and determine clinical scenarios, regardless of time of day, that warrant a phone call, an “immediate interrupt” text, or a “delayed interrupt” text. In March 2015, resident feedback led to the addition of a third option to the sender interface. This option allowed messages to be sent as “For Your Information (FYI)” only, which would not lead to an interruption. “FYI” messages (for example, to notify that an ambulance had been booked for a patient), were instead placed in an electronic message board that could be viewed by the resident through the application. This change relied upon interdisciplinary trust and a commitment from residents to ensure that “FYI” messages were reviewed regularly.

Communication guidelines were transformed into poster format and displayed as a reference at nursing stations in July 2015 (Site 2) and February 2016 (Site 1; Figure 1). Nurse managers audited messages from nurses and provided feedback. In March 2016, a focused intervention was piloted across both sites to specifically limit nonurgent text messages during educational hours. First, educational hours were emphasized within the interface to make senders aware of their potential for interruption. In June 2016, the interface was further modified. Once the message application was opened during a defined educational time, an imbedded notification advised the sender to reevaluate the urgency of the communication and if appropriate, to delay sending the message until educational rounds were over or send an “FYI” message. This “alert” did not impede senders from sending a message through the system at any time (Figure 2A-D illustrates the evolution of the message interface).

Text interruptions (January 2014 to December 2016), phone calls (April 2015-December 2016), and emails (October 2014 to December 2016) received by team smartphones during educational hours were tracked. Total text messages sent over a 24-hour period and the type of message (“immediate interrupt,” “delayed interrupt,” and “FYI”) were also monitored. Calls were encouraged only in the case of emergent patient care matters, and monitoring calls would thus help identify whether senders bypass the message system due to deterioration in patient status or confusion surrounding the new message interface. Emails sent to team smartphones came from a variety of sources, including hospital administration, physicians, and patient flow coordinators who are not involved in direct patient care. Emails served as a “negative control” because of the predicted random variability in the email interruption frequency. Additional balancing measures included tracking Critical Care Outreach Team consultations and “Code Blue” (cardiac arrest) announcements over the same period to ensure that limiting educational interruptions did not result in increased deterioration of patient status.

Statistical process control charts (u charts) assessed the frequency of each type of educational interruption (text, call, or email) per team on a monthly basis. The total educational interruptions per month were divided by the number of educational hours per month to account for variation in educational hours each month (for example, during holidays when educational rounds do not take place). If call logs or email data were unavailable for individual teams or time periods, then the denominator was adjusted to reflect the number of teams and educational hours in the sample for that month.

Two 4-week samples of interrupting text messages received by the 8 teams during educational hours were deidentified, analyzed, and compared in terms of content and urgency. A preintervention sample (November 17 to December 14, 2014) was compared to a postintervention sample (November 14 to December 11, 2016). Messages from the 2014 and 2016 samples were randomized, deidentified for date and time, and analyzed for urgency by 3 independent adjudicators (2 senior residents and 1 staff physician) to avoid biasing the postintervention analysis toward improvement. Messages were classified as “urgent” if the adjudicator felt a response or action was required within 1 hour. Messages not meeting these criteria were classified as “nonurgent” or “indeterminate” if the urgency of the message could not be assessed because it required further context. Fleiss kappa statistic evaluated agreement among adjudicators. Individual urgency designations were compared for each message, and discrepant rankings were addressed through repeated joint assessments. Disagreements were resolved through discussion and comparison against communication guidelines. In addition, messages reporting a “critical lab,” requiring physician notification as per institutional policy, were reclassified as “urgent.” The proportion of “nonurgent” messages sent during educational hours was compared between baseline and post-intervention periods using the Chi-square test.

“FYI” messages sent from November 14 to December 11, 2016 were audited using the same adjudication process to determine if “FYI” designations were appropriate and did not contain urgent patient care communications.

 

RESULTS

Total text messages sent to team smartphones, the type of message the sender intended (“immediate interrupt,” “delayed interrupt,” or “FYI”), and total text interruptions received by the resident over the study period are illustrated in Figure 3. The introduction of the “FYI” message in March 2015 was associated with reduced text message interruptions, from a mean of 18.0 (95% CI, 17.2 to18.8) interrupting messages per team per day to 14.1 (95% CI, 13.6 to14.5) in March 2015 and 12.7 (95% CI, 12.2 to 13.2) after May 2016 (Supplemental Figure 1). The numbers of “delayed interrupt” and “FYI” messages increased over time.

Analysis of text interruptions during educational hours indicated 3 distinct phases (Figure 4). A mean of 0.92 (95% CI 0.88 to 0.97) text interruptions per team per educational hour was found during the first phase (January 2014 to July 2015). The message frequency decreased to a mean of 0.81 (95% CI, 0.77 to 0.84) messages per team per educational hour starting August 2015, following the implementation of the “FYI” message option for senders (March 2015) and dissemination of communication guidelines (July 2015). Finally, a further reduction to a mean of 0.59 (95% CI, 0.51 to 0.67) messages per team per educational hour began in June 2016 after the creation of the alert message that reminded senders of educational hours (March 2016, modified June 2016). Change in the interruption frequency was sustained over the following 6 months to the end of the observation period in December 2016.

Incoming phone call logs were available from April 2015 to December 2016, with a mean of 0.62 (95% CI, 0.56 to 0.67) calls per team per educational hour, which did not change over the study period (Supplementary Figure 2). The overall number of calls to team smartphones also did not change during the measurement period. Incoming email data were available from October 2014 to December 2016, with a mean of 0.94 (95% CI, 0.88 to 1.0) emails per team per educational hour, which did not change over the study period (Supplementary Figure 3). Internal medicine service discharges, “Code Blue” announcements, and Critical Care Outreach Team consultations remained stable over the measurement period.

Independent ranking of the combined 4-week samples of educational text interruptions from 2014 and 2016 revealed an initial 3-way agreement on 257/455 (56%) messages (Fleiss Kappa 0.298, fair agreement), which increased to 405/455 (89%) messages after the first joint assessment and reached full consensus after a third joint assessment that included classifying all messages that communicated institution-defined “critical lab” values as “urgent.”

Overall, 71 (16%) messages were classified as “urgent,” 346 (76%) as “nonurgent,” and 38 (8%) as “indeterminate.” After unblinding of the message date and time, 273 text messages were received during the baseline measurement period (November 17 to December 14, 2014) and 182 messages were received during the equivalent time period 2 years later (November 14 to December 11, 2016), consistent with the reduced volume of educational interruptions observed (Figure 4). A total of 426 (94%) messages were sent by nurses, and the remaining ones were sent by pharmacists (n = 20), ward clerks (n = 3), social workers (n = 4), speech language pathologist (n = 1), or device administrator (n = 1).

The proportion of “nonurgent” messages decreased from 223/273 (82%) in 2014 to 123/182 (68%) in 2016 (P ≤ .01). Although the absolute number of urgent messages remained similar (33 in 2014 and 38 in 2016), the proportion of “urgent” messages increased from 12% to 21% of the total messages received (P = .02). Seventeen (6%) messages had indeterminate frequency in 2014 compared to 21 (11.5%) in 2016 (NS).

An audit of consecutive “FYI” messages (November 14-December 11, 2016) revealed an initial agreement in 384/431 (89%), reaching full consensus after repeated joint assessments. A total of 406 (94%) “FYI” messages were appropriately sent, while 10 (2%) represented urgent communications that should have been sent as interruptions. In 15 (4%) cases, the appropriateness of the message was indeterminate.

DISCUSSION

Sequential interventions over a 36-month period were associated with reduced nonurgent text message interruptions during educational hours. A clinical communication process was formally defined to accurately match message urgency with communication modality. A “noninterrupt” option allowed nonurgent text messages to be posted to an electronic message board, rather than causing real-time interruption, thereby reducing the overall volume of interrupting text messages. Modifying the interface to alert potential senders to protected educational hours was associated with reductions in educational interruptions. Through a blinded analysis of the text message content between 2014 and 2016, we determined that nonurgent educational interruptions were significantly reduced, and the number of urgent communications remained constant. Reduced nonurgent interruptions have the potential to improve the learning climate on the medical teaching unit during protected educational hours.

 

At baseline, 82% of the sampled text messages sent during educational hours across both sites were considered nonurgent. The estimated proportion of urgent messages varies in the literature (5%-34%)^13-18 possibly due to center-specific methods of defining and measuring urgent messages. For example, different assessor training backgrounds, different numbers of assessors, and varying institutional policies are described.^13-17 We considered an urgent message to require a response or action within 1 hour or to represent an established “critical lab value” as per the institution. The high proportion of nonurgent interruptions found in this study and other works demonstrates the widespread nature of this problem within inpatient hospital settings; this phenomenon could potentially lead to unintended consequences on efficiency and medical education.

Few other initiatives have aimed to reduce interruptions to medical trainees during educational sessions. At one center, replacing numeric pagers with alphanumeric pagers decreased the need to return pages during educational sessions but did not decrease the overall number of pages.²¹ Another center implemented an inbox tool that reduced daytime nonurgent numeric pages.¹⁵ Similar to our center’s previous experience,¹¹ the total number of communications increased with the creation of the inbox tool.¹⁵ Unexpectedly, the introduction of an “FYI” option for senders in March 2015 did not increase the total number of messages.

Increasing use of text messages for communication between physicians and allied health professions has resulted in higher volumes of interruptions compared with conventional paging.^6,7,9 Excessive interruptions create a “crisis mode” work climate,¹⁰ which could compromise patient safety^25-27 and hamper trainees’ attainment of educational objectives.^18-20,23 During educational sessions, audible text, phone call, and email interruptions disrupt all learners in addition to the resident receiving the message. The creation of the “FYI” message option in March 2015 was associated with reduced overall daily interruptions, which may improve efficiency in residents’ clinical duties^17,18 and minimize multi-tasking that could lead to errors.²⁸ However, adding a real-time notification during educational hours (March 2016, modified June 2016) exerted the greatest impact specifically on educational interruptions. Engaging physicians in the creation and ongoing modification of instant-messaging interfaces can help customize technology to meet the needs of users.^15,29 Our work provides a strategy for improving communication between nurses and physicians in a teaching hospital setting, by achieving consensus on levels of urgency of different messages, providing a non-interrupting message option, and providing nurses with real-time information about educational hours.

Potential unintended consequences of the interventions require consideration. Discouraging interruptions may have reduced urgent patient care communications but were mitigated by enabling senders to ignore/override interruption warnings. We did not observe an increase in the number of overall calls to team devices, “Code Blues,” or critical care team consultations. However, we found that a very small (2%) but important group of “FYI” messages should have been sent as urgent interrupting messages, thereby underscoring the necessity for continuous feedback to senders on the clinical communication process.

Our study has limitations. Although educational interruptions can cause fragmented learning at our institution,¹⁹ the impact of reduced interruptions on the quality of educational sessions can only be inferred because we did not formally assess resident or staff physician perceptions on this outcome during the interventions. Moreover, we were unable to quantify interruptions received through personal smartphones, a frequent method of physician-physician communication.³⁰ Phone calls are the most intrusive of interruptions but were not the focus of interventions. Future work must consider documenting perceived appropriateness of calls in real time, similar to previous studies assessing paging urgency.^13,14,18 Biased ranking of message urgency was minimized by utilizing 3 independent adjudicators blinded to message date throughout the adjudication process and by applying established communication guidelines where available. Nevertheless, retrospective assessment of message urgency could be limited by a lack of clinical context, which may have been more apparent to the original sender and the recipient. Finally, at our center, a close relationship with the communication platform programmer made sequential modifications possible, while other institutions may have limited ability to make such changes. A different approach may be useful in some cases, such as modifying academic teaching times to limit interruptions.²³

In a large academic center, a high number of interrupting smartphone messages cause unnecessary distractions and reduce learning during educational hours. “Nonurgent” educational interruptions were reduced through successive improvement cycles, and ultimately by modifying the program interface to alert senders of educational hours. Further reduction in interruptions and sustainability may be achieved by studying phone call interruptions and by formalizing audit and feedback of sender’s adherence to standardized clinical communication methods.

ACKNOWLEDGMENT

Dr. Wu is supported by an award from the Mak Pak Chiu and Mak-Soo Lai Hing Chair in General Internal Medicine, University of Toronto. The authors would like to acknowledge Jason Uppal for his ongoing contribution to the improvement of clinical text message communications at our institution.

 

Disclosures

The authors have nothing to disclose.

On general medical wards, effective interprofessional communication is essential for high-quality patient care. Hospitals increasingly adopt secure text-messaging systems for healthcare team members to communicate with physicians in lieu of paging.^1-3 Text messages facilitate bidirectional communication^4,5 and increase perceived efficiency^6-8 and are thus preferred over paging by nurses and trainees. However, this novel technology unintentionally causes high volumes of interruptions.^9,10 Compared to paging, sending text messages and calling smartphones are more convenient and encourage communication of issues in real time, regardless of urgency.¹¹ Interrupting messages are often perceived as nonurgent by physicians.^6,12 In particular, 73%-93% of pages or messages sent to physicians are found to be nonurgent.^13-17

Pages, text messages, or calls not only interrupt day-to-day tasks on the ward^{6,7,10,11,17,18} but also educational sessions,^18-21 which are essential to the clinical teaching unit (CTU). Interruptions reduce learning and retention²² and are disruptive to the medical learning climate.^18-20,23

Internal medicine CTUs at our large urban academic hospital network utilize a smartphone-based text messaging tool for interdisciplinary communication. Nonurgent interruptions are frequent during educational seminars, which occur at our institution between 8 AM and 9 AM and 12 PM and 1 PM on weekdays.^10,11,19 In a preliminary analysis at one hospital site, an average of three text messages (range 1-11), 2 calls (range 0-8), and 3 emails (range 0-13) interrupted each educational session. Physicians and nurses can disagree on the urgency of messages or calls for the purposes of patient care and workflow.^6,11,12,24 Nurses have expressed a desire for guidance regarding what constitutes an urgent clinical communication.⁶

This project aimed to reduce nonurgent text message interruptions during educational rounds. We hypothesized that improved decision support around clinical prioritization and reminders about educational hours could reduce unnecessary interruptions.

METHODS

This study was approved by the institution’s Research Ethics Board and conducted across 8 general medical CTU teams at an academic hospital network (Sites 1 and 2). Each CTU team provides 24-hour coverage of approximately 20–28 patients. The most responsible resident from each team carries an institution-provided smartphone, which receives secure texts, phone calls, and emails from nurses, social workers, physiotherapists, speech language pathologists, dieticians, pharmacists, and other physicians. Close collaboration with the platform developer permitted changes to be made to the system when needed. Prior to our interventions, a nurse could send a text message as either an “immediate interrupt” or a “delayed interrupt” message. Messages sent via the “delayed interrupt” option would be added to a queue and would eventually lead to an interrupting message if not replied to after a defined period. Direct phone calls were reserved for especially urgent or emergent communications.

Meetings were held with physicians and nursing managers at Site 1 (August 2014) and Site 2 (January 2015) to establish consensus on the communication process and determine clinical scenarios, regardless of time of day, that warrant a phone call, an “immediate interrupt” text, or a “delayed interrupt” text. In March 2015, resident feedback led to the addition of a third option to the sender interface. This option allowed messages to be sent as “For Your Information (FYI)” only, which would not lead to an interruption. “FYI” messages (for example, to notify that an ambulance had been booked for a patient), were instead placed in an electronic message board that could be viewed by the resident through the application. This change relied upon interdisciplinary trust and a commitment from residents to ensure that “FYI” messages were reviewed regularly.

Communication guidelines were transformed into poster format and displayed as a reference at nursing stations in July 2015 (Site 2) and February 2016 (Site 1; Figure 1). Nurse managers audited messages from nurses and provided feedback. In March 2016, a focused intervention was piloted across both sites to specifically limit nonurgent text messages during educational hours. First, educational hours were emphasized within the interface to make senders aware of their potential for interruption. In June 2016, the interface was further modified. Once the message application was opened during a defined educational time, an imbedded notification advised the sender to reevaluate the urgency of the communication and if appropriate, to delay sending the message until educational rounds were over or send an “FYI” message. This “alert” did not impede senders from sending a message through the system at any time (Figure 2A-D illustrates the evolution of the message interface).

Text interruptions (January 2014 to December 2016), phone calls (April 2015-December 2016), and emails (October 2014 to December 2016) received by team smartphones during educational hours were tracked. Total text messages sent over a 24-hour period and the type of message (“immediate interrupt,” “delayed interrupt,” and “FYI”) were also monitored. Calls were encouraged only in the case of emergent patient care matters, and monitoring calls would thus help identify whether senders bypass the message system due to deterioration in patient status or confusion surrounding the new message interface. Emails sent to team smartphones came from a variety of sources, including hospital administration, physicians, and patient flow coordinators who are not involved in direct patient care. Emails served as a “negative control” because of the predicted random variability in the email interruption frequency. Additional balancing measures included tracking Critical Care Outreach Team consultations and “Code Blue” (cardiac arrest) announcements over the same period to ensure that limiting educational interruptions did not result in increased deterioration of patient status.

Statistical process control charts (u charts) assessed the frequency of each type of educational interruption (text, call, or email) per team on a monthly basis. The total educational interruptions per month were divided by the number of educational hours per month to account for variation in educational hours each month (for example, during holidays when educational rounds do not take place). If call logs or email data were unavailable for individual teams or time periods, then the denominator was adjusted to reflect the number of teams and educational hours in the sample for that month.

Two 4-week samples of interrupting text messages received by the 8 teams during educational hours were deidentified, analyzed, and compared in terms of content and urgency. A preintervention sample (November 17 to December 14, 2014) was compared to a postintervention sample (November 14 to December 11, 2016). Messages from the 2014 and 2016 samples were randomized, deidentified for date and time, and analyzed for urgency by 3 independent adjudicators (2 senior residents and 1 staff physician) to avoid biasing the postintervention analysis toward improvement. Messages were classified as “urgent” if the adjudicator felt a response or action was required within 1 hour. Messages not meeting these criteria were classified as “nonurgent” or “indeterminate” if the urgency of the message could not be assessed because it required further context. Fleiss kappa statistic evaluated agreement among adjudicators. Individual urgency designations were compared for each message, and discrepant rankings were addressed through repeated joint assessments. Disagreements were resolved through discussion and comparison against communication guidelines. In addition, messages reporting a “critical lab,” requiring physician notification as per institutional policy, were reclassified as “urgent.” The proportion of “nonurgent” messages sent during educational hours was compared between baseline and post-intervention periods using the Chi-square test.

“FYI” messages sent from November 14 to December 11, 2016 were audited using the same adjudication process to determine if “FYI” designations were appropriate and did not contain urgent patient care communications.

 

RESULTS

Total text messages sent to team smartphones, the type of message the sender intended (“immediate interrupt,” “delayed interrupt,” or “FYI”), and total text interruptions received by the resident over the study period are illustrated in Figure 3. The introduction of the “FYI” message in March 2015 was associated with reduced text message interruptions, from a mean of 18.0 (95% CI, 17.2 to18.8) interrupting messages per team per day to 14.1 (95% CI, 13.6 to14.5) in March 2015 and 12.7 (95% CI, 12.2 to 13.2) after May 2016 (Supplemental Figure 1). The numbers of “delayed interrupt” and “FYI” messages increased over time.

Analysis of text interruptions during educational hours indicated 3 distinct phases (Figure 4). A mean of 0.92 (95% CI 0.88 to 0.97) text interruptions per team per educational hour was found during the first phase (January 2014 to July 2015). The message frequency decreased to a mean of 0.81 (95% CI, 0.77 to 0.84) messages per team per educational hour starting August 2015, following the implementation of the “FYI” message option for senders (March 2015) and dissemination of communication guidelines (July 2015). Finally, a further reduction to a mean of 0.59 (95% CI, 0.51 to 0.67) messages per team per educational hour began in June 2016 after the creation of the alert message that reminded senders of educational hours (March 2016, modified June 2016). Change in the interruption frequency was sustained over the following 6 months to the end of the observation period in December 2016.

Incoming phone call logs were available from April 2015 to December 2016, with a mean of 0.62 (95% CI, 0.56 to 0.67) calls per team per educational hour, which did not change over the study period (Supplementary Figure 2). The overall number of calls to team smartphones also did not change during the measurement period. Incoming email data were available from October 2014 to December 2016, with a mean of 0.94 (95% CI, 0.88 to 1.0) emails per team per educational hour, which did not change over the study period (Supplementary Figure 3). Internal medicine service discharges, “Code Blue” announcements, and Critical Care Outreach Team consultations remained stable over the measurement period.

Independent ranking of the combined 4-week samples of educational text interruptions from 2014 and 2016 revealed an initial 3-way agreement on 257/455 (56%) messages (Fleiss Kappa 0.298, fair agreement), which increased to 405/455 (89%) messages after the first joint assessment and reached full consensus after a third joint assessment that included classifying all messages that communicated institution-defined “critical lab” values as “urgent.”

Overall, 71 (16%) messages were classified as “urgent,” 346 (76%) as “nonurgent,” and 38 (8%) as “indeterminate.” After unblinding of the message date and time, 273 text messages were received during the baseline measurement period (November 17 to December 14, 2014) and 182 messages were received during the equivalent time period 2 years later (November 14 to December 11, 2016), consistent with the reduced volume of educational interruptions observed (Figure 4). A total of 426 (94%) messages were sent by nurses, and the remaining ones were sent by pharmacists (n = 20), ward clerks (n = 3), social workers (n = 4), speech language pathologist (n = 1), or device administrator (n = 1).

The proportion of “nonurgent” messages decreased from 223/273 (82%) in 2014 to 123/182 (68%) in 2016 (P ≤ .01). Although the absolute number of urgent messages remained similar (33 in 2014 and 38 in 2016), the proportion of “urgent” messages increased from 12% to 21% of the total messages received (P = .02). Seventeen (6%) messages had indeterminate frequency in 2014 compared to 21 (11.5%) in 2016 (NS).

An audit of consecutive “FYI” messages (November 14-December 11, 2016) revealed an initial agreement in 384/431 (89%), reaching full consensus after repeated joint assessments. A total of 406 (94%) “FYI” messages were appropriately sent, while 10 (2%) represented urgent communications that should have been sent as interruptions. In 15 (4%) cases, the appropriateness of the message was indeterminate.

DISCUSSION

Sequential interventions over a 36-month period were associated with reduced nonurgent text message interruptions during educational hours. A clinical communication process was formally defined to accurately match message urgency with communication modality. A “noninterrupt” option allowed nonurgent text messages to be posted to an electronic message board, rather than causing real-time interruption, thereby reducing the overall volume of interrupting text messages. Modifying the interface to alert potential senders to protected educational hours was associated with reductions in educational interruptions. Through a blinded analysis of the text message content between 2014 and 2016, we determined that nonurgent educational interruptions were significantly reduced, and the number of urgent communications remained constant. Reduced nonurgent interruptions have the potential to improve the learning climate on the medical teaching unit during protected educational hours.

 

At baseline, 82% of the sampled text messages sent during educational hours across both sites were considered nonurgent. The estimated proportion of urgent messages varies in the literature (5%-34%)^13-18 possibly due to center-specific methods of defining and measuring urgent messages. For example, different assessor training backgrounds, different numbers of assessors, and varying institutional policies are described.^13-17 We considered an urgent message to require a response or action within 1 hour or to represent an established “critical lab value” as per the institution. The high proportion of nonurgent interruptions found in this study and other works demonstrates the widespread nature of this problem within inpatient hospital settings; this phenomenon could potentially lead to unintended consequences on efficiency and medical education.

Few other initiatives have aimed to reduce interruptions to medical trainees during educational sessions. At one center, replacing numeric pagers with alphanumeric pagers decreased the need to return pages during educational sessions but did not decrease the overall number of pages.²¹ Another center implemented an inbox tool that reduced daytime nonurgent numeric pages.¹⁵ Similar to our center’s previous experience,¹¹ the total number of communications increased with the creation of the inbox tool.¹⁵ Unexpectedly, the introduction of an “FYI” option for senders in March 2015 did not increase the total number of messages.

Increasing use of text messages for communication between physicians and allied health professions has resulted in higher volumes of interruptions compared with conventional paging.^6,7,9 Excessive interruptions create a “crisis mode” work climate,¹⁰ which could compromise patient safety^25-27 and hamper trainees’ attainment of educational objectives.^18-20,23 During educational sessions, audible text, phone call, and email interruptions disrupt all learners in addition to the resident receiving the message. The creation of the “FYI” message option in March 2015 was associated with reduced overall daily interruptions, which may improve efficiency in residents’ clinical duties^17,18 and minimize multi-tasking that could lead to errors.²⁸ However, adding a real-time notification during educational hours (March 2016, modified June 2016) exerted the greatest impact specifically on educational interruptions. Engaging physicians in the creation and ongoing modification of instant-messaging interfaces can help customize technology to meet the needs of users.^15,29 Our work provides a strategy for improving communication between nurses and physicians in a teaching hospital setting, by achieving consensus on levels of urgency of different messages, providing a non-interrupting message option, and providing nurses with real-time information about educational hours.

Potential unintended consequences of the interventions require consideration. Discouraging interruptions may have reduced urgent patient care communications but were mitigated by enabling senders to ignore/override interruption warnings. We did not observe an increase in the number of overall calls to team devices, “Code Blues,” or critical care team consultations. However, we found that a very small (2%) but important group of “FYI” messages should have been sent as urgent interrupting messages, thereby underscoring the necessity for continuous feedback to senders on the clinical communication process.

Our study has limitations. Although educational interruptions can cause fragmented learning at our institution,¹⁹ the impact of reduced interruptions on the quality of educational sessions can only be inferred because we did not formally assess resident or staff physician perceptions on this outcome during the interventions. Moreover, we were unable to quantify interruptions received through personal smartphones, a frequent method of physician-physician communication.³⁰ Phone calls are the most intrusive of interruptions but were not the focus of interventions. Future work must consider documenting perceived appropriateness of calls in real time, similar to previous studies assessing paging urgency.^13,14,18 Biased ranking of message urgency was minimized by utilizing 3 independent adjudicators blinded to message date throughout the adjudication process and by applying established communication guidelines where available. Nevertheless, retrospective assessment of message urgency could be limited by a lack of clinical context, which may have been more apparent to the original sender and the recipient. Finally, at our center, a close relationship with the communication platform programmer made sequential modifications possible, while other institutions may have limited ability to make such changes. A different approach may be useful in some cases, such as modifying academic teaching times to limit interruptions.²³

In a large academic center, a high number of interrupting smartphone messages cause unnecessary distractions and reduce learning during educational hours. “Nonurgent” educational interruptions were reduced through successive improvement cycles, and ultimately by modifying the program interface to alert senders of educational hours. Further reduction in interruptions and sustainability may be achieved by studying phone call interruptions and by formalizing audit and feedback of sender’s adherence to standardized clinical communication methods.

ACKNOWLEDGMENT

Dr. Wu is supported by an award from the Mak Pak Chiu and Mak-Soo Lai Hing Chair in General Internal Medicine, University of Toronto. The authors would like to acknowledge Jason Uppal for his ongoing contribution to the improvement of clinical text message communications at our institution.

 

Disclosures

The authors have nothing to disclose.