Technology and Health Care 23 (2015) 233–241 DOI 10.3233/THC-140865 IOS Press
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Are physician pagers an outmoded technology? Raman Mehrzad∗ and Michael Barza Department of Medicine, Steward Carney Hospital, Boston, MA, USA Received 27 June 2014 Accepted 25 August 2014 Abstract. BACKGROUND: Pagers are the most commonly used method of communications in American hospitals. However, its financial cost and efficiency is unknown. OBJECTIVE: To evaluate the efficiency of conventional hospital pagers and to estimate the financial cost of time wasted by the use of these pagers. METHODS: We conducted a survey among 100 clinicians, nurses and pharmacists in our community teaching hospital, estimating the time spent in the process of sending and responding to pages and the financial equivalent of this time, and evaluating the potential advantages of hospital-based wireless telephones compared with traditional pagers. RESULTS: A total of 70 clinicians completed the survey for a response rate of 70%. The average time spent per daytime shift in using the paging system was between 48 and 66 minutes for physicians, 120 minutes for nurses and 165 minutes for pharmacists. The financial cost of time lost for a single medical ward for one month was estimated to be $2,732–$17,250, depending on the case scenario. CONCLUSIONS: Our study suggests that the traditional paging system is an inefficient means of communication between clinicians and hospital staff and that a switch to direct phone calls might be far more cost-effective. Similar considerations probably apply to most hospitals that still use traditional pagers. Keywords: Pagers, technology, communication, effectiveness, telephones
1. Introduction Pagers are wireless telecommunication devices that receive and display numeric or text messages [1]. The first practical paging service was launched in 1950 for physicians in New York [2]. Today, pagers are the most commonly used method of communication in American hospitals. However, despite rapid advances in communications technology in recent years, we found only 18 studies published over the past 16 years that evaluated systems of communication between health care professionals, with no study estimating the cost or efficiency of the conventional pager systems [3–5]. Digital enhanced cordless telecommunication (DECT) phones are domestic cordless phones which use base stations to connect one or more handsets to a telecom network. By using directional antennas the phones can cover an area in excess of one kilometer. Talk time of several hours and standby time ∗ Corresponding author: Raman Mehrzad, Department of Medicine, Steward Carney Hospital, 2100 Dorchester Ave, Boston, MA 02124, USA. Tel.: +1 774 240 0060; Fax: +1 617 474 3811; E-mail: [email protected].
c 2015 – IOS Press and the authors. All rights reserved 0928-7329/15/$35.00
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of several days on one rechargeable battery charge is standard [6]. These phones have the capability to make instant phone calls, send text messages, record voice messages, display caller identification and has a phonebook. DECT phones work with a peak power of 0.25 W and a frequency of 1900 MHz. They send signals in pulses, which make the risk for potential interference much lower than with regular mobile phones: a distance of >50 cm between a DECT telephone and medical equipment is safe [7]. Importantly, they can be HIPAA-compliant and they are already being used in some hospitals in the United States [8,9]. In many European countries the DECT phones are presently a standard way of communication in clinical practice [13]. There are many advantages DECT phones have over pagers, where the most important feature is that one can be reached directly and immediately. However, one disadvantage is that, unlike pagers, they do not work outside the hospital [6]. In this paper, we evaluate the efficiency and cost of the paging system by a survey-based approach, and make a comparison with DECT phones as a potentially superior replacement. We have estimated the value of time lost by nurses and pharmacists but not by physicians because physicians’ tasks and rates of remuneration are too variable to be meaningfully estimated for this study. Accordingly, the estimate is a partial cost analysis. 2. Methods 2.1. Study design We conducted a 10-question survey among physicians, nurses and pharmacists in our community teaching hospital in Boston, Massachusetts. Our hospital has 159 licensed beds with 50 annual residents and approximately 3,500 discharges per year. Physicians participating in our survey had a range of subspecialties, including internal medicine doctors, general surgeons, pulmonologists, cardiologists, nephrologists, neurologists, anesthesiologists and an infectious disease consult to mention a few. Their average workload varies from approximately 15–30 patients/day. Some of the physicians were also involved in research activities. Survey forms were handed out in person by one of the authors; after filling out the survey, respondents dropped the responses anonymously in a box. Pages can be sent either through an internet-based system (Amion Physician Scheduling at www. amion.com) or directly through the hospital operator. Participants were recruited randomly from a list of attending physicians, medical residents, registered nurses and clinical pharmacists. Respondents were asked to estimate, by recollection, their answers to the survey questions. The surveys were handed out to each employee and collected after one month for analysis. 2.2. Subjects and study selection We analyzed the number of pages sent and received, the most commonly-used and preferred methods of communication among groups of caregivers, the estimated time lost in using the paging system and the number of urgent pages, i.e. pages that, in the opinion of the recipient, required prompt attention (< 5 minutes). For questions regarding respondent’s relative use and preference for pagers, the comparative option for communication was a direct telephone call to the recipient, using either a hospital telephone system or mobile phones. For most calculations, we determined a mean and standard deviation. A financial analysis was performed, estimating the cost of the paging system in terms of time lost by the caller in waiting for a response. The analysis was restricted to registered nurses and clinical
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Table 1 Usage characteristics of pages by hospital personnel Characteristic Pages sent or received per shift* Mean pages deemed urgent (by party noted) Pages not returned Minutes to send page Minutes to respond to page Minutes for page sent by the indicated party to be returned Minutes spent per shift∗ Fraction of shift spent sending and responding to pages Pagers are most used method of communication∗∗ Pagers are preferred method of communication∗∗
Attending physicians 3 (sent) 12 (received) 23% (by recipient) 2 pages/week 3 4 6
Residents
Nurses
Pharmacists
6 (sent) 10 (received) 27% (by recipient) 2 pages/week 6 3 4
10 (sent)
11 (sent)
59% (by nurse) 15% 2 N/A 10
26% (by pharmacist) 26% 2 N/A 13
66 11%
48 8%
120 25%
165 35%
55%
70%
45%
58%
90% (via hospital operator) 20%
80% (via hospital operator) 10%
∗ One daytime shift (physicians 10 hours; nurses and pharmacists 8 hours); ∗∗ Percentage of respondents reporting greatest use of or preference for pagers; All data except for percentages are mean values.
pharmacists because their work typically requires a response from the physician for them to proceed. A comparable analysis was not conducted for attending physicians or residents because the varying work duties of these groups made such an analysis unreliable. The costs were calculated by mean time spent, pagers sent and hourly salaries. 3. Results 3.1. Demographics The survey was sent to 100 clinicians, namely, included physicians, nurses and pharmacists. 70 clinicians completed the survey for a response rate of 70%, including 10 attending physicians, 30 medical residents, 20 registered nurses, and 10 clinical pharmacists. The results are summarized in Table 1. 3.2. Outcome for attending physicians Pagers, were the most used (55%) for both sending and receiving messages and were the preferred (45%) method of receiving communication by attending physicians. Direct phone calls through either the hospital telephone system or mobile phones were the second most used (27.5%) and preferred (30%) method of communication. In total, 66 minutes/day were spent in communicating through pagers in a 10-hour shift per attending physician. 3.3. Outcome for medical residents Pagers were the most used modality for both sending and receiving messages by 70% of residents and were preferred for both purposes by 58% of residents. The second most used method of communication
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R. Mehrzad and M. Barza / The efficiency of the paging system 14 12 10 Minutes tto send page 8 Minutes tto respond to page 6 Minutes ffor page to bee returned
4 2 0 Aendings
Residents
Nurses
Pharmacists
Fig. 1. Time spent in sending and responding to pages and waiting for pages to be returned by healthcare groups. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/THC-140865)
was paging through the operator (20%), while the second most preferred method of communication was by direct phone calls (26%). Medical residents spent an average of 48 minutes/day in communicating through pagers in a 10-hour shift per medical resident. 3.4. Outcome for registered nurses In contrast to reports by physicians, the most used method of paging by nurses was through the hospital operator (90%), followed by pages through Amion (10%). When asked a hypothetical question as to their preferred method of communication, 80% of nurses preferred direct phone calls (i.e. to a DECT phone or mobile phone), followed by pages to the recipient’s pager (20%). Nurses spent an average of 120 minutes/day per nurse in communicating through pagers in an 8-hour shift. 3.5. Outcome for clinical pharmacists The most used method of paging was through the page operator (80%), followed by pages initiated directly through Amion (20%) to the recipient’s pager. The preferred method of communication was through direct phone calls (90%), followed by paging through the operator (10%). Pharmacists spent an average of 165 min/day per pharmacist in communicating through pagers in an 8-hour shift. 4. Financial analysis To estimate the financial cost of time spent in communicating through pagers, we presumed that delays in the process interfered with work flow. The analysis was restricted to nurses and pharmacists on a single, general medical, 28-bed ward. For these nurses and pharmacists, it was assumed that the physician’s response was needed for the worker to proceed with his or her task. We calculated the value of the time lost as the fraction of the typical individual’s time (Table 1) expressed as salary. We made the calculation only for the daytime shift, during which it is likely that the greatest number of pages occur; because there are also many pages in the evening, our calculations represent a substantial underestimate.
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100% 90% 80% 70% 60%
Most used method of communicaon
50%
Preeferred method of communicaon.
40% 30% 20% 10% 0% Aendings
Residentss
Nurses
Pharmacists
Fig. 2. Percentage of healthcare groups for whom pagers were the most used and the preferred method of communication. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/THC-140865)
4.1. Cost of operating current pagers We estimated the cost of the current pagers and the cost of the time spent in initiating communication for 4 nurses and 1 pharmacist to cover the 8-hour day shift of a 28-bed medical ward for one month in our hospital as follows. In our community teaching hospital, there are a total of 311 operating pagers used to cover a variety of services. The carrier is paid $6.62 per month per pager. Each pager consumes 2 batteries per month, for a total of 622 batteries for all pagers, per month. A set containing 24 batteries costs $20 per box. Consequently, the total cost for the paging system is $2,600 per month. – Number of pagers: 311 – Number of batteries per month: 2 × 311 = 622 – Cost for contracting one pager per month: $6.62 – 24-pack of batteries: $20 (311 × $6.62) + (26 battery boxes × $20) ≈ $2, 578 per month for 311 pagers
4.2. Cost of time spent by nurses and pharmacists using current pagers A total of 4 nurses and 1 pharmacist are required for coverage of one 28-bed medical ward for one shift. Because a nurse or pharmacist may continue to work for some of the time while waiting for a page to be returned, we constructed two scenarios (Table 2): – Worst-case scenario: assumes both the time it takes to page someone and the time it takes for the call to be returned are wasted. – Best-case scenario: assumes only the time it takes to page someone is wasted, not the time for the call to be returned. The average hourly salaries for registered nurses and clinical pharmacists at our institution are approximately $54.00 and $52.00 respectively which rates are above average in the United States [10,11].
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4.3. Worst-case scenario In the worst-case scenario, we assume that the total time it takes to page someone and have a page returned is wasted (12 min for one nurse to send page and receive response, 15 min for the pharmacist). Subsequently, the total time loss per month is: Nurses: ((12 min × 10 pages)/60 min) × 1 nurses × 30 days ≈ 60 h Pharmacists: ((15 min × 11 pages)/60min) × 1 pharmacists × 30 days ≈ 82.5 h Thus, a nurse working one shift per day wastes 60 hours per month. At a salary of $54.00 per hour, this amounts to $3,240 per month of wasted time. For a pharmacist, the comparable figure is $4,290. To staff a 28 bed floor with four nurses and one pharmacist would cost $17,250 per month in wasted time. 4.4. Best-case scenario Here, we assume that only the time it takes to page someone is wasted, i.e. 2 min per page sent. The total cost per month for the four day shift nurses and pharmacist in this scenario is $2,732. 5. DECT phones Starting price for a DECT phone is as low as $11.00 a piece [12]. These phones have a rechargeable battery included, and thus, there is no extra cost for batteries as there are with pagers. There is a one-time cost for building the infrastructure with base stations, wires and antennas, and will depend on the size of the hospital. Typically, the full installation range between $2,000–$30.000 [13]. Thus, a reasonable cost estimate for a hospital of our size would be: 300 (amount of physicians, residents and nurses) × 11 + 15,000: ≈ $18,300. This is a one-time cost. Estimating that each DECT phone has a life time of one year, the total cost each year would be $3,300 for replacement, although, these phones typically would last much longer. Consequently, even for the best case scenario outlined above, our hospital will save money within the first year of the implementation of the DECT phones. 6. Discussion Although the paging system is the most commonly used method of communication in American hospitals, it is time-consuming and inefficient. Attending physicians spend about 66 minutes per shift and residents spend 48 minutes per shift in responding to pages, while even more time is spent by nurses and pharmacists in sending and waiting for responses to pages. Aside from the time lost in the transaction, if there is any delay in returning the call, the caller often will have left the original site imposing a further burden in communication. Even though many pages are relatively urgent, the responses are often not prompt. Also, an appreciable number of pages are not returned, presumably because the recipient ignored or forgot to respond to the page or because the “wrong” person was paged. This situation occurred on average with 2 pages per week received by attending physicians, 15% of pages sent by nurses, and 26% of pages sent by pharmacists. We do not know the outcome of such missed pages. However, such lapses can lead to issues of patient safety.
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Table 2 Calculated financial cost of time lost in using the paging system for day shift Different scenarios Worst case scenario ∗ Person-hours/month for one shift per day ∗∗ Cost ($/month) per worker Cost per month for one shift per day
Best case scenario ∗ Person-hours/month for one shift per day Cost per month for per worker ∗∗
Cost ($/month) for one shift per day
Nurse
Pharmacist
60 h (1 nurse) $3,240 $12,960 (4 nurses)
82.5 h (1 pharmacist) $4,290 $4,290 (1 pharmacist)
10 (1 nurse) $540 (4 nurses) $2.160 (4 nurses)
11 h (1 pharmacist) $572 (1 pharmacist) $572 (1 pharmacist)
∗ Person-hour (The quantity of work which one person can perform in one hour); $54/hour; Pharmacist = $52/hour.
Total
$7,530 $17,250
$1,112 $2,732 ∗∗
Nurse =
About half of attending physicians and residents but only 10–20% of nurses and pharmacists preferred pages as the mode of communication. This difference probably reflects the sense of urgency on the part of the various parties, i.e. nurses and pharmacists, who are sending pages, want a quick response to their question whereas physicians, who receive the pages and are often occupied by other tasks, prefer not to have to respond immediately as would be the case if the call were made to a DECT phone. There are many disadvantages of the use of pagers. The standard paging system is a multistep (time consuming) process: the caller must log on to a computer, log on to the web system, find the pager number, type a message/number, and wait for the call back. In our institution, a page usually serves as a request for a phone call conversation. By contrast, DECT phones should lead to a more prompt response, shortening the total time taken. DECT phones have many advantages over pagers (Table 3). Most importantly, one can reach the other person directly and immediately. Calls with the DECT phone can be made quickly with the aid of a built-in phone book. Although the infrastructure is costly to build initially, this is a one-time cost, likely to be greatly outweighed by the reduction in time wasted. A disadvantage of these phones is that, unlike pagers, they do not work outside the hospital. However, the owner can leave a voice message in the DECT phone, redirecting the caller to a cell phone. Our financial analysis provides an estimate of the financial waste at a small, community teaching hospital. It clearly shows that even in the best-case scenario, there is a significant amount of financial loss each month with the use of pagers. Considering that this analysis was only performed for nurses and a pharmacist on a single shift in a 28-bed ward of a small community teaching hospital, the actual loss in most institutions is likely to be much higher. There are other costs for the transaction beyond those described above. These include (1) the time wasted by ward secretaries and other healthcare personnel in tracking down the initial caller once the call is returned; (2) the distractions and interruptions of work attributable to these delays. However, we admit that calls to a DECT or cell phone can be a distraction for the recipient. A better estimate of the time lost would require a detailed time-motion study. In any event, the time lost through delays in communication is certainly an opportunity cost, i.e. a cost due to the loss of other, valuable activities such as interactions with patients. Limitations of this study are its reliance on a survey-based approach with subjective answers and the lack of direct comparison with the use of DECT phones. In addition, the financial estimates are based
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R. Mehrzad and M. Barza / The efficiency of the paging system Table 3 Advantages and disadvantages of pagers compared with DECT phones
Advantages Standard practice within most hospitals
Pagers Disadvantages Responding to a pager is dependent on availability of a phone
DECT phones Advantages Disadvantages Instant phone calls and text Not a standard practice messaging within most hospitals
Pages with a text message can help recipient assess the urgency of the matter
The paging process requires multiple steps
A one-step phone call but little ability to assess urgency
Requires building an infrastructure with base stations, wires and antennas.
The pager can be brought home and will work outside the hospital
No provision to save a contact list Limited memory While the pagers are off, received pages are lost Requires replacement batteries
Contact list (phonebook) with caller ID Superior memory Voice message system
Does not work far from the base station
Rechargeable batteries
on assumptions, especially as to the proportion of time spent with the use of pagers that is “wasted”. In addition, we estimated the value of time lost for nurses and pharmacists but not for physicians because the variability of tasks and rates of remuneration for physicians would have made it difficult to obtain a meaningful estimate. Finally, the study was conducted in a community teaching hospital. It is possible that our findings would not apply to other types of institutions, such as tertiary care hospitals and institutions with large fellowship and research programs. Prospective studies are warranted to assess the most effective communication strategy.
Conflict of interest The authors declare that there is no financial, organizational or any other type of conflict of interest.
Funding There is no external source that funded this project.
Contributors Both authors reviewed the scientific literature, interpreted the data, and wrote the manuscript.
References [1] [2]
Rouse M. Pager. Search mobile Computing. Available at: http://searchmobilecomputing.techtarget.com/definition/pager. Ennis C. Pocket Radio Pages Doctors Night Or Day. Popular Science. January 1951. Available at: http://books.google. com/books?id=ZyEDAAAAMBAJ&pg=PA104&dq=popular+science+1950+can+our+jets+support&hl=en&ei=4n2TJmUBNnhnQfCvvGJDg&sa=X&oi=book_result&ct=result&resnum=5&ved=0CD8Q6AEwBA#v=onepage&q&f= true.
R. Mehrzad and M. Barza / The efficiency of the paging system [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13]
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Wu RC, Tran K, Lo V, O’leary KJ, Morra D et al. Effects of clinical communication interventions in hospitals: a systematic review of information and communication technology adoptions for improved communication between clinicians. Int J Med Inform. 2012 Nov;81(11):723-32. Solvoll T, Scholl J, Hartvisgen G. Physicians interrupted by mobile devices in hospitals: understanding the interaction between devices, roles, and duties. J Med Internet Res. 2013 Mar 7;15(3):e56. Ortega GR, Taksali S, Smart R et al. Direct cellular vs. indirect pager communication during orthopaedic surgical procedures: a prospective study. J Technol Health Care. 2009;17(2):149-57. ETR 178. European Telecommunications Standards Institute.1997. Available at: http://www.etsi.org/deliver/etsi_etr/ 100_199/178/02_60/etr_178e02p.pdf. J. Welinder, C. Tonevik, and U. Bostrom et al., “The introduction of DECT in health care environments,” Swedish Nat. Testing Res. Inst. SP Rep. 1997:18. Health Insurance Portability and Accountability Act (HIPAA). Available at: http://www.plantronics.com/us/support/kb/ detail.jsp?vfurl=/articles/en_US/Product_Information/Plantronics-and-HIPAA&retURL=/articles/en_US/How_To/RN 16®ion=us&c=All&lang=en_US. Health Insurance Portability and Accountability Act (HIPAA). Available at: http://www.plantronics.com/us/ support/kb/detail.jsp?vfurl=/articles/en_US/Documentation/DECT-6-0-Wireless-Security-Statement&retURL=%2 Fapex%2FknowledgeSearch®ion=us&p=&c=All&k=hipaa&t=All&lang=en_US&popup=false&c=All. 2012 ADVANCE for Nurses Salary Survey results. Available at: http://nursing.advanceweb.com/Web-Extras/OnlineExtras/2012-Salary-Survey-Results.aspx. Bureau of Labor Statistics. Occupational Employment and Wages, May 2012.29-1051 Pharmacists. Available at: http:// www.bls.gov/oes/current/oes291051.htm. Cost of DECT phones. Available at: http://www.amazon.com/VTech-CS6409-Accessory-Handset-Cordless/dp/B004OA 6VU0/ref=sr_1_2?s=electronics&ie=UTF8&qid=1400449787&sr=1-2&keywords=dect+phones. Application of DECT phones. Available at: http://www.dectweb.com/Introduction/applications.htm.
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Are physician pagers an outmoded technology? Raman Mehrzad∗ and Michael Barza Department of Medicine, Steward Carney Hospital, Boston, MA, USA Received 27 June 2014 Accepted 25 August 2014 Abstract. BACKGROUND: Pagers are the most commonly used method of communications in American hospitals. However, its financial cost and efficiency is unknown. OBJECTIVE: To evaluate the efficiency of conventional hospital pagers and to estimate the financial cost of time wasted by the use of these pagers. METHODS: We conducted a survey among 100 clinicians, nurses and pharmacists in our community teaching hospital, estimating the time spent in the process of sending and responding to pages and the financial equivalent of this time, and evaluating the potential advantages of hospital-based wireless telephones compared with traditional pagers. RESULTS: A total of 70 clinicians completed the survey for a response rate of 70%. The average time spent per daytime shift in using the paging system was between 48 and 66 minutes for physicians, 120 minutes for nurses and 165 minutes for pharmacists. The financial cost of time lost for a single medical ward for one month was estimated to be $2,732–$17,250, depending on the case scenario. CONCLUSIONS: Our study suggests that the traditional paging system is an inefficient means of communication between clinicians and hospital staff and that a switch to direct phone calls might be far more cost-effective. Similar considerations probably apply to most hospitals that still use traditional pagers. Keywords: Pagers, technology, communication, effectiveness, telephones
1. Introduction Pagers are wireless telecommunication devices that receive and display numeric or text messages [1]. The first practical paging service was launched in 1950 for physicians in New York [2]. Today, pagers are the most commonly used method of communication in American hospitals. However, despite rapid advances in communications technology in recent years, we found only 18 studies published over the past 16 years that evaluated systems of communication between health care professionals, with no study estimating the cost or efficiency of the conventional pager systems [3–5]. Digital enhanced cordless telecommunication (DECT) phones are domestic cordless phones which use base stations to connect one or more handsets to a telecom network. By using directional antennas the phones can cover an area in excess of one kilometer. Talk time of several hours and standby time ∗ Corresponding author: Raman Mehrzad, Department of Medicine, Steward Carney Hospital, 2100 Dorchester Ave, Boston, MA 02124, USA. Tel.: +1 774 240 0060; Fax: +1 617 474 3811; E-mail: [email protected].
c 2015 – IOS Press and the authors. All rights reserved 0928-7329/15/$35.00
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of several days on one rechargeable battery charge is standard [6]. These phones have the capability to make instant phone calls, send text messages, record voice messages, display caller identification and has a phonebook. DECT phones work with a peak power of 0.25 W and a frequency of 1900 MHz. They send signals in pulses, which make the risk for potential interference much lower than with regular mobile phones: a distance of >50 cm between a DECT telephone and medical equipment is safe [7]. Importantly, they can be HIPAA-compliant and they are already being used in some hospitals in the United States [8,9]. In many European countries the DECT phones are presently a standard way of communication in clinical practice [13]. There are many advantages DECT phones have over pagers, where the most important feature is that one can be reached directly and immediately. However, one disadvantage is that, unlike pagers, they do not work outside the hospital [6]. In this paper, we evaluate the efficiency and cost of the paging system by a survey-based approach, and make a comparison with DECT phones as a potentially superior replacement. We have estimated the value of time lost by nurses and pharmacists but not by physicians because physicians’ tasks and rates of remuneration are too variable to be meaningfully estimated for this study. Accordingly, the estimate is a partial cost analysis. 2. Methods 2.1. Study design We conducted a 10-question survey among physicians, nurses and pharmacists in our community teaching hospital in Boston, Massachusetts. Our hospital has 159 licensed beds with 50 annual residents and approximately 3,500 discharges per year. Physicians participating in our survey had a range of subspecialties, including internal medicine doctors, general surgeons, pulmonologists, cardiologists, nephrologists, neurologists, anesthesiologists and an infectious disease consult to mention a few. Their average workload varies from approximately 15–30 patients/day. Some of the physicians were also involved in research activities. Survey forms were handed out in person by one of the authors; after filling out the survey, respondents dropped the responses anonymously in a box. Pages can be sent either through an internet-based system (Amion Physician Scheduling at www. amion.com) or directly through the hospital operator. Participants were recruited randomly from a list of attending physicians, medical residents, registered nurses and clinical pharmacists. Respondents were asked to estimate, by recollection, their answers to the survey questions. The surveys were handed out to each employee and collected after one month for analysis. 2.2. Subjects and study selection We analyzed the number of pages sent and received, the most commonly-used and preferred methods of communication among groups of caregivers, the estimated time lost in using the paging system and the number of urgent pages, i.e. pages that, in the opinion of the recipient, required prompt attention (< 5 minutes). For questions regarding respondent’s relative use and preference for pagers, the comparative option for communication was a direct telephone call to the recipient, using either a hospital telephone system or mobile phones. For most calculations, we determined a mean and standard deviation. A financial analysis was performed, estimating the cost of the paging system in terms of time lost by the caller in waiting for a response. The analysis was restricted to registered nurses and clinical
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Table 1 Usage characteristics of pages by hospital personnel Characteristic Pages sent or received per shift* Mean pages deemed urgent (by party noted) Pages not returned Minutes to send page Minutes to respond to page Minutes for page sent by the indicated party to be returned Minutes spent per shift∗ Fraction of shift spent sending and responding to pages Pagers are most used method of communication∗∗ Pagers are preferred method of communication∗∗
Attending physicians 3 (sent) 12 (received) 23% (by recipient) 2 pages/week 3 4 6
Residents
Nurses
Pharmacists
6 (sent) 10 (received) 27% (by recipient) 2 pages/week 6 3 4
10 (sent)
11 (sent)
59% (by nurse) 15% 2 N/A 10
26% (by pharmacist) 26% 2 N/A 13
66 11%
48 8%
120 25%
165 35%
55%
70%
45%
58%
90% (via hospital operator) 20%
80% (via hospital operator) 10%
∗ One daytime shift (physicians 10 hours; nurses and pharmacists 8 hours); ∗∗ Percentage of respondents reporting greatest use of or preference for pagers; All data except for percentages are mean values.
pharmacists because their work typically requires a response from the physician for them to proceed. A comparable analysis was not conducted for attending physicians or residents because the varying work duties of these groups made such an analysis unreliable. The costs were calculated by mean time spent, pagers sent and hourly salaries. 3. Results 3.1. Demographics The survey was sent to 100 clinicians, namely, included physicians, nurses and pharmacists. 70 clinicians completed the survey for a response rate of 70%, including 10 attending physicians, 30 medical residents, 20 registered nurses, and 10 clinical pharmacists. The results are summarized in Table 1. 3.2. Outcome for attending physicians Pagers, were the most used (55%) for both sending and receiving messages and were the preferred (45%) method of receiving communication by attending physicians. Direct phone calls through either the hospital telephone system or mobile phones were the second most used (27.5%) and preferred (30%) method of communication. In total, 66 minutes/day were spent in communicating through pagers in a 10-hour shift per attending physician. 3.3. Outcome for medical residents Pagers were the most used modality for both sending and receiving messages by 70% of residents and were preferred for both purposes by 58% of residents. The second most used method of communication
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R. Mehrzad and M. Barza / The efficiency of the paging system 14 12 10 Minutes tto send page 8 Minutes tto respond to page 6 Minutes ffor page to bee returned
4 2 0 Aendings
Residents
Nurses
Pharmacists
Fig. 1. Time spent in sending and responding to pages and waiting for pages to be returned by healthcare groups. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/THC-140865)
was paging through the operator (20%), while the second most preferred method of communication was by direct phone calls (26%). Medical residents spent an average of 48 minutes/day in communicating through pagers in a 10-hour shift per medical resident. 3.4. Outcome for registered nurses In contrast to reports by physicians, the most used method of paging by nurses was through the hospital operator (90%), followed by pages through Amion (10%). When asked a hypothetical question as to their preferred method of communication, 80% of nurses preferred direct phone calls (i.e. to a DECT phone or mobile phone), followed by pages to the recipient’s pager (20%). Nurses spent an average of 120 minutes/day per nurse in communicating through pagers in an 8-hour shift. 3.5. Outcome for clinical pharmacists The most used method of paging was through the page operator (80%), followed by pages initiated directly through Amion (20%) to the recipient’s pager. The preferred method of communication was through direct phone calls (90%), followed by paging through the operator (10%). Pharmacists spent an average of 165 min/day per pharmacist in communicating through pagers in an 8-hour shift. 4. Financial analysis To estimate the financial cost of time spent in communicating through pagers, we presumed that delays in the process interfered with work flow. The analysis was restricted to nurses and pharmacists on a single, general medical, 28-bed ward. For these nurses and pharmacists, it was assumed that the physician’s response was needed for the worker to proceed with his or her task. We calculated the value of the time lost as the fraction of the typical individual’s time (Table 1) expressed as salary. We made the calculation only for the daytime shift, during which it is likely that the greatest number of pages occur; because there are also many pages in the evening, our calculations represent a substantial underestimate.
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100% 90% 80% 70% 60%
Most used method of communicaon
50%
Preeferred method of communicaon.
40% 30% 20% 10% 0% Aendings
Residentss
Nurses
Pharmacists
Fig. 2. Percentage of healthcare groups for whom pagers were the most used and the preferred method of communication. (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/THC-140865)
4.1. Cost of operating current pagers We estimated the cost of the current pagers and the cost of the time spent in initiating communication for 4 nurses and 1 pharmacist to cover the 8-hour day shift of a 28-bed medical ward for one month in our hospital as follows. In our community teaching hospital, there are a total of 311 operating pagers used to cover a variety of services. The carrier is paid $6.62 per month per pager. Each pager consumes 2 batteries per month, for a total of 622 batteries for all pagers, per month. A set containing 24 batteries costs $20 per box. Consequently, the total cost for the paging system is $2,600 per month. – Number of pagers: 311 – Number of batteries per month: 2 × 311 = 622 – Cost for contracting one pager per month: $6.62 – 24-pack of batteries: $20 (311 × $6.62) + (26 battery boxes × $20) ≈ $2, 578 per month for 311 pagers
4.2. Cost of time spent by nurses and pharmacists using current pagers A total of 4 nurses and 1 pharmacist are required for coverage of one 28-bed medical ward for one shift. Because a nurse or pharmacist may continue to work for some of the time while waiting for a page to be returned, we constructed two scenarios (Table 2): – Worst-case scenario: assumes both the time it takes to page someone and the time it takes for the call to be returned are wasted. – Best-case scenario: assumes only the time it takes to page someone is wasted, not the time for the call to be returned. The average hourly salaries for registered nurses and clinical pharmacists at our institution are approximately $54.00 and $52.00 respectively which rates are above average in the United States [10,11].
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4.3. Worst-case scenario In the worst-case scenario, we assume that the total time it takes to page someone and have a page returned is wasted (12 min for one nurse to send page and receive response, 15 min for the pharmacist). Subsequently, the total time loss per month is: Nurses: ((12 min × 10 pages)/60 min) × 1 nurses × 30 days ≈ 60 h Pharmacists: ((15 min × 11 pages)/60min) × 1 pharmacists × 30 days ≈ 82.5 h Thus, a nurse working one shift per day wastes 60 hours per month. At a salary of $54.00 per hour, this amounts to $3,240 per month of wasted time. For a pharmacist, the comparable figure is $4,290. To staff a 28 bed floor with four nurses and one pharmacist would cost $17,250 per month in wasted time. 4.4. Best-case scenario Here, we assume that only the time it takes to page someone is wasted, i.e. 2 min per page sent. The total cost per month for the four day shift nurses and pharmacist in this scenario is $2,732. 5. DECT phones Starting price for a DECT phone is as low as $11.00 a piece [12]. These phones have a rechargeable battery included, and thus, there is no extra cost for batteries as there are with pagers. There is a one-time cost for building the infrastructure with base stations, wires and antennas, and will depend on the size of the hospital. Typically, the full installation range between $2,000–$30.000 [13]. Thus, a reasonable cost estimate for a hospital of our size would be: 300 (amount of physicians, residents and nurses) × 11 + 15,000: ≈ $18,300. This is a one-time cost. Estimating that each DECT phone has a life time of one year, the total cost each year would be $3,300 for replacement, although, these phones typically would last much longer. Consequently, even for the best case scenario outlined above, our hospital will save money within the first year of the implementation of the DECT phones. 6. Discussion Although the paging system is the most commonly used method of communication in American hospitals, it is time-consuming and inefficient. Attending physicians spend about 66 minutes per shift and residents spend 48 minutes per shift in responding to pages, while even more time is spent by nurses and pharmacists in sending and waiting for responses to pages. Aside from the time lost in the transaction, if there is any delay in returning the call, the caller often will have left the original site imposing a further burden in communication. Even though many pages are relatively urgent, the responses are often not prompt. Also, an appreciable number of pages are not returned, presumably because the recipient ignored or forgot to respond to the page or because the “wrong” person was paged. This situation occurred on average with 2 pages per week received by attending physicians, 15% of pages sent by nurses, and 26% of pages sent by pharmacists. We do not know the outcome of such missed pages. However, such lapses can lead to issues of patient safety.
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Table 2 Calculated financial cost of time lost in using the paging system for day shift Different scenarios Worst case scenario ∗ Person-hours/month for one shift per day ∗∗ Cost ($/month) per worker Cost per month for one shift per day
Best case scenario ∗ Person-hours/month for one shift per day Cost per month for per worker ∗∗
Cost ($/month) for one shift per day
Nurse
Pharmacist
60 h (1 nurse) $3,240 $12,960 (4 nurses)
82.5 h (1 pharmacist) $4,290 $4,290 (1 pharmacist)
10 (1 nurse) $540 (4 nurses) $2.160 (4 nurses)
11 h (1 pharmacist) $572 (1 pharmacist) $572 (1 pharmacist)
∗ Person-hour (The quantity of work which one person can perform in one hour); $54/hour; Pharmacist = $52/hour.
Total
$7,530 $17,250
$1,112 $2,732 ∗∗
Nurse =
About half of attending physicians and residents but only 10–20% of nurses and pharmacists preferred pages as the mode of communication. This difference probably reflects the sense of urgency on the part of the various parties, i.e. nurses and pharmacists, who are sending pages, want a quick response to their question whereas physicians, who receive the pages and are often occupied by other tasks, prefer not to have to respond immediately as would be the case if the call were made to a DECT phone. There are many disadvantages of the use of pagers. The standard paging system is a multistep (time consuming) process: the caller must log on to a computer, log on to the web system, find the pager number, type a message/number, and wait for the call back. In our institution, a page usually serves as a request for a phone call conversation. By contrast, DECT phones should lead to a more prompt response, shortening the total time taken. DECT phones have many advantages over pagers (Table 3). Most importantly, one can reach the other person directly and immediately. Calls with the DECT phone can be made quickly with the aid of a built-in phone book. Although the infrastructure is costly to build initially, this is a one-time cost, likely to be greatly outweighed by the reduction in time wasted. A disadvantage of these phones is that, unlike pagers, they do not work outside the hospital. However, the owner can leave a voice message in the DECT phone, redirecting the caller to a cell phone. Our financial analysis provides an estimate of the financial waste at a small, community teaching hospital. It clearly shows that even in the best-case scenario, there is a significant amount of financial loss each month with the use of pagers. Considering that this analysis was only performed for nurses and a pharmacist on a single shift in a 28-bed ward of a small community teaching hospital, the actual loss in most institutions is likely to be much higher. There are other costs for the transaction beyond those described above. These include (1) the time wasted by ward secretaries and other healthcare personnel in tracking down the initial caller once the call is returned; (2) the distractions and interruptions of work attributable to these delays. However, we admit that calls to a DECT or cell phone can be a distraction for the recipient. A better estimate of the time lost would require a detailed time-motion study. In any event, the time lost through delays in communication is certainly an opportunity cost, i.e. a cost due to the loss of other, valuable activities such as interactions with patients. Limitations of this study are its reliance on a survey-based approach with subjective answers and the lack of direct comparison with the use of DECT phones. In addition, the financial estimates are based
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R. Mehrzad and M. Barza / The efficiency of the paging system Table 3 Advantages and disadvantages of pagers compared with DECT phones
Advantages Standard practice within most hospitals
Pagers Disadvantages Responding to a pager is dependent on availability of a phone
DECT phones Advantages Disadvantages Instant phone calls and text Not a standard practice messaging within most hospitals
Pages with a text message can help recipient assess the urgency of the matter
The paging process requires multiple steps
A one-step phone call but little ability to assess urgency
Requires building an infrastructure with base stations, wires and antennas.
The pager can be brought home and will work outside the hospital
No provision to save a contact list Limited memory While the pagers are off, received pages are lost Requires replacement batteries
Contact list (phonebook) with caller ID Superior memory Voice message system
Does not work far from the base station
Rechargeable batteries
on assumptions, especially as to the proportion of time spent with the use of pagers that is “wasted”. In addition, we estimated the value of time lost for nurses and pharmacists but not for physicians because the variability of tasks and rates of remuneration for physicians would have made it difficult to obtain a meaningful estimate. Finally, the study was conducted in a community teaching hospital. It is possible that our findings would not apply to other types of institutions, such as tertiary care hospitals and institutions with large fellowship and research programs. Prospective studies are warranted to assess the most effective communication strategy.
Conflict of interest The authors declare that there is no financial, organizational or any other type of conflict of interest.
Funding There is no external source that funded this project.
Contributors Both authors reviewed the scientific literature, interpreted the data, and wrote the manuscript.
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