N717a-Context of Care
Veronica Nieva, PhD
Project Director and Editor-in-Chief
Agency For Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850
Dear Dr. Nieva,
I am writing to you regarding the innovation entitled Pager-Based System Enables Prompt Communication and Acknowledgement of Critical Laboratory Results, Eliminating Thousands of Phone Calls to Physicians, implemented by the Vanderbilt University Medical Center in 2008. This innovation was accessed at http://innovations.ahrq.gov/node/5536 and received “moderate” evidence rating. I am an acute care nurse practitioner student at the Yale School of Nursing in my final year, with clinical experience in ICUs, EDs and community health clinic settings. I also have a Masters' degree in Public Health with a focus on HIV/AIDS and associated interventions. My main research and clinical interests are related to access to care and underserved populations; however, since my involvement in implementing Electronic Medical Records at a free clinic where I previously worked, I have become increasingly interested in medical technology as a means of increased efficiency and quality improvement.
I found this innovation of particular interest after observing the patient load of a health care provider, such as a physician, resident or APRN, in ICU. During my clinical hours in several intensive care units across the state of Connecticut, I have observed that nurses who are responsible for drawing labs, often do so at a different time than documented in the providers' orders, due to patient load or convenience to the patient. It is therefore difficult for the provider to remain abreast to available lab results, which can lead to a delay in addressing abnormal lab results. My research on this topic revealed that reporting of abnormal lab results is a national problem and that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has prioritized improvement of lab result communication as a patient safety issue. The ALERTS system, implemented by Vanderbilt University Medical Center addresses this priority through the use of a pager notification. Although I have not seen a similar innovation implemented in practice, my research indicates that similar innovations are being rolled-out nationally to address poor communication and errors in reporting of lab results. I am impressed by the use of a low cost innovation, which uses existing technology to address this patient safety issue, however, I am also apprehensive about the true impact of this innovation and the new issues it poses.
My foremost concern regarding the evidence supporting this innovation is the primary outcome measure. The outcomes assessed as a means to evaluate the ALERTS innovation include; time of provider response to critical lab values and hours saved on phone calls by laboratory technicians. While these are undoubtedly important in creating an efficient system, they do not assess improvement in care. It becomes less important that the provider be notified of critical lab results in a timely manner, if this does not translate into more timely care as a response to the increased efficiency. Other medical institutions have implemented similar pager-based notification systems for critical lab results in the inpatient setting and have found conflicting evidence on improved quality of care (Etchells et al., 2010; Etchells et al., 2011; Kuperman et al., 1999). Only Kuperman et al. at Brigham and Women's Hospital in Boston, MA found a reduction in time from receipt of critical lab results to orders for related treatment (Kuperman et al., 1999). Etchells et al. of Sunnybrook Hospital in Toronto, Ontario, found no statistical significance in timeliness of care when using the pager alert system or the traditional phone call method of critical lab result delivery (Etchells et al., 2010; Etchells et al., 2011). Due to the uncertainty of the evidence on quality improvement, it would be advisable for Vanderbilt University Medical Center to conduct a study on the impact of the ALERTS system on reduction in time of care in order to appropriately assess the success of the program.
My second concern with the ALERTS innovation is related to hierarchy of care. In an article by Reddy et al., three challenges to the use of the wireless alert system in hospitals were identified. One of these challenges was “maintaining hierarchies”, in this case bypassing the nurse or resident (Reddy, Pratt, McDonald, & Shabot, 2003). The Vanderbilt University ALERTS system attempts to address this potential challenge by initiating an “FYI page” to the charge nurse for the patients' unit in addition to the page to the primary provider; however in my experience this is unlikely to alleviate the problem. In ICUs where I have worked, the charge nurse is often assigned to provide direct care for at least one patient. Since critical laboratory results are common in the ICU setting, receiving pages for all critical lab results will place an enormous burden on the charge nurse who then must relay this information to the nurse responsible for direct care for that specific patient. Additionally, in the ICU, there are often standing orders for electrolyte repletion and other common treatments that may address critical lab results. As a result, the nurses are able to rapidly respond to these critical results without contacting the physician or resident. By failing to send a page to the nurse providing direct care for a specific patient, critical but easily resolvable treatments may be delayed.
Similarly, in an academic institution, the resident or intern is usually responsible for direct oversight of the patients' conditions, including checking lab results and determining next steps for treatment. It is unclear under the ALERTS system if the page is sent to the attending or the resident. As Reddy et al. reported an attending saying, [he]”only wants to be notified when there is a problem” and not when there is a critical lab result that the resident could handle on their own (Reddy et al., 2003). The ALERTS system is unfortunately not set up to provide results sometimes, which can also create an issue of over-paging. The Result Notification via Alphanumeric Pagers (ReNAP) system, implemented at Brigham and Women's Hospital, however; does take the concept of over-paging into consideration. Under this system, providers can sign up to be paged about specific lab values or specific patients, making the system more amenable to the needs of the attendings in an academic institution who oversee a number of residents and fellows (Poon, Kuperman, Fiskio, & Bates, 2002).
Lastly, the use of non-laboratory trained staff in delivering lab results may add an additional step in acting on critical lab results. Providers who may have questions regarding lab results will now have to call the lab after speaking with the operator, rather than discussing their concerns during the initial phone call. Under the ALERTS system, phone calls to the provider are only initiated when the provider does not confirm receipt of the text message within ten minutes. In a paper by Parl et al., Vanderbilt's ALERTS system was successful in reaching providers' via page in 95% of all cases. In the remaining 5% of cases, the hospital operator contacted the provider to report the critical lab results (Parl et al., 2010). The only rationale provided for using the operator to convey these results was access to the provider schedule in the hospital. However, the use of the operator not only requires training of the operator in pronunciation and reporting of laboratory results, it also interferes with the ability for the provider to ask questions to the lab technician about the results. Since the pager-based system alleviates 95% of the burden from lab technicians, it seems most efficient to have the lab technician initiate the phone call for the remaining 5% of reportable critical lab results.
Vanderbilt University Medical Center's initiative to address reporting of abnormal lab results through a low cost technological innovation is a primary example of the benefit of wedding information technology and medicine. It is innovations like this that not only improve patient safety, but also increase efficiency and burden on human resources in the medical field. I applaud this initiative and its ability to address the JCAHO patient safety priorities, however, updates to the ALERTS system are necessary to improve its utility. Since the implementation of ALERTS in 2008, many other hospital systems have created pager-based systems for communicating abnormal lab results. A collaborative effort or shared lesson's learned can result in a system that does not disturb hierarchy within the healthcare setting, facilitates communication between providers and laboratory staff and most importantly ensures that quality of care is impacted by the innovation. I hope that future versions of the ALERTS system will be improved by the rapidly growing evidence-base around communicating abnormal lab results.
Thank you for your time and for you dedication to quality improvement in healthcare.
Rachel Popick, RN MPH
Etchells, E., Adhikari, N. K. J., Cheung, C., Fowler, R., Kiss, A., Quan, S., … Wong, B. (2010). Real-time clinical alerting: Effect of an automated paging system on response time to critical laboratory values—a randomised controlled trial. Quality and Safety in Health Care, 19(2), 99. Retrieved from http://qualitysafety.bmj.com/content/19/2/99.short.
Etchells, E., Adhikari, N. K. J., Wu, R., Cheung, M., Quan, S., Mraz, R., … Morra, D. (2011). Real-time automated paging and decision support for critical laboratory abnormalities. BMJ Quality & Safety, Epub ahead of print, October 9, 2011.
Kuperman, G. J., Jonathan, M., Tanasijevic, M. J., Ma'Luf, N., Rittenberg, E., Jha, A., … Bates, D. W. (1999). Improving response to critical laboratory results with automation. Journal of the American Medical Informatics Association, 6(6), 512.
Parl, F. F., O'Leary, M. F., Kaiser, A. B., Paulett, J. M., Statnikova, K., & Shultz, E. K. (2010). Implementation of a closed-loop reporting system for critical values and clinical communication in compliance with goals of the joint commission. Clinical Chemistry, 56(3), 417-423. Retrieved from http://www.clinchem.org/cgi/reprint/56/3/417
Poon, E. G., Kuperman, G. J., Fiskio, J., & Bates, D. W. (2002). Real-time notification of laboratory data requested by users through alphanumeric pagers. Journal of the American Medical Informatics Association, 9(3), 217. Retrieved from http://184.108.40.206/content/9/3/217.abstract
Reddy, M. C., Pratt, W., McDonald, D. W., & Shabot, M. M. (2003). Challenges to physicians' use of a wireless alert pager. AMIA 2003 Annual Symposium.