Development and implementation of paging and escalation guidelines to improve interprofessional communication on surgical units

Abstract

Introduction: Suboptimal interprofessional communication in the surgical inpatient setting has important implications for patient safety. Our departmental quality committee identified numerous safety events resulting from discordant expectations between surgical floor nurses and surgical residents or advanced practice providers (APPs) who serve as responding clinicians (RCs), and from reluctance to escalate clinical concerns. Alphanumeric paging is frequently used to communicate, but there are opportunities to enhance its effectiveness. This initiative sought to improve perceptions of communication and responsiveness between nurses and RCs by providing a shared language and set of expectations about the urgency of pages, appropriate responses and the process of escalation to other team members if necessary.

Methods: An interprofessional team of surgical faculty, nurses and residents solicited input from surgical floor nurses, operating room nurses, residents, APPs and attendings on their perceptions of communication barriers among team members via online surveys and focus groups. Guidelines were iteratively developed. They specify that every page should be classified as STAT, Urgent, Please Call or FYI. Each classification is associated with an expected response time and pathway for contacting alternative team members if no response is received. After 3 months of implementation on our hospital's two main general surgery units, follow-up online surveys with multiple-choice and free-response questions assessed perceived impacts on communication and clinical care. Differences in categorical variables were assessed with χ² tests, and free text was analysed inductively.

Results: After implementation, nurses reported favourable effects on communication, including significantly improved responsiveness during night shifts and timeliness from RCs during day shifts. Residents and attendings perceived the intervention to have overall neutral to mildly positive effects on communication.

Conclusions: Paging and Escalation Guidelines are a feasible approach to enhance the perceptions of communication between nurses and RCs by aligning expectations, streamlining responses and decreasing barriers to escalation.

Keywords: Communication; Nurses; Quality improvement; Surgery.

Figure 1. General Surgery Paging and Escalation Guidelines, as implemented during the intervention. The QR link to the feedback survey at the bottom right was removed for publication purposes. ACS, Acute Care Surgery; FSBG, finger stick blood glucose; GI, gastrointestinal; MRSA, methicillin-resistant Staphylococcus aureus; OR, operating room; QR, quick response; RC, responding clinician; STEMI, ST-elevation myocardial infarction; VRE, vancomycin-resistant Enterococcus.

Figure 2. Nurses’ perceptions about the Paging and Escalation Guidelines. (A) Impact on their ability to convey their degree of clinical concern and expected response time, identify the person to whom concerns should be escalated and escalate concerns if necessary (n=26). (B) Impact on overall responsiveness of RCs during day shifts and night shifts from preintervention (n=68 for day shifts and 60 for nights) to postintervention (n=28 and 27). (C) Impact on timeliness of responses from RCs during day shifts and night shifts from preintervention (maximum n=67 for day shifts and 53 for nights) to postintervention (maximum n=25 for days and 24 for nights). * indicates p<0.05. RC, responding clinician.

Figure 3. RCs’ perceptions about the Paging and Escalation Guidelines. (A). Impact on quality of communication (n=11). (B). Impact on frequency of nurses providing a direct phone extension from preintervention (n=46) to postintervention (n=17). * indicates p<0.05. RC, responding clinician.