Elsevier

Annals of Emergency Medicine

Volume 54, Issue 3, September 2009, Pages 368-378
Annals of Emergency Medicine

The practice of emergency medicine/original research
Evaluation of an Asynchronous Physician Voicemail Sign-out for Emergency Department Admissions

https://doi.org/10.1016/j.annemergmed.2009.01.034Get rights and content

Study objective

Communication failures contribute to errors in the transfer of patients from the emergency department (ED) to inpatient medicine units. Oral (synchronous) communication has numerous benefits but is costly and time consuming. Taped (asynchronous) communication may be more reliable and efficient but lacks interaction. We evaluate a new asynchronous physician-physician sign-out compared with the traditional synchronous sign-out.

Methods

A voicemail-based, semistructured sign-out for routine ED admissions to internal medicine was implemented in October 2007 at an urban, academic medical center. Outcomes were obtained by pre- and postintervention surveys of ED and internal medicine house staff, physician assistants, and hospitalist attending physicians and by examination of access logs and administrative data. Outcome measures included utilization; physician perceptions of ease, accuracy, content, interaction, and errors; and rate of transfers to the ICU from the floor within 24 hours of ED admission. Results were analyzed both quantitatively and qualitatively with standard qualitative analytic techniques.

Results

During September to October 2008 (1 year postintervention), voicemails were recorded about 90.3% of medicine admissions; 69.7% of these were accessed at least once by admitting physicians. The median length of each sign-out was 2.6 minutes (interquartile range 1.9 to 3.5). We received 117 of 197 responses (59%) to the preintervention survey and 113 of 206 responses (55%) to the postintervention survey. A total of 73 of 101 (72%) respondents reported dictated sign-out was easier than oral sign-out and 43 of 101 (43%) reported it was more accurate. However, 70 of 101 (69%) reported that interaction among participants was worse. There was no change in the rate of ICU transfer within 24 hours of admission from the ED in April to June 2007 (65/6,147; 1.1%) versus April to June 2008 (70/6,263; 1.1%); difference of 0%, 95% confidence interval –0.4% to 0.3%. The proportion of internists reporting at least 1 perceived adverse event relating to transfer from the ED decreased a nonsignificant 10% after the intervention (95% confidence interval –27% to 6%), from 44% preintervention (32/72) to 34% postintervention (23/67).

Conclusion

Voicemail sign-out for ED–internal medicine communication was easier than oral sign-out without any change in early ICU transfers or the perception of major adverse events. However, interaction among participants was reduced. Voicemail sign-out may be an efficient means of improving sign-out communication for stable ED admissions.

Introduction

The transfer of a patient from the emergency department (ED) to the inpatient floors is a complex process fraught with potential for error.1, 2, 3 Although errors at this transition of care are multifactorial,1 sign-out communication plays an important role.1, 2, 3

Sign-out between emergency medicine and internal medicine physicians is typically oral (or “synchronous”), involving a face-to-face or telephone conversation about the patient. Synchronous communication has numerous advantages, including opportunities for confirmation, clarification, error detection, relationship building, negotiation about management and disposition, and multidirectional information flow.4, 5, 6, 7 Studies of health care workers show they are overwhelmingly inclined toward synchronous communication.8 The ED is no exception: 80% of ED communication is typically synchronous.9, 10, 11

However, synchronous communication between emergency and internal medicine physicians can be challenging to conduct because of the physical distance between the ED and the inpatient unit, multiple competing demands on physicians' time, rapidly changing information, professional differences in expectations, the chaotic nature of the ED, and frequent physician turnover.1, 2, 6, 12 At times, these challenges inhibit the quality of communication or prevent it from occurring at all. In addition, the interruptions in work required to initiate the conversation, as well as the interruptions that occur during the conversation, may themselves pose a threat to patient safety.8, 13, 14

Written or recorded (“asynchronous”) communication is an alternate format that has several advantages. It is efficient, allowing information to be provided and received at the most convenient time for workflow.15, 16 It is durable, eliminating the “game of telephone” that occurs with sequential oral communication and reducing the risk of missing sign-out altogether.16, 17, 18 In some cases, it has been shown to promote more complex and sophisticated interactions because participants have time to reflect before providing information or asking questions.16, 19, 20 Finally, it can be accessed repeatedly, simultaneously, and by a variety of people with different needs.21, 22 Nurses have long used asynchronous communication methods for handoffs.23, 24, 25, 26, 27

Nonetheless, asynchronous communication has important limitations. It cannot be adjusted in response to the experience or understanding of the recipient, may reduce opportunities for error detection and feedback, limits relationship building and restricts the ability of the recipient to influence either the discussion or future action.16, 20 If the team is thus prevented from coming to a shared mental model, performance can suffer.28 Perhaps for these reasons, asynchronous handoff among physicians is relatively uncommon.29 One exception in the ED is the “whiteboard,” on which key information can be seen at a glance, and which can also serve as a means of 2-way communication.22, 30

Qualitative analysis revealed that the existing oral sign-out between emergency and internal medicine physicians at our institution suffered from the typical challenges of synchronous communication, leading to dissatisfaction among both emergency and internal medicine physicians.1 As one part of a multifaceted initiative to improve handoffs and workflow, internal medicine and emergency medicine clinical leaders implemented a new, asynchronous sign-out system in which emergency physicians dictated a semistructured sign-out to a voicemail system. Internal medicine physicians listened to the voicemail and called with follow-up questions as needed.

Asynchronous and synchronous communication has not been directly compared to our knowledge in interspecialty handoffs. This initiative was expected to improve efficiency, reduce the frequency of missed sign-out, and increase the participation of ED physicians with direct knowledge of the patient. However, because of the drawbacks of asynchronous communication, its potential overall effect on patient care was uncertain. We thus describe and evaluate this quality improvement initiative with particular attention to the quality and safety of handoff communication.

Section snippets

Study Design

The intervention was structured as a quality improvement initiative, featuring rapid evaluation, feedback, and modification as needed. An important feature of such “action research” is that the intervention often changes midcycle in response to continuous evaluation and feedback.31 This approach is akin to the Plan-Do-Study-Act method pioneered by Shewart, in which the intervention is studied and modified in real time.32 We describe both the initial intervention and modifications made in

Results

We received a total of 117 of 197 responses (59%) to the preintervention survey, excluding internal medicine interns. These included responses from 39 of 60 ED house staff and physician assistants (65%), 21 of 37 hospitalists (57%), and 57 of 99 internal medicine house staff (58%). We received a total of 113 of 206 responses (55%) to the postintervention survey. These included responses from 39 of 63 ED house staff and physician assistants (62%), 34 of 44 hospitalists (77%), and 40 of 99

Limitations

This study has several limitations. First, the majority of our results are subjective, although we included one objective measure of adverse events, ICU transfers. We attempted to mitigate recall bias by prospectively collecting preintervention data. Nonetheless, we did not evaluate the sign-outs themselves, nor did we examine efficiency measures such as ED length of visit, which was confounded by simultaneous initiatives at our institution. Second, the study was conducted at a single, academic

Discussion

This report describes the effects of a switch from synchronous to asynchronous communication between internal medicine and ED physicians about newly admitted patients. Overall, physicians reported improvements to workflow, ease, and efficiency without adverse effects on patient safety, despite having been deeply skeptical about the intervention beforehand. ED utilization was high and was sustained at 1 year. As predicted by participants, however, the new system substantially reduced interaction

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      Citation Excerpt :

      The main proposed advantages of asynchronous handoffs are the reduction of time needed to transmit the information and the reduced disruption of workflow. Disadvantages highlighted are the inability to ask for clarification, the decreased satisfaction with the process by inpatient providers, and the potential for the information to get lost or to not be reviewed by the inpatient provider before the patient arriving to the floor (1,3,6). The traditional model for handoffs between the ED and inpatient floor involves a verbal signout process in which the ED providers initiate contact with the admitting team to discuss the case.

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    Supervising editor: Robert L. Wears, MD, MS

    Author contributions: LIH, VP, NRS, JDS, TM, GYJ, and RGK conceived the intervention, designed the study, and selected the measures. LIH, VP, NRS, and GYJ supervised the conduct of the trial and data collection. LIH managed the data, including quality control. LIH, VP, and RGK analyzed the qualitative data; LIH analyzed the quantitative data. LIH drafted the article, and all authors contributed to its revision. LIH takes responsibility for the paper as a whole.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Dr. Horwitz is supported by Yale-New Haven Hospital and by the National Center for Research Resources (NCRR). Neither Yale-New Haven Hospital nor the NCRR had any role in the design and conduct of the study; collection, management, analysis and interpretation of the data; or preparation, review and approval of the article. This publication was made possible by the CTSA grant UL1 RR024139 and KL2 RR024138 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and NIH roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the NCRR or NIH.

    Reprints not available from the authors.

    Publication date: Available online March 12, 2009.

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