Pagers Enable Patients Awaiting Test Results to Leave Pediatric Emergency Department, Improving Patient Flow and Satisfaction

Problem Addressed

• Long wait times: The National Hospital Ambulatory Care Survey indicates that, while mean ED waiting time is about 1 hour, wait times can reach 6 hours or more.¹ At the Hospital for Sick Children, winter waiting times (defined as the time from patient arrival until being seen by a doctor) in the ED ranged from 3 to 5 hours; winter is the time of heaviest ED volume at the hospital. 
• High stress levels: Waiting in an ED can be stressful for any patient or family member, especially in pediatric EDs, where parents are not only worried about their child’s health but also must keep the patient (and often his or her siblings) amused and/or quietly occupied during an extended wait.²
• Excessive "downtime" awaiting results, recommendations: ED patients often occupy rooms/bays for hours while awaiting followup test results and subsequent care recommendations from physicians.³ This excessive downtime creates longer waits for other patients.

Description of the Innovative Activity

• Screening for eligibility: After examining the patient, the ED physician decides whether a patient is sufficiently stable to leave the ED examination area while awaiting further information, such as the results of a laboratory test, x-ray, or another simple clinical "test" (e.g., waiting to see if a baby can tolerate a feed). In general, patients who have a low probability of needing reexamination before discharge will be given a pager and temporarily released from the ED. Patients who are ill, infectious, or on intravenous fluids do not qualify for the program. 
• Requesting and dispensing the pager: The physician requests a pager, either writing it as part of other medical orders or verbally asking a nurse. The nurse fulfills the medical orders (if any) and directs the patient to the ED unit clerk (a position similar to an administrative assistant or receptionist), who gives the patient’s family 1 of 20 available pagers. The clerk also activates the pager and demonstrates how it will vibrate when it is time to return to the ED reception desk. Families often go to the cafeteria or walk in the hallways while waiting. 
• Turning over the room: Once the patient departs, staff clean the bay/bed and bring in a new patient.
• Recalling the patient: When test results arrive, the physician asks the unit clerk to page the patient. The unit clerk calls the doctor when the patient arrives.
• Final consultation with physician: The physician briefly talks to the patient and family in the reception area or ED patient care area hallway, providing feedback regarding test results and reminding them of any needed followup care. If the test results are cause for concern, the patient and family are taken to the first available ED bay and provided with appropriate care.

References/Related Articles

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Results

• Anecdotal evidence of improved patient flow: Although the hospital has not systematically studied the impact of pager use, anecdotal reports suggest that physicians and nurses believe the program has improved patient flow and feel comfortable releasing stable patients from a bed. Pagers appear to have become an integral part of how the ED manages patient flow, as evidenced by the fact that demand for pagers remains strong, with broken pagers being quickly replaced. 
• Anecdotal evidence of high patient satisfaction: Clinicians report positive reactions from parents to the offer to leave the ED, as they generally appreciate the opportunity to more easily pass the time with their children. An earlier RCT of a similar program at the hospital (which provided pagers to families who had to wait 1 hour or more for an initial physician examination) found that the initiative did not significantly improve overall patient satisfaction with the ED experience (which is likely to be driven by many factors other than the pager). Qualitative feedback from parents during the study, however, indicated a highly favorable response to the pager. 

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Securing the pagers: A corporation donated pagers to the pediatric ED. When corporate sponsorship ended, the hospital purchased a pager system.  
• Training unit clerk: The unit clerk was trained to activate the pagers, a very simple process.
• Testing initial program: The hospital initially gave the pagers to families facing long waits in the ED waiting room. After piloting the use of pagers in this way, clinicians decided that they felt uncomfortable allowing patients to leave the ED before being assessed by a physician.  
• Revising the program: As noted previously, clinicians began noticing that patients and families faced long waits after being seen by physicians, and thus decided to give the pagers to these families.  
• Educating staff: Clinicians received informal briefings about the new program during their shifts. The program was also described in e-mails and newsletter updates. 

Resources Used and Skills Needed

• Staffing: The program requires no new staff, as existing staff incorporate it into their daily routines.
• Costs: The upfront cost of the the program was approximately $4,000 to $5,000 to cover system installation and the purchase of 20 pagers; a small monthly fee is also incurred. 

Funding Sources

Hospital for Sick Children

Getting Started with This Innovation

• Buy the right kind of pagers: To prevent theft, program developers recommend the purchase of short-range pagers that can be activated to work only within the hospital. Patients and families should be notified of the pager's limitations when they are distributed. Pagers should also be well-built and large enough that they are difficult to lose. The Hospital for Sick Children bought pagers with a rubberized outer shell so that they bounce rather than break when dropped. To date, Hospital for Sick Children has not experienced any theft or loss of pagers.  
• Design a sanitation policy: Design a pager sanitization policy that meets with hospital infection control procedures. At the Hospital for Sick Children, sanitation procedures call for a simple wipe of each pager after use, with more stringent sanitation being used only in cases where the child is determined to have a highly infectious disease. 
• Solicit donations from telecommunications companies: These companies may view a donation as an appealing (high-profile, yet low-cost) philanthropic gesture.