Communication is one of the foundations on which safe, high quality care is built. The nature of hospital medicine requires that providers be efficient and effective in communicating with multiple disciplines. This need for timely communication must continually be balanced with the need to minimize interruptions in workflow. Interruptions not only lead to distraction, they also add inefficiency to the care process and have been shown to contribute to an increased risk of medical error1. A major source of interruptions for providers are pagers that emit an audible tone with each message received. This interruptive nature makes pagers a less-than-ideal tool for communicating non-urgent (provider to address within one hour) messages. In addition to increasing interruptions, pagers do not facilitate closed loop communication, another feature that has been shown to improve safety2. It is therefore in the best interest of excellent patient care to explore less-interruptive, closed-loop methods for non-urgent communication.
Inbox Messaging is intended to provide a less disruptive closed-loop method of communication for non-urgent messages.
Inbox Messaging is an interface within the electronic health record (EHR) that functions similarly to e-mail. A multi-disciplinary communication workgroup identified this interface as having potential to not only decrease interruptions, but to also facilitate closed-loop communication. Inbox is currently utilized between the hours of 0700 and 1800 for non-urgent nurse-provider communication about patients on the hospital medicine service. An algorithm guides the nurse in triaging information. If non-urgent, the nurse utilizes the Inbox from within the EHR. Providers check Inbox between patients (approximately every hour) and address messages as appropriate (write an order, reply via inbox, and/or call the nurse). A visual signal within the EHR provides notification when new messages are received. Urgent messages continue to be communicated via paging. The number of RN non-urgent pages per day was 109.4 (SD=15.2) prior to the Inbox intervention, with a significant decrease (p<.001) during follow-up to 39.1 (SD=15.4) pages per day. At the same time, the number of messages per day increased from 0 to 75.5 (SD=16.7) messages during follow-up. As desired, the mean number of RN urgent pages was unchanged from 15.2 per day to 13.9 per day (p=.58).
Cerner Inbox Messaging decreases the frequency of non-urgent pager-related interruptions in workflow. Expansion of Inbox to night shift, ancillary staff and surgery services is currently being explored.