1. Using NNAPPS (Nighttime Nurse and Physician Paging System) to Maximize Resident Call Efficiency within 2011 ACGME Work Hour Restrictions Jason B. Young, MD, Aaron C. Baker, MD, Judie Boehmer, RN, Karen M. Briede, RN, Shirley A. Thomas, RN, Cheryl L. Patzer, RN, Christina Pineda, RN, Gina Cates, RN, Joseph M. Galante, MD University of California, Davis Medical Center 2012 Surgical Education Week APDS Annual Meeting March 21, 2012

2. Background  ACGME: July 2011 Common Program Requirements:  Continued balance of:  Patient care duties  Patient safety  Overnight call schedule coverage  Resident education, training and rest  Alertness Management / Fatigue Mitigation Strategies:  “Strategic napping”

3. Background  Paging Systems:  Valuable mode of communication  Yet frequent paging disruptive to:  Sleep  fatigue  medical errors, MVCs, impaired health  Patient care  Work rounds  Resident education

4. NNAPPS  Development of New Nighttime Paging Strategy ― NNAPPS:  Daytime logbook (non-urgent pt care issues):  Checked by resident at 06:00, 12:00, & 18:00  Charge RN reviews periodically  Nighttime paging:  Nighttime pages from 19:00 to 07:00 screened by Charge RN  Emergent pages sent immediately  Urgent pages batched appropriately  Non-urgent pages deferred until am

5. Hypothesis  Implementation of NNAPS Will Lead to:  Improved RN and MD communication  Reduce non-urgent nighttime pages to residents  Maintain high standards of pt care

6. Methods  Design:  Prospective study at University teaching hospital  Logging of pages by residents working overnight call shifts  Nightly b/t 20:00 – 06:00 over 2 month period  Urgency of pages determined by independent review of 2 observers  Participants:  PGY-1 to PGY-5 surgery residents  9 surgical services:  General Surgery; Transplant; Burn; CT; SICU x 2; Trauma x 2; Surgery Consult

7. Methods  Implementation:  Pilot phase:  NNAPPS implemented onto General Surgery Ward  Compared to non – NNAPPS wards  Transferability phase:  NNAPPS implemented onto Transplant Ward  Compared to pre – NNAPPS Transplant Ward data  Outcome Measures (Pre – NNAPPS vs. NNAPPS):  Comparison of mean:  Non-urgent pages per night shift  Total pages per night shift  Total pages / pt during a night shift

8. Results – Pilot Descriptive Characteristic No. (%) Total Pages 637 Night Shifts 80 Hours851 Patients921 Pages Originated by RN 406 (64%)

9. Results – Pilot Descriptive Characteristic No. (%) Urgent Pages 335 (53%) Non – Urgent Pages 154 (24%) New Order 238 (37%) Patient Assessment 158 (25%) No Action 219 (34%) Non – Urgent Non – Urgent 117/219 (53%)

10. Results – Pilot Outcome No NNAPPS (Mean ± SD) NNAPPS P – Value Non-Urgent Pages/Shift 2.49 ± 2.56 0.05 ± 0.22 <.001 Total Pages/Shift 10.15 ± 5.00 1.45 ± 1.36 <.001

11. Results – Pilot

12. Results – Transplant Ward Outcome Pre NNAPPS (Mean ± SD) NNAPPS P – Value Non-Urgent Pages/Shift 2.14 ± 1.96 0.46 ± 0.52.015 Total Pages/Shift 6.14 ± 2.45 3.69 ± 1.93.024 Total Pages/Pt/Shift 0.68 ± 0.28 0.38 ± 0.21.007

13. Conclusions  Streamlined Nighttime Paging System ― NNAPPS:  Reduced non-urgent pages to residents  Reduced pt care interruptions  Increased non-interrupted resident sleep

14. Conclusions  Streamlined Nighttime Paging System ― NNAPPS:  Beneficial to resident education (improvement of sleep patterns)  Maintains quality & safety of pt care  Transferability  Sustainability

15. Thank You