This hypothetical example written by Dr. Daniel Sands in his paper "Challenges in Healthcare Communications: How Technology Can Increase Efficiency, Safety, and Satisfaction" shows how bad things can get when plans for communication go awry.
A 77year-old woman, is hospitalized for congestive heart failure. She is weak and need assistance getting out of bed. At 10:05 p.m., Sophia initiates a call for help using the nurse call button by her bedside. The ward clerk is away from the nurse station and does not hear the call. At10:15 p.m., Sophia calls the station again; this time she reaches the clerk. She explains her problem through the remote microphone in her room. The clerk asks Sophia who her nurse is, but Sophia cannot remember. The clerk looks up a specific name, assuming that it is the correct name of the nurse assigned to Sophia, and initiates an overhead page at 10:20 p.m. The clerk, however, is unaware that she called the wrong nurse and goes about her work. At 10:30 p.m., Sophia calls the clerk again, becoming angry at the delay. The clerk realizes her error and pages the covering nurse, who arrives at the patient’s room at 10:35 p.m., horrified to find Sophia sprawled on the floor and in pain because she attempted to reach the bathroom without assistance. Sophia subsequently was found to have fractured her hip from the fall.
Two days after Sophia’s hip surgery, she experienced pain at the incision site and a fever. After examining Sophia, the nurse went to the nurses’ station to call the covering physician, referring to a handwritten list of names to find who she believed was the right doctor. The doctor she paged did not respond, so the nurse paged other physicians on the list. Eventually, one of the doctors called her back, but explained that she was not responsible for Sophia and suggested that the nurse page a different physician who might be covering. The physician, a hospitalist, called back and eventually checked in on Sophia. He recommended that Sophia be seen by an orthopedic surgeon. He paged the surgeon, whose name was in Sophia’s medical record. Ten minutes later and after no response, the doctor determined that the surgeon was not available and paged the covering surgeon, not knowing he was in the middle of surgery and unable to respond. Two hours and several pages later, the covering surgeon called back and agreed to see Sophia.
The covering surgeon ordered a CT scan to pinpoint Sophia’s problem. Sometime later, the radiologist paged the surgeon to discuss his findings. The surgeon informed the hospitalist that the joint appeared free of infection. Because of Sophia’s multiple medical conditions, the hospitalist wanted to consult with an infectious disease specialist. He looked up names in the physician directory, calling each one sequentially, leaving either a message or initiating a page. After 20 minutes, he reached a specialist who was making rounds at a different hospital; the specialist agreed to see Sophia later that day. After the exam, he ordered some tests and prescribed medication. Unbeknownst to the doctors, another infectious disease specialist was at another hospital near by the entire time and could have seen and treated Sophia five hours earlier. When Sophia was admitted to the hospital, a special working group was formed to develop a plan for her discharge or transfer from the hospital to another facility. This planning takes place for every elderly patient, and for all patients who have multiple or complex medical problems.
In Sophia’s case, the plan was to send her home with a visiting nurse and other home services. Sophia’s hip fracture, however, prohibited her discharge. The team, which included nearly everyone on the above list, did not meet until five days after Sophia was hospitalized—arguably five days too late. They hastily discussed her various issues and coordinated a plan with Sophia and her family. Because their meetings were face to face, not everyone was able to attend, including Sophia’s cardiologist. When the team was unable to obtain input from key participants during regular meetings, they would either proceed without relevant input or appoint someone to obtain the input—usually via a page, phone call, or email—and report back to the group, often not until the following meeting. Discharge planning activities escalated leading up to the day of Sophia’s release. Unfortunately, the rehabilitation hospital that the team recommended for Sophia did not have an available bed when she was ready to be discharged, forcing them to scramble to find a different facility. Because of the delay in arranging her transfer, Sophia stayed in the hospital two more days, costing the hospital more than $2,000. Unfortunately, Sophia later developed a cardiac complication that could have been avoided had the discharge planning team involved her cardiologist. The discharge planning process failed, in large part, due to a lack of communications among the team and a limited number of communication tools. The busy and highly mobile nature of healthcare workers makes it difficult to conduct in-person meetings or use other synchronous channels of communication. Despite this, most hospitals remain stubbornly committed to using only face-to-face meetings and telephone calls, requiring participants to be available at a particular time to communicate. These limitations are unacceptable in the frenetic and unpredictable hospital environment. Hospitals must provide other options for collaboration.
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