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Introduction Paging is a vital part of patient care that allows quick contact between physicians and other hospital personnel. There was no structured way to send a page to physicians at our institution. We hypothesized that by standardizing paging format, scheduling laboratory draw times, and using order clean-up sheets, through a bundle of interventions called Better Etiquette for Effective Paging, we would decrease the number of pages received on the pediatric intensive care unit (PICU) resident pager by 15%. Methods This project was a quality improvement initiative in a 25-bed multidisciplinary PICU in a tertiary children's hospital. Baseline data collection was performed in December 2015, categorized by time of day received and type of page. Interventions were paging standards to include relevant information, scheduling laboratory draw times, and order clean-up sheets. We collected postintervention data over 3 years to monitor for sustained change. Results The average number of pages decreased from a baseline of 4.71 pages/patient/d in 2015 to 3.70 in 2016 (21% decrease), 3.32 in 2017 (30% decrease), and 2.74 in 2018 (42% decrease). The average PRISM 3 score remained similar in all sets (2.52, 2.50, 2.10, and 2.35). The standardized mortality ratio was not adversely affected by the decrease in pages (0.58, 1.07, 1.19, and 0). Conclusion Standardizing the format of pages and using scheduled laboratory times with order clean-up sheets has decreased the number of pages/patient/d in the PICU by 42% without adversely affecting patient care. We can continue to improve communication among the patient care team by emphasizing efficient, standardized communication using Better Etiquette for Effective Paging.

The operating room (OR) is a busy environment with multiple opportunities for distraction. A well-trained anesthesiologist or certified registered nurse anesthetist (CRNA) should remain focused on providing excellent patient care despite these potential distractions. The purpose of this narrative review is to present the multiple types of OR distractions and evaluate each for their level of distraction and their likely impact on patient safety. Distractions in the OR are common and numerous types of distractions exist. Loud OR background noise can lead to miscommunication within the OR team. In several studies, OR noise has been shown to decrease vigilance and possibly delay recognition of non-routine events. The most commonly observed distracting events are "small talk" and staff entering and exiting the OR and most intense distracting events are faulty or unavailable equipment. Phone and pager use can be particularly distracting. Self-initiated distractions can be seen as unprofessional and can negatively impact patient safety. The impact of OR distractions on patient outcomes deserves more vigorous investigation. We must provide anesthesia trainees with the skills to remain vigilant despite numerous and varied OR distractions while also attempting to reduce such OR distractions to improve patient safety. Further research is needed to inform the institution of policies to lessen unnecessary OR distractions.

BACKGROUND For decades, the main communication technology in hospitals has been the paging system. In the era of digital communication, smartphones have been adopted by hospitals seeking to modernize processes and offer real-time, two-way communication to increase efficiency. OBJECTIVE The aim of this study was to explore physicians' and nurses' perceptions of the impact of smartphones on communication and efficiency. METHODS Mann-Whitney U-tests were used to compare differences in item scores between physicians and nurses on 17 questionnaire items relating to smartphone impact on interpersonal relationships and communication, efficiency and reliability. An open-ended question was used to elicit additional feedback. RESULTS In total, 43 nurses and 27 physicians participated in the study. Nurses' ratings were significantly higher than physicians' on a number of questionnaire items, including the following: smartphones have a positive impact on efficiency (Mdn = 4.0 vs. 3.0, U = 321.0, p = 0.027, r = .33), smartphones increase my accessibility to physicians (Mdn = 5.0 vs. 3.0, U = 277.0, p = 0.009, r = 0.42) and smartphones reduce interruptions versus pagers (Mdn = 4.0 vs. 2.0, U = 224.0, p > 0.0001, r = 0.47). CONCLUSION The findings suggest that smartphone technology may reduce the locus of control for physicians, potentially limiting their ability to prioritize patients' needs and manage workflow efficiently.

Tasks which are scheduled at irregular intervals afford greater scheduling flexibility but are also more difficult to remember. Difficulty remembering clinical tasks not only create potential inefficiencies in patient care but were also identified as a source of anxiety among our residents. We implemented RadRemind! an automated system of pager notifications in order to improve patient care and reduce residents’ anxiety. RadRemind! utilizes only an external shared APACHE, MySQL, PHP server. A set of CRON jobs activate a PHP script which pulls information from our resident schedule as JSON data. It then identifies the appropriate residents to notify and then sends a cURL request to a web-based paging service to trigger notifications to residents’ pagers. Each activation of the script was logged in an SQL database. An anonymous survey assessing multiple aspects of efficacy was sent to residents after 3 months of implementation. Seventeen of 29 residents responded to the survey. Residents reported a mean of 2 successful reminders (defined as responsibilities which had been otherwise forgotten prior to the page notification) in the last month which was found to be statistically significant via one-sample t test (t = 3.3, p

Introduction: Heart-related incidents cause over 50% of LODD in firefighters (FF). Physical, health-related, and emotional stress are all part of the FF job; and these all increase BP levels and cardiac risk. Using ambulatory BP (ABP) monitoring to measure BP over time and quantify the BP surge with alarm is a novel way to assess risk, so we compared a group of FF to Civilians. We hypothesized that FF would have worse CV health and higher BP surges compared to civilians. Methods: We included 43 FF and 30 Civilians who completed 3 visits: ABP monitoring with pager activation, a fasted clinical appt, and fitness testing. Participants wore the ABP cuff for a 12-hr period, during which they were paged by a pager app (OnPage) or by emergency service dispatch. When the pager sounded, they were instructed to force an ABP reading to assess the BP surge. Average BP levels and surges were determined. Fasted visit included BP, body fat, lipid panel, and vascular health measures. Fitness test included a treadmill VO 2peak and a battery of other fitness tests. Participants also completed a health history form and the DASS-21 questionnaire assessing stress, anxiety, and depression. Results: We found that FF (39.4 ± 2.2 yrs) had worse CV health, better fitness, but higher stress and depression levels compared to Civilians (39.7 ± 2.7 yrs), P2peak (35.2 ± 0.9 vs 37.1 ± 1.8 ml/kg-min) but better plank pose (110.1 ± 9.5 vs 73.8 ± 6.7), wall sit (112.7 ± 15.9 vs 59.4 ± 5.2 sec), and #steps climbed in 2 min (320.8 ± 10.1 vs 280.2 ± 11.8). FF had worse overall psychometric characteristics: higher DASS-21 total score 13.9 ± 2.3 vs 5.5 ± 1.3; depression score 5.1 ± 1.3 vs 0.7 ± 0.3; stress score 5.9 ± 0.9 vs 2.7 ± 0.7; but similar anxiety scores 2.9 ± 0.4 vs 2 ± 0.6. Conclusions: In conclusion, with this subset of baseline data, we confirmed that FF have worse CV health, stress, depression and perceived health ratings. It is known that exercise and diet can improve all of these. Therefore, our participants are currently undergoing a diet and exercise intervention to assess changes in health, psychometric scores, and BP surge levels.

Problem Implementation of bedside rounds enhances communication and collaboration between physicians and nurses, resulting in improved clinical outcomes. Yet, the literature demonstrates that it remains difficult for nurses to attend rounds if they don't know when they are happening. Purpose This project aimed to increase nurses' presence and participation at bedside rounds in a pediatric acute care unit, enhance teamwork and collaboration, and improve quality outcomes. Design and methods Nurses carried a pager so that physicians could alert them of rounds. Perception of teamwork and collaboration was assessed via surveys pre- and post-intervention as well as the annual survey evaluating RN and MD interactions from the National Database of Nursing Quality Indicators™ (NDNQI®). Other quality outcome measures included length of stay and patient satisfaction through Press Ganey™ surveys. Results Findings demonstrated that when nurses were notified in advance, their participation in rounds increased from 44.4 to 73%. Length of stay decreased from 2.5 days prior to the project to an average of 2.10 days during the project. Scores on inpatient satisfaction surveys increased from 82.4 to 92.2%, and nursing communication improved from 83.3 to 95.65%. Conclusion Interprofessional collaboration as reflected by the inclusion of nurses at bedside rounds led to positive outcomes in patient care. Implications Increasing nurses' presence and providing them with a role at rounds is an important step towards fostering teamwork and collaboration with physicians and enhancing team-based care in a pediatric inpatient setting. Further research measuring the impact of interprofessional collaboration in healthcare is needed.

Background The intractable problem of young novice driver road crashes, and the critical role of emergency responders in attending road crashes, is well-recognised as is the critical role of situation awareness skills (SAS, ie. an understanding of ‘what is going on’ in a specific situation). Emergency responders may be young novice drivers and young novice ambulance drivers, therefore SAS will be required for safe road use. This project explored the SA demands upon young novice ambulance drivers (‘drivers’) in Queensland, Australia. Method A synthesis of literature regarding SAS relevant to drivers was followed by a hierarchical task analysis (HTA) and a perceptual cycle model (PCM) to explicate the complex emergency ambulance driver dispatch and response system and SAS requirements. Results Inadequate SA is a likely contributor to risks for drivers, patients, and other road users. The HTA revealed a plethora of opportunities for inadequate SAS to negatively impact safety. The PCM highlighted complex environmental information modifies driver ‘world’ schema (eg., medical procedures) which in turn directs their actions (eg., attending to radio/pager) that in a cyclical manner relies upon complex environmental information, etcetera. Discussion and concluding remarks Emergency responder SA appears quite different to ‘ordinary drivers’, suggesting well-developed road-related schema are required before young novice ambulance drivers are behind the wheel in a highly-emotive, time-critical situation. Drivers are not simply ‘driving’; they are engaged in a breadth of tasks while driving (e.g., accessing dynamic case details) which, for safety, rely upon adequate SAS, therefore training programs should target SAS development.

Objective To determine if pager interruptions affect operative time, safety, or complications and management of pager issues during a simulated laparoscopic cholecystectomy. Design Twelve surgery resident volunteers were tested on a Simbionix Lap Mentor II simulator. Each resident performed 6 randomized simulated laparoscopic cholecystectomies; 3 with pager interruptions (INT) and 3 without pager interruptions (NO-INT). The pager interruptions were sent in the form of standardized patient vignettes and timed to distract the resident during dissection of the critical view of safety and clipping of the cystic duct. The residents were graded on a pass/fail scale for eliciting appropriate patient history and management of the pager issue. Data was extracted from the simulator for the following endpoints: operative time, safety metrics, and incidence of operative complications. The Mann-Whitney U test and contingency table analysis were used to compare the 2 groups (INT vs. NO-INT). Setting Level I trauma center; Simulation laboratory. Participants Twelve general surgery residents. Results There was no significant difference between the 2 groups in any of the operative endpoints as measured by the simulator. However, in the INT group, only 25% of the time did the surgery residents both adequately address the issue and provide effective patient management in response to the pager interruption. Conclusion Pager interruptions did not affect operative time, safety, or complications during the simulated procedure. However, there were significant failures in the appropriate evaluations and management of pager issues. Consideration for diversion of patient care issues to fellow residents not operating to improve quality and safety of patient care outside the operating room requires further study.

Most of the fire brigades in Baden-Württemberg are volunteer forces, hence creating the need for readily available and reliable alerting and communication systems for these forces as well. Digital Pagers are the standard means of alerting but, due to their limited reliability, alternative and complementary methods like Apps, SMS, etc. are also used by these volunteer forces. Regarding communication at the scene, the transition from open analogue to encrypted digital radio systems has been on its way for nearly 20 years. As of today, new technology is available for police forces whilst fire brigades still have to use analogue systems. This contribution analyses the situation, past and present, planning and attempts at improvement.

An electronic audit tool to track the donning and doffing practices of personal protective equipment in the emergency department Maya Jusza, Ramya Sridhar, Jennifer Woods, Sharon Drury Background: Maintaining the safety of patients and healthcare professionals is a priority in all healthcare settings. Infection prevention measures such as donning and doffing practices of personal protective equipment (PPE) have become even more imperative in light of the SARS-CoV-2 pandemic. Potential PPE breaches and the degree of frontline compliance are currently being analyzed through the use of paper PPE audit tools which can be laborious and time-consuming. The development of an electronic alternative would improve frontline safety and enhance the efficiency of data collection, while optimizing the ability to share these observations with the frontline team in real time. Two nursing leadership students from the University of Alberta were tasked with developing an electronic PPE audit tool prototype for the University of Alberta Hospital’s emergency department. Implementation: An electronic PPE audit tool prototype was developed using Google Forms which provided a user-friendly interface. Google applications were used as no confidential or patient data was collected during PPE audits. The prototype auto-populated the data entries into linked spreadsheets and interactive data dashboards that visualized the data using graphs in real time. This enabled users to easily identify trends and direct educational interventions as required. Instructional one pagers and screencast videos were also created to accompany the prototype. The prototype was reviewed by and received extensive support from: Unit Managers, Patient Care Managers, Process Improvement Nurses, Infection Prevention Control (IPC), the Executive Director of the University of Alberta Hospital and Stollery emergency department and Edmonton Zone medicine programs, and the University of Alberta Hospital and Mazankowski Executive Leadership Team. Several changes and improvements were made using the Plan-Do-Study-Act cycle. This prototype has currently been replicated onto an Alberta Health Services (AHS) server and has completed the formal testing phase with a planned application launch date. Evaluation Methods: Plan-Do-Study-Act cycles were used to guide the implementation of this audit tool prototype. After development, the prototype was tested and revised which included six rounds of audit trials at the University of Alberta Hospital’s emergency department and on some inpatient medicine units. This prototype was consistently evaluated at various stages of development and changes were made to include feedback. After approval was received to recreate this prototype onto an AHS compatible server, additional changes were made to ensure functionality. These changes included adding designations and simplifying certain questions. IPC was consulted to ensure the steps outlined for donning and doffing in the prototype were accurate and reflected requirements in the clinical environment. Results: This audit tool prototype has gathered tremendous support through various demonstrations of its ability to streamline data collection in the healthcare setting. This data is relevant to the safety of both frontline workers and patients as it identifies inconsistencies in donning and doffing practices. In addition, the prototype also complements the Edmonton zone-wide PPE coaching initiative by allowing for a quantitative measurement of its efficacy. This has prompted the fast-tracked replication of an AHS compatible version with the assistance of a dedicated team that includes the creators of the prototype tool, IPC, Quality Assurance, Information Technology, and Clinical Services Development. This version has a scheduled launch date on March 22, 2021 and is to be initially rolled out to University of Alberta’s emergency department and medicine units. The objective is to eventually make this the standardized PPE audit tool throughout Alberta. Advice and Lessons Learned: 1) In order to be sustainable and implemented site-wide, an AHS compatible tool isrequired. The use of Google applications is not preferred as data will be stored outside ofthe AHS server. Even though there is no confidential information, wide-spread use mayoverwhelm the Google platform and a Gmail account is required to view data. An in-house AHS alternative has been developed. 2) Several discussions took place regarding discretions on what steps can be auditedaccording to IPC protocols. For example, some clinical nurse educators prefer handhygiene to be completed between donning steps, while this is not mandatory or auditableaccording to IPC. In addition, several discussions took place to identify the operationaland business owners of this tool which are required to support the AHS compatibleversion of the application. 3) PPE audits are vital across all hospital departments to improve the quality of healthcare.The use of PPE during patient care has grown exponentially due to the SARS-CoV2pandemic and has amplified the need for an electronic alternative to the existing paperPPE audit tool. The electronic audit tool offers an innovative way to accurately andefficiently collect and display data which will promote an improved quality of care.

Instant messaging technology is fast, reliable and can transmit large volumes of data. It has the potential to revolutionise communication and decision making in a healthcare industry, which, for the large part, still lives in an archaic world of pagers and faxes. However, before we can tap into the vast potential of such technology, we must ensure we do not fall prey to data security breaches and the resultant scaremongering headlines of the Mail Online from October 2015 (figure 1).1 Figure 1 Headline of Mail Online article from October 2015 warning of the risks of sharing confidential patient data over WhatsApp. In the particular article they cite, which surveyed doctors and nurses at five London hospitals, over 95% of doctors and nurses who responded owned smartphones. Among the doctors, 64.7% had used SMS-based messaging, 46.0% had used picture messaging and 33.1% had used app-based messaging technology to transfer patient-related clinical information; 27.5% of them believed they had patient-related clinical information on their smartphones at the time.2 The implications for data security are obvious, yet seem to be ignored by practising clinicians. A further UK-based survey indicated that app-based messaging tools such as WhatsApp formed an important part of daily communication within clinical teams, with 72.5% of respondents believing that it was a ‘good thing’.3 A literature search centring around WhatsApp, conducted in June 2016, identified 41 articles in the published literature. Analysis of these articles revealed multiple uses for the app within healthcare, including communication between clinicians, communication with patients and education (figure 2). Published articles originated from a diverse set of countries and specialties, but, conspicuously, there were no articles originating from the USA, where the Health Insurance Portability and Accountability Act places strict regulations on the storage and transfer of medical records (figure 2). Interestingly, only …

This study assessed the effects of a vibrating pager on reduction of rapid eating. The study also evaluated two strategies for fading the pager, by intensity and by frequency. The pager was successful in decreasing the pace of eating to an appropriate level and the pager prompt was successfully faded. Fading by frequency was ineffective in maintaining an appropriate pace of eating while intensity fading was successful.

Appropriate handling of ‘critical’ laboratory test result values is an essential component of timely, quality patient care. While interinstitutional variability exists,1 critical values have historically been defined as potentially ‘life-threatening’ if not attended to quickly,2 necessitating prompt notification of a responsible clinician. Given patient safety implications, timely communication of results to a provider is a common regulatory element, including: (1) Joint Commission patient safety goals,3 (2) Clinical Laboratory Improvement Amendments4 and (3) the International Organization for Standardization.5 Inpatient values comprise a significant proportion of notifications,6 and among inpatients, oncology inpatients typically constitute a substantial volume.7 After laboratory result generation, contacting a responsible clinician can be complicated by multiple barriers. Previous approaches to improve this process include using call centres, automatic pager notifications and automatic personal digital assistant (PDA) telephone notifications.8–11 In our hospital, the inpatient haematology/oncology/stem cell transplantation (H/O) service had an overall notification success rate substantially lower than the hospital average as an effect of the large volume of critical results that typically returned in a short time period at certain times of day, leading to a multidisciplinary initiative to improve the notification process. In our free-standing 360-bed paediatric hospital, ‘overall’ successful critical result notification must: (1) be acknowledged by a licenced individual provider (LIP) and (2) meet criteria for ‘timely’ notification, indicating that both outgoing notification from the laboratory/call centre and LIP acknowledgement occur within 30 min of result generation. H/O inpatients account for 15%–20% of all inpatient critical values but had a significantly lower overall successful notification rate than the hospital average. Timely outgoing notification occurred >90%, but timely LIP acknowledgement was

Background: An on call infectious diseases (ID) pharmacist may be used as a resource for physicians, pharmacists, and other health care providers to help answer questions regarding anti-infective agents. Objective: To assess type, requestor, resources dedicated, and temporal trends of questions received through an ID pharmacist on call pager program. A secondary objective was to gather insight as to how this information was utilized to inform educational initiatives. Methods: This was a retrospective study of questions received by the ID pharmacist on call via pager at a large academic medical center. Question data were documented in a central database and analyzed to assess temporal trends and question type, and qualitatively analyzed to determine areas for targeted educational efforts. Results: The ID pharmacist on call recorded 545 questions during the 1-year study period; questions were composed of various antimicrobial agent–related queries, including antibiotic spectrum and selection (n = 251, 46.1%), dosing of antimicrobials (n = 195, 35.8%), and drug monitoring (n = 26, 4.8%). Targeted educational initiatives secondary to questions received included pharmacist education regarding the use of polymyxin antibiotics and antibiotic dosing protocol updates. Conclusions: An ID pharmacist on call pager program was utilized to inquire about antibiotic spectrum and selection for the majority of questions. Records of questions received may be utilized to direct educational efforts and create or revise targeted resources for pharmacists and other clinicians.

Emergency medical services (EMS) provides a critical role in the rapid treatment, stabilization, and transfer of patients in the prehospital setting. The national EMS provider for Israel has developed a robust and unique organization of volunteers with advanced telecommunication strategies to activate and direct them in order to improve these processes. The volunteers include local high school students, international college students, emergency medical technicians, on-call volunteers, motorcyclists, and Life Guardian first responders. The telecommunication strategies include pagers, push-to-talk over cellular, and sophisticated smartphone-based software applications. These are monitored and directed via a central command and control station. Such processes, both on an organizational as well as technical level, can be adapted to improve prehospital emergency care.

Devices commonly used for wireless media include mobile computers, desktop, handheld computer systems, personal digital assistants (Personal organizers), cellular phones, pen- based personal computers, as well as pagers. Wireless networks operate identical to wired networks, having said that, wireless networks have to turn information signals right into a form suited for transmission using the air tool.

Although many books and literature have been written in Braille system for visually impaired people, no convenient method exists for them to access electronic materials or e-books or convert their Braille messages to electronic format such as files on computer systems. There are some basic electronic systems available for access to braille materials, but most of them lack in suitability for computer-based interaction and suffer from privacy issues. In this paper, we present the design and implementation of a low-cost wireless braille system hand glove that enables visually impaired people to read from a computer by sensing vibration on their fingers and write to a computer by bending fingers or doing hand gestures. Slot sensors installed on the hand glove are used for writing and pager motors are used for reading. The device is low cost and effective and operates in real time.

Background Frequent pages can disrupt workflow, interrupt patient care, and may contribute to physician burnout. We hypothesized that paging volumes followed consistent temporal trends, regardless of the medical or surgical service, reflecting systems based issues present in our hospitals. Methods A retrospective review of the hospital paging systems for 4 services at The Ottawa Hospital was performed. Resident paging data from April 1 to July 31, 2018 were collected for services with a single primary pager number including orthopaedic surgery, general surgery, neurology, and neurosurgery. Trends in paging volume during the 4-month period were examined. Variables examined included the location of origin of the page (emergency room vs. inpatient unit), and day/time of the page. Results During the study period, 25,797 pages were received by the 4 services, averaging 211 (± Standard Deviation (SD) 12) pages per day. 19,371 (75%) pages were from in-patient hospital units, while 6426 (24%) were pages from the emergency room. The median interval between pages across all specialties was 22:30 min. Emergency room pages peaked between 16:30 and 20:00, while in-patient units peaked between 17:30 and 18:30. Conclusions Each service experienced frequent paging with similar patterns of marked increases at specific times. This study identifies areas for future study about what the factors are that contribute to the paging patterns observed.

For nearly 40 years I’ve been part of an on-call rota, but this Christmas will be my last on-call commitment, ever. In my first hospital jobs I was on call one in three, which included 8 am on Friday to 5 pm on Monday. As a new partner at my general practice I worked one in five, my pager never far from my side. I still recall those night time home visits, never quite knowing where to go, with only the A-Z as a guide. In recent years I’ve gradually withdrawn from the full on-call rota, being allowed to stop the red-eye shift a few years ago, weekends more recently; …

Background Clinicians, including nurse practitioners (NPs), face a number of challenges in delivering high-quality care including frequent interruptions that can potentially compromise patient safety and job satisfaction. Local problem Trauma NPs voiced frustration with their efforts to provide efficient, high-quality care with frequent interruptions, most commonly pager alerts. The purpose of this quality improvement (QI) initiative was to increase trauma NPs' perceptions of patient safety and improve NPs' job satisfaction by reducing workflow interruptions. Methods The Model for Improvement guided this initiative. Interventions The aims of this initiative were to reduce the percentage of nonurgent workflow interruptions via pager alerts by 20% and to increase the utilization of a standardized trauma NP patient rounding process from 0% to 50%. Results Use of the standardized rounding process improved from 0% to 87%. Interruptions via pager alerts decreased by 36.2%. All nine (100%) trauma NP survey responses revealed an improvement in NP perception of patient safety and job satisfaction. Conclusion The QI initiative found that increasing communication during rounds by using a standardized rounding process involving the bedside registered nurse can minimize interruptions and improve the efficiency of a trauma NP team. The key to the success of the QI initiative was the implementation of a standardized rounding process.

Background The first on-call shift is a scary proposition for a new foundation doctor, and is a task for which many feel unprepared. Simulation training is increasingly used to help prepare final year medical students for working on-call, but often consists of discrete stations instead of a resembling a continuous on-call shift (Wald et al. 2016). This method allows students to practice medical management of acutely unwell patients, but may not provide adequate training in necessary non-technical skills for working on-call such as organisation, prioritisation, responding to pagers, and working under time pressure. We set out to develop an effective simulated on-call training session, which would incorporate these non-technical skills and help prepare medical students for working on call. Summary of work 5 simulated on-call sessions were run with a total of 18 final year Cardiff medical students. At the start each student received a pager and a brief handover including 2 outstanding tasks. During the session students were paged with details of new tasks to complete, and could receive multiple requests in quick succession requiring prioritisation of tasks. In total each student had to complete 10 simulated tasks situated in different hospital wards at University Hospital of Wales. At the end of the session the students were individually debriefed on their performance, and quantitative and qualitative feedback was collected. Summary of results On a scale of 1–10 all 18 students rated the usefulness of the session as 10. After the simulation the students reported a significantly higher confidence in: responding to pagers (p The students identified these key factors that contributed to the usefulness of the session: practising prioritising tasks, practising routine F1 tasks, situating the tasks on hospital wards, and use of real pagers. Discussion and conclusions The students gave very positive feedback regarding the simulation and found the inclusion of non-technical skills to be the most useful aspect. By designing the simulation as a continuous experience we were able to incorporate aspects of working on-call such as task prioritisation which the students had not previously been exposed to and which they valued highly. Recommendations It is important that on-call training fully incorporates non-technical skills for it to be effective. On-call simulation training should be designed as a continuous session instead of discrete simulated tasks. References Wald D, Peet A, Cripe J, Kinloch M. (2016). A simulated Night on Call experience for graduating medical students. MedEdPORTAL; 12:10483. https://doi.org/10.15766/mep_2374-8265.10483

Introduction Studies have shown that levels of medical students feeling prepared for professional practice have remained static since 20131–3, despite multiple reforms in medical education. Preparedness is vital to ensure patients are getting the best, safest care, and for the well-being of foundation doctors (FY1) to avoid stress and burnout. There has been a rise in use of simulation technology in medical education, with evidence of its efficacy across postgraduate and continuing professional education2, and simulation is now increasingly used in the undergraduate domain. This study seeks to examine whether simulation is an effective methodology to prepare final year medical students for FY1. Methods This mixed methods, two phase study compared a ‘Ward simulation’ where students moved around a simulated ward dealing with scenarios they encountered with a ‘Bleep simulation’ where medical students were given a pager (known as a ‘bleep’) responded to ‘bleeps’ about different aspects of patient care. The simulation was designed to develop key competencies for FY1. Questionnaires and interviews were administered immediately after the simulation (student phase) and 6 months later (doctor phase) to assess changes over time. Results Overall, 72.5% of students felt prepared for practice. Students that undertook the bleep simulation were non-significantly more prepared (OR 1.2, p= 0.638) compared to those that undertook the ward simulation. There were no significant differences between the groups for key competencies including non-technical skills and dealing with acutely unwell patients. Although there were no significant differences between the student and doctor phase, the trend was towards FY1s feeling less prepared than they had thought as students. Qualitative data highlighted the importance of experiential learning through simulation, allowing students to manage situations that they would be unable to in the real clinical environment, with the advantage of repetitive practice to build confidence. The qualitative data also demonstrated FY1s change of behaviours as a result of the simulation. Discussion and conclusions This study suggests that no matter the format, simulation is effective to develop the knowledge and skills required for the transition to professional practice. Furthermore, participants in this study demonstrated a change in behaviours, thereby showing Kirkpatrick level two and three outcomes. Despite this, levels of preparedness echo the wider literature and suggest there is still some room for improvement. This may be achieved with embedding simulation alongside clinical experience in a range of formats, and involving stakeholders, students and FY1s in designing effective simulation teaching. References GMC. General Medical Council - National Training Surveys 2019 [Available from: https://webcache.gmc-uk.org/analyticsrep/saw.dll?Dashboard. Goldacre MJ, Lambert TW, Svirko E. Foundation doctors’ views on whether their medical school prepared them well for work: UK graduates of 2008 and 2009. Postgraduate medical journal 2014;90(1060):63–8. Goldacre MJ, Taylor K, Lambert TW. Views of junior doctors about whether their medical school prepared them well for work: questionnaire surveys. BMC medical education 2010;10:78. Draycott TJ, Crofts JF, Ash JP, Wilson LV, Yard E, Sibanda T, et al. Improving neonatal outcome through practical shoulder dystocia training. Obstetrics and gynecology 2008;112(1):14–20.

Rapid growth in advance technologies haschanged the life of sales force. Sales Force Automation (SFA) ismarketing tool which provides the functions to sales team andmanagers to monitor sales, forecast sales and analyze employeeperformance. Acceptance of the SFA tools such as phone, pagers,wireless devices etc., in sales tasks will remain an issue for salesforce. Researcher wants to investigate the impact of SFA systemon performance of salesman from Pakistani Fast MovingConsumer Goods (FMCG) perspective. They have selected 162salespersons from Lahore based companies (who are usingautomated sales devices), and sample size and MANOVA(Multivariate Analysis of Variance) were utilized to find out therelationship between independent and dependent variables. Ithas found that SFA system has positive relationship withimprovement in performance and sales of salesforce.

The advancements in technology development have paved a way for the innovations in telecommunication field. The telephones had been recreated into pagers and then into mobile phones which reduced the size and increased the portability. This increased the obsolescence rate due to the planned obsolescence of the manufacturers. e-waste or the electronic waste has been the talk for the past decade due to their increased generation rate. Though various regulations have been passed in the year 2012 and 2016 for controlling the generation of e-waste nothing persist to the extent. The mushrooming mobile industries are the major criteria for the higher generation of e-waste. A study has been done to find out the flow of mobile phones which would become an e-waste in near future. Questionnaires have been designed and distributed to the reputed dealers/retailers and the list of authorised mobile brands was accounted. From the study, only 40% of the mobile brands prevalent in the city were authorised which includes the fast-moving brands like Oppo, Vivo and Xiaomi. The study revealed that many mobiles that have been sold during the great sale days have not been authorised which increases the e-waste generation (orphaned e-waste) and so stringent rules should be made in accordance with the authorisation of retailing mobile phones. This could help create awareness on the extended producer responsibility where the dealers/retailers would play a major part in reducing e-waste generation.

Introduction Identifying errors in the ward environment, healthcare organisation or interaction between the multiprofessional team members is crucial. Such identification may prevent serious mistakes that can occur in high pressure gastroenterology emergencies. Unannounced multiprofessional in situ simulation can be an effective means of identifying latent patient safety threats before they occur. We set up a standardised in situ simulation programme centred around speciality specific emergency scenarios not only to improve skills, team working and communication but also to identify and address latent errors. The in situ faculty consisted of a consultant gastroenterologist; skills tutor; education fellow and director of medical education. Methods We identified key learning objectives for several different emergency scenarios including: massive upper gastrointestinal haemorrhage; septic shock; post-procedure complications and cardiac arrest. Using a wireless high fidelity simulation manikin we ran 15 unannounced sessions between February 2017 and January 2019. There was a minimum of three faculty in attendance in each of the sessions and an overall total of 67 participants representing the spectrum of different professions including: doctors; nurses; health care assistants and students from nursing, medical, and physician associate backgrounds. Following completion of the scenario a structured debrief was conducted. Latent errors affecting patient safety at an individual, team or organisational level were identified and discussed. Following the scenarios, actions were put in place designed to address the identified errors in a timely fashion. Results During the 15 unannounced sessions between February 2017 and January 2019 we identified the following latent errors: shortage of Sengstaken-Blakemore tubes, Bair Hugger and a step for CPR on the ward; lack of awareness as to how to activate the major haemorrhage protocol; junior doctors without working pagers; deficiencies in resuscitation skills amongst non-training grade doctors; members of the multiprofessional team forgetting each others’ names and parts of the ALS algorithm; not knowing where the oral glucose gel is kept on the ward. Since the identification of these errors corrective measures have included: laminated ALS algorithms attached to the resuscitation trolleys and dedicated major haemorrhage protocol training at junior doctor induction. Equipment shortages including sourcing the relevant equipment has been undertaken by ward management. Dedicated training days for the non-training grade doctors has also been undertaken. Conclusions In situ simulation is highly effective in identifying latent errors that could have potentially deleterious consequences on patient safety. This allows corrective measures to be undertaken in advance of real-life emergencies.

Nowadays, technology and mobile applications have become involved in various areas of life. Therefore, the need for applications in areas such as healthcare is significant. A survey was conducted at the College of Dentistry in Imam Abdulrahman bin Faisal University. Survey results of this academic environment show a need for a system to link dental students with supervisors. Current commercially available off-the-shelf applications do not cater for all requirements. This paper proposes a solution that supports the interaction between the supervisor, and the student at the College. However, such a system can be extended to work in other dental colleges within the Kingdom of Saudi Arabia and beyond.

This paper analyses the 'failure' of a patient safety intervention. Our study was part of a randomised controlled trial (RCT) of bed and bedside chair pressure sensors linked to radio pagers to prevent bedside falls in older people admitted to hospital. We use agential realism within science and technology studies to examine the fall and its prevention as a situated phenomenon of knowledge that is made and unmade through intra-actions between environment, culture, humans and technologies. We show that neither the intervention (the pressure sensor system), nor the outcome (fall prevention) could be disentangled from the broader sociomaterial context of the ward, the patients, the nurses and (especially) their work through the RCT. We argue that the RCT design, by virtue of its unacknowledged assumptions, played a part in creating the negative findings. The study also raises wider questions about the kind of subjectivities, agencies and power relations these entanglements might effect and (re)produce in the hospital ward.

With the emergence of low-latency non-volatile memory (NVM) storage, the software overhead, incurred by the operating system, becomes more prominent. The Linux (monolithic) kernel, incorporates a complex I/O subsystem design, using redundant memory copies and expensive user/kernel context switches to perform I/O. Memory-mapped I/O, which internally uses demand paging, has recently become popular when paired with low-latency storage. It improves I/O performance by mapping the data DMA transfers directly to userspace memory and removing the additional data copy between user/kernel space. However, for data-intensive applications, when there is insufficient physical memory, frequent page faults can still trigger expensive mode switches and I/O operations. To tackle this problem, we propose CO-PAGER, which is a lightweight userspace memory service. CO-PAGER consists of a minimal kernel module and a userspace component. The userspace component handles (redirected) page faults, performs memory management and I/O operations and accesses NVM storage directly. The kernel module is used to update memory mapping between user and kernel space. In this way CO-PAGER can bypass the deep kernel I/O stacks and provide a flexible/customizable and efficient memory paging service in userspace. We provide a general programming interface to use the CO-PAGER service. In our experiments, we also demonstrate how the CO-PAGER approach can be applied to a MapReduce framework and improves performance for data-intensive applications.

Background During the COVID-19 pandemic, the critical role of the hospital Infection Prevention department was highlighted. To serve as a resource, Infection Preventionists (IP) at a large, quaternary-care center are reachable during normal hours and an IP covers a 24-hour on-call pager on a rotating basis. During the pandemic, the number of IP pages skyrocketed from an average of 6 pages to over 50 pages per day. With this unprecedented strain and limited human resources, innovative changes were made within the department. Methods During the acute phase of our COVID-19 response, IPs flexed from a 7 day on call period to a shortened 3–4-day period. To offload the number of IP pages, a hospital epidemiologist pager was created. The department physically relocated to the hospital's centralized incident command center and implemented Microsoft TeamsTM. System-wide IP videoconferences were scheduled. Lastly, structured work-at-home options were created. Results Shortening the length of time covering the on-call pager reduced the burden and allowed IPs to obtain adequate rest between periods of coverage. The hospital epidemiologist pager served as a resource when physician input was requested, which helped offload the number of calls placed to the IP. Physically relocating and implementing Microsoft TeamsTM promoted teamwork, accessibility, and communication within the department and the hospital. During the 4-week acute phase of our COVID-19 response, 16 videoconferences improved communication and needs of the 3-hospital system. Lastly, many IPs opted for work-from-home options, improving the sense of support and well-being of team members. Conclusions We describe strategies that may be implemented by departments to meet organizational needs while promoting the wellbeing of staff. These changes may be used during periods of high-demand or may be permanent based on feedback from key stakeholders.

Despite promises that pagers would be gone by the end of 2021, hospitals look set to retain them for critical situations at least, Jo Best reports

The differences in business models, lending products and risk control of lending products of Internet financial lending platforms have led to the disorderly growth of Internet Financial platforms in China for a long time. With the voice of financial innovation, the number of platforms and the scale of transactions have increased significantly. In this pager, we will enter the network diffusion model to analyze the physical and statistical characteristics of the competitive behavior and fierce competition behavior of the Internet financial lending platform, and understand the overall characteristics of the Internet P2P lending platform under the specific platform classification, and finally put forward the corresponding policy suggestions.

SummaryIntroduction: Hospital-based medical services are increasingly utilizing team-based pagers and smartphones to streamline communications. However, an unintended consequence may be higher volumes of interruptions potentially leading to medical error. There is likely a level at which interruptions are excessive and cause a ‘crisis mode’ climate.Methods: We retrospectively collected phone, text messaging, and email interruptions directed to hospital-assigned smartphones on eight General Internal Medicine (GIM) teams at two tertiary care centres in Toronto, Ontario from April 2013 to September 2014. We also calculated the number of times these interruptions exceeded a pre-specified threshold per hour, termed ‘crisis mode’, defined as at least five interruptions in 30 minutes. We analyzed the correlation between interruptions and date, site, and patient volumes.Results: A total of 187,049 interruptions were collected over an 18-month period. Daily weekday interruptions rose sharply in the morning, peaking between 11 AM to 12 PM and measuring 4.8 and 3.7 mean interruptions/hour at each site, respectively. Mean daily interruptions per team totaled 46.2 ± 3.6 at Site 1 and 39.2 ± 4.2 at Site 2. The ‘crisis mode’ threshold was exceeded, on average, 2.3 times/day per GIM team during weekdays. In a multivariable linear regression analysis, site ([uni03B2]6.43 CI95% 5.44 –7.42, pConclusion: Interruptions were related to site-specific features, including volume, suggesting that future interventions should target the culture of individual hospitals. Excessive interruptions may have implications for patient safety especially when exceeding a maximal threshold over short periods of time.

Background Paging systems continue to be used by the majority of hospitals despite the nearly ubiquitous use of personal and/or corporate smartphones by hospital clinicians. Integrated multi-platform smartphone apps, such as the Vocera® Collaboration Suite (VCS), have the potential to be a reliable, efficient, and secure methods of communication in hospitals. Objective To examine the effect of VCS, on communication and the efficiency of communication between hospital clinicians. Methods A Three-month prospective observational study was completed at two tertiary care hospitals, and one community hospital, at Island Health (Vancouver Island, British Columbia, Canada). Hospitalists, obstetricians, intensivists, and pharmacists piloted the VCS smartphone app in the replacement of pagers. Switchboard operators, ICU nurses, and ICU unit clerks had access to the app via a desktop computer based web console. Our primary outcome was the difference in page turnaround time before and after the implementation of VCS. We also conducted baseline and post-study surveys and measured the volume of the app׳s usage. Results Physicians responded to pages faster (5.5 vs 3min; p Conclusions Smartphone based communication systems, such as Vocera ® Collaboration Suite, improve the speed of, and satisfaction with hospital communication when compared to pagers. Reduced phone battery life should be considered when implementing VCS.

Hardware simulation pager usually is very expensive and can only simulate 16 subscriber line or 32 subscriber line. And in FMC (fixed and mobile convergence) system, FSK (frequency shift keying) is used to transfer information between home gateway and the program controlled switch. In this paper, a novel FSK call simulation method to design a pager is proposed to use software to simulate the interaction of FSK between home gateway and the program controlled switch during a normal call procedure, and to meet the demand of the performance and capacity testing of the FMC system. The FSK call simulation includes a back-end management system and a foreground simulation system. And the foreground simulation system consists of MP (module process) module, SP (subscriber process) module, ASIG (analog signal) module, and so on. The MP is the module’s main control process, and it will control the logic of call, and transfer simulation control information between back-end management system and the other modules in the foreground. The SP is the module, in which the FSK call simulation process lying in. And ASIG module can send FSK signal to home gateway, and receive FSK signal from home gateway. The novel FSK call simulation method can test the performance and capacity of the FMC platform by the means of software, and lower the expense of testing.

Background The growing number of monitoring devices, combined with suboptimal patient monitoring and alarm management strategies, has increased "alarm fatigue," which have led to serious consequences. Most reported alarm man- agement approaches have focused on the critical care setting. Since 2007 Dartmouth-Hitchcock (Lebanon, New Hamp- shire) has developed a generalizable and effective design, implementation, and performance evaluation approach to alarm systems for continuous monitoring in general care settings (that is, patient surveillance monitoring). Methods In late 2007, a patient surveillance monitoring system was piloted on the basis of a structured design and implementation approach in a 36-bed orthopedics unit. Beginning in early 2009, it was expanded to cover more than 200 inpatient beds in all medicine and surgical units, except for psychiatry and labor and delivery. Results Improvements in clinical outcomes (reduction of unplanned transfers by 50% and reduction of rescue events by more than 60% in 2008) and approximately two alarms per patient per 12-hour nursing shift in the original pilot unit have been sustained across most D-H general care units in spite of increasing patient acuity and unit occupancy. Sample analysis of pager notifications indicates that more than 85% of all alarm conditions are resolved within 30 seconds and that more than 99% are resolved before escalation is triggered. Conclusion The D-H surveillance monitoring system employs several important, generalizable features to manage alarms in a general care setting: alarm delays, static thresholds set appropriately for the prevalence of events in this setting, directed alarm annunciation, and policy-driven customization of thresholds to allow clinicians to respond to needs of individual patients. The systematic approach to design, implementation, and performance management has been key to the success of the system.

Background Interprofessional hospital communication is vital for high-quality patient care. However, staff have reported that nursing pages are often sent to the wrong residents, leading to service delays, interruptions, and safety risks. The aim of this quality improvement project was to reduce day shift pages to general internal medicine (GIM) teams by 25% over 10 months by helping nurses page the right residents the first time. Methods This study was conducted at a Canadian tertiary academic hospital and involved three GIM teams on seven inpatient wards. The Model for Improvement was used to explore root causes and redesign how nurses and switchboard operators contacted residents. Multiple change ideas were tested: posting daily resident assignments on digital monitors, redirecting switchboard pages to internal medicine residents, and forwarding pagers in learning sessions. The primary outcome was the average number of pages/team/week to GIM residents. Evaluation was conducted with statistical process control charts and qualitative feedback. Results A total of 19,925 pages were reviewed from 226 resident shifts over 39 weeks. Average pages/team/week (Monday to Friday, 08:00 to 17:00) decreased by 38.3% (133 to 82) postimplementation. More nurses reported often or always knowing which residents were assigned to patients, increasing from 0% to 38.1%. Fewer residents reported often or always receiving pages about another resident's patient, decreasing from 50.0% to 26.7%. Conclusion Quality improvement methods were used to streamline the paging process on GIM wards, resulting in fewer pages and improved communication efficiency.

We evaluated the feasibility of a mobile phone-based geolocation technology in patients with ventricular assist devices (VAD). We prospectively enrolled VAD patients with a smartphone for 6 months. A proprietary mobile technology platform (Position Health, Reading, MA) was downloaded onto Apple or Android smartphones. When a patient entered an emergency department, the app was activated and a "ping" with patient location and contact information was sent to our VAD team pager. Fifty-four patients were approached, and 21 were enrolled. The primary reason for nonenrollment was lack of smartphone (46%). The technology was active for 3780 patient-days and activated on 4 occasions, all cases in which patients were inside a hospital but not seeking emergency care. When surveyed at 3 and 6 months, 90% and 100% of patients, respectively, reported the app remained active on their phones; 14 of 18 (78%) reported the app was helpful and gave them additional reassurance. Implementing this technology for VAD patients was feasible and accepted by patients and providers, but a larger study is needed to demonstrate an impact on care delivery.

Objectives Efficient and accurate communication between healthcare professionals (HCPs) serves as the backbone to safe and efficient care delivery. Traditional pager-based interpersonal communication may contribute to inefficient communication practices and lapses in medical care. Methods This study aimed to examine the impact of Medic Bleep, a National Health Service (NHS) information governance-compliant instant messaging application, in an NHS Hospital Trust. We examined Medic Bleep’s impact on participant time and workflow using time–motion methodology. Cohorts of doctors and nurses using both Medic Bleep and the traditional pager were compared. Secondary endpoints of our study were to assess whether efficient communications could lead to better resource utilisation, patient safety as well as better quality of work life for the end user. Results Assimilation of Medic Bleep corresponded to a reduction in mean task-duration that was statistically significant ( p Conclusion Medic Bleep reduced time spent on the tasks requiring interpersonal communication. Efficiencies were seen in Discharge Patient Flow, Patient Review and TTO categories. This improved HCP availability and response times to the benefit of patients. End users revealed that Medic Bleep had a positive effect on quality of work life.