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American Journal of Kidney Diseases

Prospective Analysis of After-Hour Pages to Nephrology Fellows

      To the Editor:
      Practicing nephrologists and fellows have expressed dissatisfaction with their careers,
      • Kaminetzky C.P.
      • Keitz S.A.
      • Kashner T.M.
      • et al.
      Training satisfaction for subspecialty fellows in internal medicine: findings from the Veterans Affairs (VA) Learners' Perceptions Survey.
      • Leigh J.P.
      • Tancredi D.J.
      • Kravitz R.L.
      Physician career satisfaction within specialties.
      the latter identifying long work hours as one of the reasons.
      • Shah H.H.
      • Jhaveri K.D.
      • Sparks M.A.
      • Mattana J.
      Career choice selection and satisfaction among US adult nephrology fellows.
      In 2013, a total of 44% of nephrology programs participating in the National Resident Matching Program were unfilled.

      Match Results Statistics. Medical Specialities Matching Program—2013. www.nrmp.org. Accessed January 27, 2014.

      We conducted a prospective study of 6 nephrology fellows over 61 days and assessed 615 after-hour pages (AHPs). Most AHPs were from covering providers or nurses regarding inpatients. No fellow received more AHPs or consults than any other, but first-year fellows returned to the hospital and called the attending more often than second-year fellows. Table 1 reports the reasons for the AHPs and the actions performed.
      Table 1Review of 615 AHPs Received by Nephrology Fellows
      PremiseNo. of AHPs (% of total)No. of Actions Performed
      If multiple actions were performed, we asked the fellows to list the most time-consuming action.
      (%)
      No ActionGave InstructionsPlaced Order(s)Signed outSaw PtCalled PtCalled HD NurseOtherNo Reply
      Consult already seen157 (25.5)71 (45.2)56 (35.7)13 (8.3)6 (3.8)3 (1.9)1 (0.6)7 (4.5)
      New consult151 (24.5)3 (2)7 (4.6)72 (47.7)68 (45)7 (4.6)
      CRRT related120 (19.5)49 (40.8)38 (31.7)7 (5.8)9 (7.5)17 (14.2)
      Dialysis orders62 (10.1)10 (16.1)10 (16.1)37 (59.7)5 (8.1)
      HD/PD nurse concern32 (5.2)11 (34.4)11 (34.4)7 (21.9)1 (3.1)2 (6.2)
      Access issues25 (4.1)1 (4)
      Reassured the caller.
      17 (68)6 (24)1 (4)
      Patient call25 (4.1)7 (28)9 (36)9 (36)
      Telephone calls/pharmacy.
      Lab results21 (3.4)8 (38.1)6 (28.6)
      Or gave order(s).
      2 (9.5)5 (23.8)
      Miscellaneous22 (3.6)9 (40.9)2 (9.1)1 (4.5)2 (9.1)
      Called MD.
      8 (36.4)
      Abbreviations: AHP, after-hour page; CRRT, continuous renal replacement therapy; HD, hemodialysis; Lab, laboratory; PD, peritoneal dialysis; Pt, patient.
      a If multiple actions were performed, we asked the fellows to list the most time-consuming action.
      b Reassured the caller.
      c Telephone calls/pharmacy.
      d Or gave order(s).
      e Called MD.
      Our audit uncovered several areas of concern. First, fellows had to return to the hospital on 64% of overnight call nights. Second, the most common action in response to pages was “no action.” Last, half the AHPs occurred after 10:00 pm, and only 31% of nights afforded the opportunity for the ACGME-recommended minimum of 5 hours of uninterrupted sleep, which is especially important after 16 hours of duty.
      Several categories of our AHPs could be avoided through intervention. Verbal communication, rather than relying on chart notes, may have reduced up to 72 AHPs that concerned patients who had been seen previously. Educating fellows on telephone triage skills
      • Benjamin J.T.
      Pediatric residents' telephone triage experience. Relevant to general pediatric practice?.
      • Hastings S.N.
      • Whitson H.E.
      • White H.K.
      • et al.
      After-hours calls from long-term care facilities in a geriatric medicine training program.
      and, at least in our institution, improving order sets and protocols for continuous renal replacement therapy may lessen the burden of calls without compromising patient safety.
      We encourage other institutions to audit their own AHPs to identify easily rectifiable issues.

      Acknowledgements

      This study was part of a continuous quality improvement project and hence was exempt from institutional review board approval. We thank Kitbhoka Prabhakorn, Michelle Malabanan, Catherine Moore, Sandesh Parajuli, and Rebeca Monk for participation and contributions.
      Financial Disclosure: The authors declare that they have no relevant financial interests.

      References

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        • Keitz S.A.
        • Kashner T.M.
        • et al.
        Training satisfaction for subspecialty fellows in internal medicine: findings from the Veterans Affairs (VA) Learners' Perceptions Survey.
        BMC Med Educ. 2011; 11: 21
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        • Tancredi D.J.
        • Kravitz R.L.
        Physician career satisfaction within specialties.
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        • Shah H.H.
        • Jhaveri K.D.
        • Sparks M.A.
        • Mattana J.
        Career choice selection and satisfaction among US adult nephrology fellows.
        Clin J Am Soc Nephrol. 2012; 7: 1513-1520
      1. Match Results Statistics. Medical Specialities Matching Program—2013. www.nrmp.org. Accessed January 27, 2014.

      2. ACGME Duty Hours Archive. 2011. http://www.acgme.org/acgmeweb/tabid/287/GraduateMedicalEducation/DutyHours/Archive.aspx. Accessed January 5, 2014.

        • Benjamin J.T.
        Pediatric residents' telephone triage experience. Relevant to general pediatric practice?.
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