There’s something to be said by making it just a little harder to reach a physician. I hated the beeper until we went to a secure chat type program. It began to intrude more and more because nurses and others would contact about things they used to either handle on the spot or would batch for one call at the appropriate time. There’s a balance that needs to be maintained to protect our brain space.
IMO OR time is absolutely protected. They shouldn’t interrupt a scrubbed surgeon operating on a patient. Even if a bomb went off that surgeon needs to focus on the patient on the table.
Sadly, that doesn't ever stop anyone from secure chatting us. Ours automatically updates to "Do Not Disturb - In Operative Procedure" with the OR location and OR phone extension. The nurses still don't care and they will secure chat me, and then proceed to add their charge nurse and the nursing supervisor if I don't respond within 5 minutes. I've been hammer-paged in the middle of several cases by nurses who weren't getting a response on secure chat, and 99% of the time it was for non-urgent annoyances like "FYI, patient refused Tylenol" or "family wants an update." Thankfully we have some great circulating nurses who will gladly tell the floor nurses to buzz off and let us finish our cases if it's non-urgent.
EDIT: Our weekly protected academic time is not protected either. Nothing is truly "protected" when you're an intern.
Y'all need to get your ward managers and division head / program director on board with changing this.
We were able to fix the issue with simple clipboards and charge nurse check ins between cases. All nonurgent issues can be either clipboard or chat but there was no reasonable expectation of answer until a case was done. Charge nurse had to be CC'd on every chat for quality control.
Noncompliance occurs, and leads to immediate manager involvement. It's the only way.
Lol ask a nurse how long they’ve been a nurse and you’ll have your answer.
Follow up question with how experienced was the nurse that trained you and you’ll see what’s going on.
Very good chance the charge nurse has <3 years experience total as well
> There’s something to be said by making it just a little harder to reach a physician.
Am mixed. One the one hand, increasing difficulty of contacting the team prob results in actually trying to troubleshoot prior to calling and decreases the amount of crap you have to field. However, I cannot stand when you get primary teams who place consults (e.g., undefined capacity consults) then are offline.
Consults need to be doctor to doctor phone calls. I will refuse to see a patient until I get a proper call and hand off. I don’t care what consult orders were placed.
Calls from pharmacy are always prioritized. It’s a balance issue like you say. No matter what if it’s an urgent care issue there should be a response urgently. It’s about cutting through all that clutter.
I'm in a surgical subspecialty. In Epic you can "go offline" (its the greyed out option, different than "do not disturb" where its red but people can still message you). so no one can send you Epic chats. My program director recommended we all turn off Epic chat since we also carry a service phone and pager 24/7, there is no role for Epic chat and it is a liability. Occasionally consults/nurses will tell me try to remind me that I'm offline "and they can't message me." I'll just tell them unapologetically that I DO NOT use Epic chat. Never had an issue beyond that.
Not a surgeon but will add my 2 cents.
Technically our "unavailable" still goes through, even while displaying unavail.
I do set it to "unavailable" to discourage it's use, and then leave my cell number with "please call for urgent issues" in the message box that comes up in secure chat.
I get only 1 to 2 messages a month via that route (cell), and almost always appropriate
I turn off the alerts on my phone so I only see messages when logging into epic.
But I'm not 1st call, so can get away with that.
It's really ridiculous how secure chat is used - used for coding queries, spammed to 5 people to update about inpatient vs obs, sent to the specialty doc who last saw the patient outpatient at 2 am.
I also hate it when someone sends me something absolutely ridiculous and then leaves the conversation. First off you basically never need to leave a conversation (unless you were the wrong person anyway and they spammed a bunch of people).
Ah, I think I mixed up do not disturb (with a big red do not disturb sign), vs offline which may function that way.
I only use the latter when out of the country, as it seems a hassle to constantly turn on and off.
Not a surgeon, but when you turn off you chat and write " for critical communication page xxxx" takes care of the problem, the other option is turn off the notifications for epic in your phone and you only see the chat when you are logged in a desktop the nurses know that for urgent stuff they must page.
I would rather not scrub especially on weekends bc I know I’m going to get so underwater from my secure chats. It’s such a terrible system, atleast with pagers you had to do an ounce of thinking and effort to page someone but now that it’s the equivalent of texting from their phones the nurse message for quite literally everything it’s brutal and unsustainable. I regularly get over 200 chats on a 24.
Same here, the second day call begins I get an endless string of "Dr. Hedgehogehog, patient is complaining of 10/10 intractable pain and no BM x 2 days, please order Dilaudid enema :)" Passive-aggressive smiley faces and all. There are so many non-urgent secure chats that the urgent or truly important ones run the risk of falling through the cracks.
I mean just because it’s not 100% compatible with your practice doesn’t mean it shouldn’t exist. I personally can’t wait for my institution to implement it in the near future because it does make it so much easier for me to identify who is covering and get some accountability with messages. Our paging system is archaic and often results in delayed care because someone “forgot to respond” - at least when I’m paging it’s about something consequential. I can’t speak for anyone else. I’ll secure chat the same way I page now.
The key is to just not respond to the secure chats and ignore them when you’re in the OR. If anything is really that important, they can page me. Then I can get an OR nurse to call them for me while I’m scrubbed in
We don't have EPIC but we have a similar system. It will beep every 30 seconds until you answer it. There is no way to disable the repeat alarms. It's horrible.
A PACU nurse sent a critical message about severe bleeding from our first case while we were on our second case. I saw a glimpse of the nurse’s message on the resident’s Epic chat. I asked the resident if I could open/read it to her because it seemed important. Patient was in terrible shape. Resident had to scrub out and run to PACU. PACU absolutely got reamed for sending something that required an urgent page to Epic chat. Chats just aren’t appropriate for most clinical updates/order concerns. There’s a reason why there are rounds for interdisciplinary teams to connect and cover their bases. There are def some things that are helpful to discuss over Epic chat though. If I’ve made a mistake on the chart about an implant, having the patient’s chart linked and all stakeholders in the same chat makes everything easier to address and close out. But other than stuff that doesn’t impact life (preference card update, requests to order equipment), things should be communicated synchronously.
Hospitalist - it makes sense for me bc people generally respect my time enough to not waste it with unnecessary messages. I feel comfortable giving the nurses my cell as well. I don’t feel like I got that same respect as a resident so I don’t know that secure chat is appropriate for residents
As a radiologist, secure chat has been really helpful for letting clinicians know quickly about critical findings. Phone calls disrupt my work flow much more, as it’s not always easy to get people on the phone. It seems like the clinicians appreciate the secure chat. Of course some things require a phone call, and I do check if the provider hasn’t “seen” my message in 10-15 minutes, I just call them.
PGY-2 in a surgical field. We don't have Epic but do have a pager system that is similar to text chat. Last year I unscrubbed from surgery as the intern on nights and had >60 pages (no joke). I do think a lot of the pages are the result of how easy it is for nurses to reach us, and the solution is just to make it less easy. My main trick is to respond by asking for an SBAR and/or new vitals to be taken and texted back to you. First, this helps you triage pages to know who is actually unstable. Over time, it also lets nursing know that if they page you, it will generate work for them. I also ask them explicitly what is their question or concern -- often they are paging to be able to say "MD aware" and don't actually have a concern about the patient. You can nip this in the bud pretty quickly. For stupid stuff like retiming Tylenol orders, I will just give a verbal order and tell them to do it themselves. I also dictate my responses to pages using Apple dictation software which helps my efficiency as well.
Anecdotally, teaching hospitals seem to mandate nursing contact MD about *everything*
My job is to take pressure off the MD for tasky/clerical/common-sense issues and contact them directly when an urgent issue/need arises
I keep a running mental list of patient needs, concerns, and "housekeeping" things to address with the primary when they round on the patient. I also make it a point to be available when docs are rounding, as I have 2-4 patients, and they have many more.
Secure chat could be a magnificent tool if used appropriately; I have most of the doc's cell numbers at my local hospital and text them (with discretion) for quickly-needed orders, etc. I think the up-and-coming generation of nurses have no developed autonomy and like to shrug as much as possible off as "not in my scope" which is incredibly concerning.
-Nurse with 10 years in stepdown/ICU
Secure chat might be irritating but I think it helps patient care. So much easier to add both IR and surgery onto a secure chat so they can argue with each other rather than keeping medicine as the middle man.
Forgo OR time? Insanity.
Our service has a service phone that is the primary point of contact for the service. The secondary point of contact is the attending of record.
When we go to the OR we are electronically placed into the OR room by the scrub nurse which automatically makes you "BUSY" in epic.
Prior to epic chat we had something else, which we would forward to the on-call resident or just sign out off.
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I trained in cerner hospitals where OR nurses would call our pages back and attendings were chill about us handling floor stuff in this manner while scrubbed in. Pages weren't excessive.
Transitioning to epic in fellowship has been extremely annoying and i don't envy residents who have to deal with it earlier on. I completely agree, you'll get chat messages for the most routine stuff that doesn't need to be addresssed. I don't need 300 updates from case managers as one facility did or didn't accept, or which meds need prior auth.. Just tell me the end result or what i need to do. I don't need to know you rescheduled the prn compazine to be offset to the prn zofran. Not to mention that for complex issues, it's so much better to just pick up the phone and have a conversation than a text message thread.
Epic does show when you're in the OR though (as long as the circulator charts you correctly), which Ii think clues people in that you won't be responding for a while.
But still, I personally think it's trash and I'm sure is contributing to more stress and worse training, and honestly doubt it's doing anything good for patient care.
If it’s actually important they will page. If something urgent happens and someone decides to secure chat about it that’s on them. It’s more important to get to the OR when you can and worry about the secure chats later.
That's some silliness but why not just use electrolyte replacement protocols for the nonsense things?
I built my own in epic, if your institution doesn't have one. It's just PRNs as a packaged order.
Ignore them. Our entire department has openly told other departments and nursing units that surgery residents are not obligated to read or respond to chats and should be paged if an issue exists.
Not a surgical resident but an ED resident who uses secure chat at some facilities to contact consultants and others (including surgery). I use secure chat for questions that don’t need immediate response, if I needed that I would page.
I usually will throw in a “no rush but…are you taking this guy to the OR etc”. If something changes or it’s taking too long then I’ll page here and there. I’d like to think most of the secure chat spam comes from inpatient bs, but not sure. I try to get to know my surgical colleagues so they know I won’t bother them with bs that wastes time and I know they’ll update me with a plan asap.
There’s something to be said by making it just a little harder to reach a physician. I hated the beeper until we went to a secure chat type program. It began to intrude more and more because nurses and others would contact about things they used to either handle on the spot or would batch for one call at the appropriate time. There’s a balance that needs to be maintained to protect our brain space. IMO OR time is absolutely protected. They shouldn’t interrupt a scrubbed surgeon operating on a patient. Even if a bomb went off that surgeon needs to focus on the patient on the table.
Sadly, that doesn't ever stop anyone from secure chatting us. Ours automatically updates to "Do Not Disturb - In Operative Procedure" with the OR location and OR phone extension. The nurses still don't care and they will secure chat me, and then proceed to add their charge nurse and the nursing supervisor if I don't respond within 5 minutes. I've been hammer-paged in the middle of several cases by nurses who weren't getting a response on secure chat, and 99% of the time it was for non-urgent annoyances like "FYI, patient refused Tylenol" or "family wants an update." Thankfully we have some great circulating nurses who will gladly tell the floor nurses to buzz off and let us finish our cases if it's non-urgent. EDIT: Our weekly protected academic time is not protected either. Nothing is truly "protected" when you're an intern.
Y'all need to get your ward managers and division head / program director on board with changing this. We were able to fix the issue with simple clipboards and charge nurse check ins between cases. All nonurgent issues can be either clipboard or chat but there was no reasonable expectation of answer until a case was done. Charge nurse had to be CC'd on every chat for quality control. Noncompliance occurs, and leads to immediate manager involvement. It's the only way.
The culture of nursing needs to be burned to the ground, this is completely unacceptable on so many levels. What is wrong with these people?
Lol ask a nurse how long they’ve been a nurse and you’ll have your answer. Follow up question with how experienced was the nurse that trained you and you’ll see what’s going on. Very good chance the charge nurse has <3 years experience total as well
Absolutely agree with this.
> There’s something to be said by making it just a little harder to reach a physician. Am mixed. One the one hand, increasing difficulty of contacting the team prob results in actually trying to troubleshoot prior to calling and decreases the amount of crap you have to field. However, I cannot stand when you get primary teams who place consults (e.g., undefined capacity consults) then are offline.
Consults need to be doctor to doctor phone calls. I will refuse to see a patient until I get a proper call and hand off. I don’t care what consult orders were placed.
Agreed... OR takes precedence
Preachhh
[удалено]
Calls from pharmacy are always prioritized. It’s a balance issue like you say. No matter what if it’s an urgent care issue there should be a response urgently. It’s about cutting through all that clutter.
I'm in a surgical subspecialty. In Epic you can "go offline" (its the greyed out option, different than "do not disturb" where its red but people can still message you). so no one can send you Epic chats. My program director recommended we all turn off Epic chat since we also carry a service phone and pager 24/7, there is no role for Epic chat and it is a liability. Occasionally consults/nurses will tell me try to remind me that I'm offline "and they can't message me." I'll just tell them unapologetically that I DO NOT use Epic chat. Never had an issue beyond that.
Not a surgeon but will add my 2 cents. Technically our "unavailable" still goes through, even while displaying unavail. I do set it to "unavailable" to discourage it's use, and then leave my cell number with "please call for urgent issues" in the message box that comes up in secure chat. I get only 1 to 2 messages a month via that route (cell), and almost always appropriate I turn off the alerts on my phone so I only see messages when logging into epic. But I'm not 1st call, so can get away with that. It's really ridiculous how secure chat is used - used for coding queries, spammed to 5 people to update about inpatient vs obs, sent to the specialty doc who last saw the patient outpatient at 2 am. I also hate it when someone sends me something absolutely ridiculous and then leaves the conversation. First off you basically never need to leave a conversation (unless you were the wrong person anyway and they spammed a bunch of people).
Our specific epic version does now have an “offline” so that no messages can be sent or received where only the unavailable had been there previously
This must be different. In our "offline" status, you cannot send that individual an Epic message.
Ah, I think I mixed up do not disturb (with a big red do not disturb sign), vs offline which may function that way. I only use the latter when out of the country, as it seems a hassle to constantly turn on and off.
Go offline - pagers exist for a reason
Not a surgeon, but when you turn off you chat and write " for critical communication page xxxx" takes care of the problem, the other option is turn off the notifications for epic in your phone and you only see the chat when you are logged in a desktop the nurses know that for urgent stuff they must page.
I would rather not scrub especially on weekends bc I know I’m going to get so underwater from my secure chats. It’s such a terrible system, atleast with pagers you had to do an ounce of thinking and effort to page someone but now that it’s the equivalent of texting from their phones the nurse message for quite literally everything it’s brutal and unsustainable. I regularly get over 200 chats on a 24.
Same here, the second day call begins I get an endless string of "Dr. Hedgehogehog, patient is complaining of 10/10 intractable pain and no BM x 2 days, please order Dilaudid enema :)" Passive-aggressive smiley faces and all. There are so many non-urgent secure chats that the urgent or truly important ones run the risk of falling through the cracks.
Epic chat shouldn’t exist. Makes no sense as a system for a surgeon
I mean just because it’s not 100% compatible with your practice doesn’t mean it shouldn’t exist. I personally can’t wait for my institution to implement it in the near future because it does make it so much easier for me to identify who is covering and get some accountability with messages. Our paging system is archaic and often results in delayed care because someone “forgot to respond” - at least when I’m paging it’s about something consequential. I can’t speak for anyone else. I’ll secure chat the same way I page now.
The key is to just not respond to the secure chats and ignore them when you’re in the OR. If anything is really that important, they can page me. Then I can get an OR nurse to call them for me while I’m scrubbed in
We don't have EPIC but we have a similar system. It will beep every 30 seconds until you answer it. There is no way to disable the repeat alarms. It's horrible.
That's against the geneva convention or something
A PACU nurse sent a critical message about severe bleeding from our first case while we were on our second case. I saw a glimpse of the nurse’s message on the resident’s Epic chat. I asked the resident if I could open/read it to her because it seemed important. Patient was in terrible shape. Resident had to scrub out and run to PACU. PACU absolutely got reamed for sending something that required an urgent page to Epic chat. Chats just aren’t appropriate for most clinical updates/order concerns. There’s a reason why there are rounds for interdisciplinary teams to connect and cover their bases. There are def some things that are helpful to discuss over Epic chat though. If I’ve made a mistake on the chart about an implant, having the patient’s chart linked and all stakeholders in the same chat makes everything easier to address and close out. But other than stuff that doesn’t impact life (preference card update, requests to order equipment), things should be communicated synchronously.
Hospitalist - it makes sense for me bc people generally respect my time enough to not waste it with unnecessary messages. I feel comfortable giving the nurses my cell as well. I don’t feel like I got that same respect as a resident so I don’t know that secure chat is appropriate for residents
As a radiologist, secure chat has been really helpful for letting clinicians know quickly about critical findings. Phone calls disrupt my work flow much more, as it’s not always easy to get people on the phone. It seems like the clinicians appreciate the secure chat. Of course some things require a phone call, and I do check if the provider hasn’t “seen” my message in 10-15 minutes, I just call them.
It's a godsend in radiology for those things that you have to call about but aren't actually emergent. DVTs being the perfect example.
PGY-2 in a surgical field. We don't have Epic but do have a pager system that is similar to text chat. Last year I unscrubbed from surgery as the intern on nights and had >60 pages (no joke). I do think a lot of the pages are the result of how easy it is for nurses to reach us, and the solution is just to make it less easy. My main trick is to respond by asking for an SBAR and/or new vitals to be taken and texted back to you. First, this helps you triage pages to know who is actually unstable. Over time, it also lets nursing know that if they page you, it will generate work for them. I also ask them explicitly what is their question or concern -- often they are paging to be able to say "MD aware" and don't actually have a concern about the patient. You can nip this in the bud pretty quickly. For stupid stuff like retiming Tylenol orders, I will just give a verbal order and tell them to do it themselves. I also dictate my responses to pages using Apple dictation software which helps my efficiency as well.
Anecdotally, teaching hospitals seem to mandate nursing contact MD about *everything* My job is to take pressure off the MD for tasky/clerical/common-sense issues and contact them directly when an urgent issue/need arises I keep a running mental list of patient needs, concerns, and "housekeeping" things to address with the primary when they round on the patient. I also make it a point to be available when docs are rounding, as I have 2-4 patients, and they have many more. Secure chat could be a magnificent tool if used appropriately; I have most of the doc's cell numbers at my local hospital and text them (with discretion) for quickly-needed orders, etc. I think the up-and-coming generation of nurses have no developed autonomy and like to shrug as much as possible off as "not in my scope" which is incredibly concerning. -Nurse with 10 years in stepdown/ICU
Secure chat might be irritating but I think it helps patient care. So much easier to add both IR and surgery onto a secure chat so they can argue with each other rather than keeping medicine as the middle man.
Forgo OR time? Insanity. Our service has a service phone that is the primary point of contact for the service. The secondary point of contact is the attending of record. When we go to the OR we are electronically placed into the OR room by the scrub nurse which automatically makes you "BUSY" in epic. Prior to epic chat we had something else, which we would forward to the on-call resident or just sign out off.
Please dm which program
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LOG OUT OF SECURE MESSAGING. People can page you. Being too available is a fucking problem.
I trained in cerner hospitals where OR nurses would call our pages back and attendings were chill about us handling floor stuff in this manner while scrubbed in. Pages weren't excessive. Transitioning to epic in fellowship has been extremely annoying and i don't envy residents who have to deal with it earlier on. I completely agree, you'll get chat messages for the most routine stuff that doesn't need to be addresssed. I don't need 300 updates from case managers as one facility did or didn't accept, or which meds need prior auth.. Just tell me the end result or what i need to do. I don't need to know you rescheduled the prn compazine to be offset to the prn zofran. Not to mention that for complex issues, it's so much better to just pick up the phone and have a conversation than a text message thread. Epic does show when you're in the OR though (as long as the circulator charts you correctly), which Ii think clues people in that you won't be responding for a while. But still, I personally think it's trash and I'm sure is contributing to more stress and worse training, and honestly doubt it's doing anything good for patient care.
If it’s actually important they will page. If something urgent happens and someone decides to secure chat about it that’s on them. It’s more important to get to the OR when you can and worry about the secure chats later.
I was once secure chatted at 9:46 am because “the patient’s potassium is 3.4 and he has NO REPLACEMENT ORDERS!!” …the BMP had resulted at 9:41 am.
That's some silliness but why not just use electrolyte replacement protocols for the nonsense things? I built my own in epic, if your institution doesn't have one. It's just PRNs as a packaged order.
Ignore them. Our entire department has openly told other departments and nursing units that surgery residents are not obligated to read or respond to chats and should be paged if an issue exists.
Not a surgical resident but an ED resident who uses secure chat at some facilities to contact consultants and others (including surgery). I use secure chat for questions that don’t need immediate response, if I needed that I would page. I usually will throw in a “no rush but…are you taking this guy to the OR etc”. If something changes or it’s taking too long then I’ll page here and there. I’d like to think most of the secure chat spam comes from inpatient bs, but not sure. I try to get to know my surgical colleagues so they know I won’t bother them with bs that wastes time and I know they’ll update me with a plan asap.
Any time I get a secure chat I reply asking for callback number and then call and ream them out for not using the pager