To the Editor:—
I wish to report several failures of paging shortcuts to facilitate arrival of operating room personnel in the event of unscheduled operating room emergencies. In each case, the paging shortcuts were intended to save the time required to call back and receive verbal information regarding the location and nature of the emergency. In two cases at two separate hospitals, a 4-digit code was used instead of a call-back number to indicate that the anesthesiology staff and/or residents should report immediately to the operating room. Because not all anesthesiology personnel were aware of the adoption of the paging shortcuts, attempts were made to call the number as if it were a standard 4-digit telephone extension. When the number was discovered to be unassigned, the hospital operator was queried, who was also unaware of the significance of the 4-digit number. In a third case, the operating room personnel paged the anesthesiologists using the 4-digit call-back extension followed by the digits 911 to indicate an emergency. Although this is a widely understood shortcut in the United States, unintended processing by the digital pager resulted in confusion. The pages were received by a Motorola Advisor Elite pager (Motorola, Inc. Boynton Beach, Florida). When a 7-digit numerical message is entered by touchtone telephone and received by this pager, a hyphen is automatically entered between the third and fourth digits to facilitate reading of a standard 7-digit US telephone number. This made the 4-digit call-back extension and the 911 “emergency code” appear to be a standard 7-digit telephone number originating outside the hospital. The identity of the 4-digit extension was further obscured by the location of the hyphen between the digits of the intended call-back number. In contrast, manually inserting a hyphen via telephone with the asterisk key would properly place the hyphen between the fourth and fifth digits, eliminating the confusion. The anesthesiology personnel attempted to call the number as if it were a standard “outside line” and arrived only after a second page directly to the operating room telephone number. Although this pager can also receive alphanumeric messages sent through the Internet, these Internet-based pages may have significant delays compared with telephone pages and are therefore rarely used in emergencies.
In each case, circumventing the normal emergency response procedure of paging to a call-back telephone number by substituting or adding informally adopted paging shortcuts resulted in failure of the intended result, which was to provide a more rapid response. One should not assume that all personnel will understand locally adopted paging shortcuts when used in emergency notification procedures unless the intended recipients are properly informed. In addition, when using one-way communication, as when using paging shortcuts, verification of information transfer does not occur as it does when a call-back number is used. Anesthesiologists may have responsibilities in several areas of a hospital. Paging shortcuts adopted by one nursing unit may not be consistent with similar shortcuts informally adopted by other units and may become a source of confusion. In addition to performing regular tests of the paging system, it may be beneficial to involve hospital-wide telecommunications personnel in paging shortcuts created by individual nursing units or adopted otherwise on an informal basis. Standardization of emergency response protocols within a hospital may reduce miscommunications.