A qualitative exploration of escalation of care in the acute ward setting

Abstract

Background: "Failure to Rescue" includes failing to prevent avoidable patient deterioration and death. Despite its use, delays in care escalation still affect patient outcomes.Aims and Objective: The aim of this qualitative service evaluation was to map the barriers and facilitators to the escalation of care in the acute ward setting and identify those that are modifiable.Design: A total of 55 hours of qualitative observations were completed to capture care escalation events. These were conducted at two hospital sites in one National Health Service trust.Methods: Observations were iterative, with research team meetings being used to discuss the data and future methods. Field notes were analysed thematically by two researchers, extracting data on barriers and facilitators to escalation of care. Results: Clinical nursing staff challenged the sensitivity and specificity of Early Warning Scores, describing tool failings in certain clinical scenarios. Staff did not escalate based on the alerting Early Warning Scores alone but used other clinical factors, such as bleeding, which are not necessarily captured in the scoring systems. Staff frequently did not re-escalate low-level scores. Patient and non-patient factors identified as posing barriers to escalation were complex care needs, patient outlier status, and involvement of multiple care teams. Factors negatively affecting the chain of communication during escalation were team tension, staffing levels, and inadequate handover. Conclusion: This service evaluation identified barriers and facilitators to the escalation of care in the acute ward setting. Unlike other studies, we found that re-escalation or tracking of deterioration was problematic. Patients identified as being at a higher risk of escalation failure included complex patients, outliers, and patients with multiple care teams. Relevance to clinical practice: This service evaluation demonstrates continuing health care communication barriers. Patient groups (complex patients and outliers) risk process failures during escalation. This can be applied in clinical practice by staff anticipating problems in these patients, documenting clear escalation pathways. K E Y W O R D S acute ward, deterioration, escalation of care, observations, qualitative

Patterns of behaviour in nursing staff actioning the afferent limb of the rapid response system (RRS): A focused ethnography

“…Most routine monitoring of vital signs involved the use of electronic monitoring equipment and was typically performed by HCAs. These findings are consistent with other literature (Ede, Jeffs, Vollam, & Watkinson, 2019; Mackintosh et al., 2014; Smith & Aitken, 2016) implying this may be common practice. There were exceptions where RNs were seen undertaking routine monitoring, this typically occurred in the context of short staffing or when a HCA was re‐deployed to a “heavier” part of the ward.…”

“…The assumption that HCAs will undertake what Ede et al. (2019) describe as “bulk monitoring” (p4) presents several potential challenges. First, it establishes a disconnect within the afferent limb between the actor responsible for collecting the clinical data, that is, measuring the vital signs and the actor expected to evaluate the information and act (Mackintosh et al., 2014).…”

Barriers and enablers of recognition and response to deteriorating patients in the acute hospital setting: A theory‐driven interview study using the Theoretical Domains Framework

“…barriers and enablers) of nursing staff enacting best practice behaviours of the afferent limb have been broadly described in a number of published review papers (Massey et al, 2017; Olsen et al, 2019; Treacy & Stayt, 2019; Wood et al, 2019). Despite acknowledgement that ALF is a problem characterised by inconsistent staff behaviour (Credland et al, 2018; Ede et al, 2019), no reports of studies were found where behaviour change theory had been applied to explore determinants. Furthermore, from the modest body of literature reporting interventions to address ALF (Bucknall et al, 2017; Connell et al, 2016; Duff et al, 2018; Liaw et al, 2016), no explicit reports of theory being applied during intervention development were identified.…”

Human factors in escalating acute ward care: a qualitative evidence synthesis

“…Human factors (HF) identified to positively or negatively affect care escalation include situational awareness, team working, communication, safety culture, workload, clinical experience, negative emotions and leadership. 6 9 13–15 However, research has historically focused on outcomes. 8 The aims of this qualitative evidence synthesis (QES) are to identify (1) how HF affect ward care escalation (2) gaps in the current literature and (3) critique literature methodologies.…”