Barriers and facilitators to implementing a process to enable parent escalation of care for the deteriorating child in hospital

Abstract

ObjectiveTo identify barriers and facilitators to implementing a parent escalation of care process: Calling for Help (C4H).DesignAudits, semi‐structured interviews and focus groups guided by the Theoretical Domains Framework.SettingAustralian paediatric hospital where a parent escalation of care process was introduced in the previous 6 months.ParticipantsFour children, 13 parents, 91 nurses and doctors including Medical Emergency Team (MET) members.Main outcome measuresParent awareness and involvement in escalating care and factors impacting implementation of C4H.ResultsTwo audits identified low level of parent awareness (16/88, 19% and 5/85, 6%). Parent involvement in escalation of care was documented in 11/62 (18%) events. The main facilitators included uniformly positive views that C4H was in the child's best interest, acknowledgement that parents had skills to recognize deterioration and would take action. C4H was considered to add to patient safety and being reviewed by the MET was a patient benefit. Key barriers were the low level of awareness, doubt about parent capabilities, concern about parents’ information overload, anticipated overuse of resources, staff unease about possible repercussions and anticipated difficulty for parents to question staff with potential negative effects on parent‐staff relationships. Overall C4H presents a challenge to traditional hospital hierarchy and culture.ConclusionsAlthough there was a low level of awareness about C4H in practice, there was in‐principle support for the concept. Initial strategies had primarily targeted policy change without taking into account the need for practice and organizational behaviour changes. Using a theoretical approach to identify key factors will enable a targeted approach to implementation.

Parent escalation of care for the deteriorating child in hospital: A health‐care improvement study

“…The mixed‐methods evaluation consisted of audit, patient health record review, interviews and focus groups. The audit found 35% of parents were aware of C4H, an increase from the pre‐implementation period when two audits showed 19% and 6% awareness . This result represented the success achieved within the first 6 months.…”

“…The audit found 35% of parents were aware of C4H, an increase from the pre-implementation period when two audits showed 19% and 6% awareness. 14…”

“…and (b) Which barriers and facilitators needed to be addressed? The work revealed a low level of parent awareness of the C4H process and human behavioural and system‐based barriers and facilitators . Reported in the current article are parts (c) Which intervention components could overcome the modifiable barriers and enhance the facilitators?…”

“…The involvement of families in safety, especially in escalating care for clinical deterioration, is recognized as complex and difficult to achieve in practice . The ‘complexity’ itself relates to the several interacting components within the intervention and also the interaction of the intervention with the health‐care context .…”

“…13 The involvement of families in safety, especially in escalating care for clinical deterioration, is recognized as complex and difficult to achieve in practice. 14,15 The 'complexity' itself relates to the several interacting components within the intervention and also the interaction of the intervention with the health-care context. 16 Health-care improvement is a term used to describe a systematic approach to increase the quality, safety and value of health-care services.…”