Can you hear me? Analysis of a Queensland patient‐initiated escalation process and the importance of communication in surgical care

Abstract

Background: Ryan's Rule is a three-step escalation process established by Queensland Health whereby patients, their families and carers can escalate concerns if a patient's health is worsening or not improving as expected. This study analysed the incidence, causes and outcomes of Ryan's Rule cases involving patients admitted under various surgical specialties across Queensland. Methods: A retrospective analysis was undertaken of cases wherein Ryan's Rule was invoked by surgical patients between 2016 and 2021. The analysis focused on rationale for invoking Ryan's Rule, clinical actions undertaken, outcomes and patient feedback. Results: The study analysed 364 activations of Ryan's Rule among surgical patients admitted across ten Queensland Health hospitals. The common causes for invoking Ryan's Rule were concern or disagreement regarding the management plan (39%), poor understanding of the care plan (32%) and feeling that concerns were not being heard (35%). Less than 1 % of cases (0.8%) met early warning criteria for deterioration, and only 0.5% required admission to ICU. The majority of Ryan's Rule cases (92%) were resolved through discussion between the treating surgical team, the patient and their representatives. In 74% of cases, the management plan did not change following the Ryan's Rule review. Conclusion: Communication is the overwhelming theme throughout the Ryan's Rule cases invoked by surgical patients. The majority of Ryan's Rules cases were initiated by issues in communication and understanding between clinicians and patients. The vast majority of cases were resolved by surgical teams establishing and maintaining clear communication with patients, their families and carers.

Martha’s rule presents a unique opportunity for improving patient care

“…Most family activated systems include an evaluation process that asks whether the family was satisfied with the response but, crucially, does not ask about patients’ experiences leading up to the call or why the call was placed. Given that most calls are said to be about breakdowns in communication, it is important to learn what that miscommunication looks like to patients 14…”

“…One hesitation that many providers have about patient activated calls is a phenomenon that has been documented in almost every system: most calls, while concerning serious health matters, do not involve active deterioration. Analyses of Ryan’s rule cases suggest that responders downplay the significance of family calls because few of the patients meet the objective criteria for deterioration 1314. Families may call much earlier in the trajectory of an illness, using subjective criteria based on their knowledge of the patient, and they may call for other reasons, such as uncontrolled pain.…”

Dialogue and understanding equals effective communication

“…Communication is the overwhelming theme in the article by Flynn et al 1 The article critiques a sample of communication in surgical wards with surgical patients over 5 years. The authors provide thoughtful contemporary analysis of the issues from the perspective of patients, families and carers.…”

“…Communication is the overwhelming theme in the article by Flynn et al 1 . The article critiques a sample of communication in surgical wards with surgical patients over 5 years.…”

“…Flynn et al . propose that this may reduce communication problems and enhance patient care, even becoming a positive experience 1 . Should those standards become better known and propagated through health care facilities and staff including surgeons?…”