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

Abstract

Objective To evaluate the implementation of an intervention for parents to escalate care if concerned about their child's clinical condition. Design Mixed‐methods health‐care improvement approach guided by the Theoretical Domains Framework. Methods Implementation of the ‘Calling for Help’ (C4H) intervention was informed by previously identified barriers and facilitators. Evaluation involved audit, review of clinical deterioration incidents, interviews and focus groups. Setting Australian specialist paediatric hospital. Participants Convenience sample of 75 parents from inpatient areas during the audit, interviews with ten parents who had expressed concern about their child's clinical condition; five focus groups with 35 ward nurses. Main outcome measures Parent awareness and utilization of C4H, parent and nurse views of factors influencing implementation. Results Parent awareness of C4H improved to 35% (25/75). Parent concern was documented prior to 21/174 (12%) clinical deterioration events. All interviewed parents and nurses who participated in focus groups were positive about C4H. Parents preferred to be informed about C4H by nurses, but nurses described this as time‐consuming and selectively chose parents who they believed would benefit most. Parents and nurses described frustrations with and trepidation in escalating care. Nurses had used C4H to expedite urgent medical review. Conclusions There was an improvement in the level of parent awareness of C4H, which was viewed positively by parents and nurses alike. To achieve a high level of parent awareness in a sustainable way, a multifaceted approach is required. Further strategies will be required for parents to feel confident enough to use C4H and to address interprofessional communication barriers.

Acute clinical deterioration and consumer escalation: The understanding and perceptions of hospital staff

“…The value of this unique insight was acknowledged, as an additional source of information to assist staff in assessing for, and identifying, deteriorating patients. This finding is consistent with those from paediatric hospitals, where clinicians supported parents’ distinctive knowledge of their child’s baseline health [ 21 ] and capability to detect early and subtle changes of clinical deterioration [ 24 , 25 ].…”

“…However, based on the current data, it is only possible to hypothesise as to what the barriers may be. Apprehensions, differing or negative perceptions, and limitations in the understanding and awareness of some staff in association with consumer escalation are potential examples that correspond with the outcomes of other studies [ 21 , 23 – 25 ]. Such considerations also link with the wider literature, which has identified that aspects such as staff commitment, understanding, role identity, and confidence all have the potential to impact upon the implementation of hospital-based interventions [ 36 ].…”

“…A finding of potentially greater significance was that, across both survey periods, there appeared to be a “limit” to this confidence, with clinician support for responding to consumer concerns decreasing as the degree of escalation, and thus clinical concern, increased. Other research has identified that staff do not consider the early stages of responding to consumer concerns as differing significantly from their normal practice [ 25 ]. This may provide some explanation for our observations.…”

“…This study was also limited to a single paediatric hospital [ 21 ]. A further two studies included clinicians, as well as patients and family members, in interviews and focus groups to examine general barriers and facilitators to the implementation of consumer escalation processes, again, within a paediatric setting [ 24 , 25 ]. The remaining papers that have broached this topic have either been small [ 17 ], a feasibility study [ 28 ], used retrospective data [ 23 ], provided only brief commentary [ 20 , 22 ], or related to a study protocol [ 34 ].…”

The Parent Role in Advocating for a Deteriorating Child: A Qualitative Study

“…15,16 How families best engage with clinicians to escalate concerns remains a challenge even after dedicated improvement interventions. [17][18][19] Without an understanding of why, when, and how families of children with neurologic impairment voice concerns, family expertise may remain underleveraged, resulting in poor communication, poor situation awareness, and preventable harm. Our objectives were to develop a comprehensive understanding of how families identify their child' s evolving state of health and communicate changes with the inpatient team.…”