Why do healthcare professionals fail to escalate as per the Early Warning System (EWS) protocol? A qualitative evidence synthesis of the barriers and facilitators of escalation

Abstract

Background: Early warning systems (EWSs) are used to assist clinical judgment in the detection of acute deterioration to avoid or reduce adverse events including unanticipated cardiopulmonary arrest, admission to the intensive care unit and death. Sometimes healthcare professionals (HCPs) do not trigger the alarm and escalate for help according to the EWS protocol and it is unclear why this is the case. The aim of this qualitative evidence synthesis was to answer the question ‘why do HCPs fail to escalate care according to EWS protocols?’ The findings will inform the update of the National Clinical Effectiveness Committee (NCEC) National Clinical Guideline No. 1 Irish National Early Warning System (INEWS). Methods: A systematic search of the published and grey literature was conducted (until February 2018). Data extraction and quality appraisal were conducted by two reviewers independently using standardised data extraction forms and quality appraisal tools. A thematic synthesis was conducted by two reviewers of the qualitative studies included and categorized into the barriers and facilitators of escalation. GRADE CERQual was used to assess the certainty of the evidence.Results: Eighteen studies incorporating a variety of HCPs across seven countries were included. The barriers and facilitators to the escalation of care according to EWS protocols were developed into five overarching themes: Governance, Rapid Response Team (RRT) Response, Professional Boundaries, Clinical Experience, and EWS parameters. Barriers to escalation included: Lack of Standardisation, Resources, Lack of accountability, RRT behaviours, Fear, Hierarchy, Increased Conflict, Over confidence, Lack of confidence, and Patient variability. Facilitators included: Accountability, Standardisation, Resources, RRT behaviours, Expertise, Additional support, License to escalate, Bridge across boundaries, Clinical confidence, Empowerement, Clinical judgment, and a tool for detecting deterioration. These are all individual yet inter-related barriers and facilitators to escalation. Conclusions: The findings of this qualitative evidence synthesis provide insight into the real world experience of HCPs when using EWSs. This in turn has the potential to inform policy-makers and HCPs as well as hospital management about emergency response system-related issues in practice and the changes needed to address barriers and facilitators and improve patient safety and quality of care.

Factors that influence hospital nurses’ escalation of patient care in response to their early warning score: A qualitative evidence synthesis

“…The theme of marrying nurses' clinical judgement with the use of the EWS is supported and reflected in the findings of previous QESs, which also recognised the role clinical judgement played in facilitating escalation of care by healthcare staff (Connolly et al, 2017;O'Neill et al, 2021). Nurse's value their own clinical judgement, experience, intuition, physical assessment findings and decision-making skills when recognising the deteriorating patient.…”

“…Communication processes were hindered by the reluctance of doctors to modify and document EWS parameters. Previous QESs similarly described doctors' aversion to EWS modifications as a barrier to EWS protocol (Connolly et al, 2017;O'Neill et al, 2021). While it is seen principally as the doctor's role to modify parameters some studies appear to suggest a possible role for nurses.…”

“…Credland et al (2018) found nurses experienced some frustration with EWS use and its perceived inflexibility with a resultant lack of compliance reflected in issues around inaccurate scoring, chart omissions, incorrectly calculated EWS and non-adherence with monitoring frequency and escalation protocols. Significantly, previous QES did not examine nurses exclusively in the context of their decision making and EWS use, rather they had broader sample inclusion criteria, thus enabling the addition of studies which recruited health care workers (HCW) as part of the study population (Connolly et al, 2017;O'Neill et al, 2021). Moreover, the scoping exercise identified several additional relevant qualitative studies which had not been included in previous reviews (Dalton et al, 2018;Ede et al, 2020;Flenady et al, 2020;Foley & Dowling, 2019;Jensen et al, 2019).…”

“…Quality appraisal of the eighteen studies using the CASP tool was carried out simultaneously with data extraction (Noyes and Lewin 2011). The WHO and Cochrane endorse CASP for novice researchers when undertaking a QES (Long et al, 2020).…”

“…An adapted version of Houghton et al's, (2016) data extraction form (permission given) was used as a blueprint to specify and exhibit each of the studies in terms of context (setting, participants and intervention) as well as study design, methodology, findings and quality of the study (Noyes & Lewin, 2011). This format assisted with both the interpretation and subsequent codifying of the data.…”