Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study.
BACKGROUND
The escalation of care process has not been explored in surgery, despite the role of communication failures in adverse events. This study aimed to develop a conceptual framework of the influences on escalation of care in surgery allowing solutions to facilitate management of sick patients to be developed.


METHODS
A multicenter qualitative study was conducted in three hospitals in London, UK. A total of 41 participants were recruited, including 16 surgeons, 11 surgical PGY1s, six surgical nurses, four intensivists, and four critical care outreach team members. Participants were submitted to semistructured interviews that were analyzed using grounded theory methodology.


RESULTS
A decision to escalate was based upon five key themes: patient, individual, team, environmental, and organizational factors. Most participants felt that supervision and escalation of care were problematic in their hospital, with unclear escalation protocols and poor availability of senior surgical staff the most common concerns. Mobile phones and direct conversation were identified to be more effective when escalating care than hospital pager systems. Transparent escalation protocols, increased senior clinician supervision, and communication skills training were highlighted as strategies to improve escalation of care.


CONCLUSIONS
This is the first study to describe escalation of care in surgery, a key process for protecting the safety of deteriorating surgical patients. Factors affecting the decision to escalate are complex, involving clinical and professional aspects of care. An understanding of this process could pave the way for interventions to facilitate escalation in order to improve patient outcome.
Centre for Patient Safety & Service Quality, Department of Surgery & Cancer, Imperial College London, London, UK. Electronic address: m.johnston@imperial.ac.uk.
Maximilian
M
Johnston
Centre for Patient Safety & Service Quality, Department of Surgery & Cancer, Imperial College London, London, UK.
Sonal
S
Arora
Centre for Health Policy, Department of Surgery & Cancer, Imperial College London, London, UK.
Dominic
D
King
North West London Hospitals NHS Trust, Imperial College London, London, UK.
Luke
L
Stroman
Department of Surgery & Cancer, Imperial College London, London, UK.
Ara
A
Darzi
D001291:Attitude of Health Personnel; D003142:Communication; D003657:Decision Making; D006801:Humans; D007400:Interprofessional Relations; D007407:Interviews as Topic; D008131:London; D010348:Patient Care Team / Q000458:organization & administration*; D061214:Patient Safety; D011182:Postoperative Care / Q000379:methods* / Q000592:standards; D011183:Postoperative Complications / Q000628:therapy*; D017211:Treatment Failure