Table 3 Key themes of facilitators of escalation amongst healthcare professionals
Key Themes (Finding) | Sub-themes and references | Characteristics of studies from which sub-themes were derived: Type of participant and setting (Reference) | Illustrative quotations (Italicised text = primary quote from a study participant; non-italicised text = secondary quote from study authors) |
|---|---|---|---|
Governance | Senior resident surgeons, surgical postgraduates year 1, intensivists, and critical care outreach team members from 3 UK hospitals [19]; Year 1 interns, Senior NCHDs and nurses in 1 Irish hospital [30]; HCAs, nurses, physicians, critical care staff and managers in 2 UK hospitals [20, 21] | “If you don’t follow the NEWS and something goes wrong then the blame rests on you and you’ve got nothing to back you up…wheras, once you call you’re protected” [30] | |
Standardisation | Nurses in 1 US hospital [25]; Mainly doctors and nurses in 8 Australian hospitals [16]; Nurses in 1 UK hospital [22]; Year 1 interns, Senior NCHDs and nurses in 1 Irish hospital [30]; HCAs, nurses, physicians, critical care staff and managers in 2 UK hospitals [20, 21] | “I will continue to use it as I’m currently using it unless the protocol changes as it’s a requirement of my job and part of the hospital’s policy (Nurse 8)” [30]. Both the escalation protocol and the CCOT at Westward promoted uniformity and standardisation with regards to response to the acutely ill patient [20]. “As soon as we get a high score we’re supposed to go straight to the staff nurse and inform them that this patient’s observations have been outside normal. And then the staff nurse will inform the doctor and say, ‘this patient’s blood pressure is below normal, is x, y, z, so if you could come and review this patient.” [21] | |
Resources | Nurses in 1 US hospital; (25) Nurses and doctors in 1 UK hospital [23]; HCPs from 3 UK hospitals [19]; HCPs from 1 Irish hospital [30]; HCPs from 2 UK hospitals [20]; Nurses from 1 UK hospital [22]; Nurses from 1 US hospital [27]. | “There is now a single resident who covers the ward for the week and twice daily attending ward rounds. I think this has made things better for juniors because they have a single point of contact who is not going to be off site or in theatre” (Surgeon) [19] The team used SBAR, the communication technique approved by the facility…. Standardised language helped participants provide information quickly and accurately [25]. | |
RRT Response | RRT Behaviours - Professionalism/Positive responses [9, 19, 25, 29, 31] | Nurses in 1 US hospital [25]; HCPs in 3 UK hospitals [19]; Nurses in 1 Norwegian hospital [31]; Nurses and doctors in 1 UK hospital [23]; Nurses in 1 US hospital [28]; HCPs in 1 US hospital [26]; Doctors and nurses in 4 Australian hospitals [17]; HCPs in 2 UK hospitals [20] Nurses in 1 Norwegian hospital [31]; Nurses and doctors in 1 UK hospital [23]; Nurses in 1 US hospital [28] | The approachable style and non-critical attitude of the MICN and their prompt responses in giving advice over the phone or reviewing the situation in person were recurrent comments throughout the interviews [31]. “ICU nurses’ expertise is reassuring. They evaluate the situation. They figure out what is going on and decide what to do” [25]. “The MICN did not ‘take over’ the situation, he only confirmed and asked for collaboration by using skills in communication and support and gave us treatment suggestions. We learned and listened; hopefully I can use this knowledge in other situations too” [31]. |
Nurses and doctors in 1 UK hospital [23]; Nurses in 1 US hospital [25]; HCPs in 1 US hospital [26] | Nurses had a sense of security and of empowerment generated by knowing skilled backup was available immediately through a single phone call [26]. | ||
Nurses and doctors in 1 UK hospital [23]; Doctors and nurses in 4 Australian hospitals [17]; Nurses in 1 Norwegian hospital [31]; HCPs in 2 UK hospitals [20]; Nurses in 1 US hospital [25]; HCPs in 1 US hospital [26]; Nurses in 1 US hospital [28] | ‘.. .an extra pair of eyes and ears for patients who are at risk of deteriorating or are in the process of deteriorating; and really able to bring critical care experience to a ward environment, to support the nurses and doctors on the ward to care for deteriorating patients on the ward. It’s a very supportive role, bringing that extra degree of knowledge and skills that we may not have on the ward to care for the patient.’ (R7, Nurse) [23] | ||
Professional Boundaries | Licence to escalate (Autonomy) [16,17,18,19,20, 23, 26, 29, 30] | Nurses and doctors in 1 UK hospital [23]; Mainly doctors and nurses in 8 Australian hospitals [16]; Doctors and nurses in 4 Australian hospitals [17]; Nurses in 1 Australian hospital [18]; Year 1 interns, Senior NCHDs and nurses in 1 Irish hospital [30]; HCPs in 3 UK hospitals [19]; HCPs in 2 UK hospitals [20]; HCPs in 1 US hospital [26] | Across both sites the score provided staff with the licence to escalate care across hierarchical and occupational boundaries [20]. “The nurses actually have something they can do about it versus just kind of watching the patient flounder (hospitalist)” [26] |
Bridge Across Boundaries (Facilitates cross-profession communication and teamwork, workaround) [17, 19, 20, 26] | Doctors and nurses in 4 Australian hospitals [17]; HCPs in 3 UK hospitals [19]; HCPs in 2 UK hospitals [20]; HCPs in 1 US hospital [26] | “We used to actually use them as a way of getting round a resident or whoever really wasn’t doing what you know you needed for your patient (Junior nursing, site 2)” [17] The EWS helped with escalation of care across boundaries: “The score is useful….if you’re handing over the phone in the middle of the night to someone you’ve never met before….they don’t know your judgement and your experience, so it’s kind of a physical....this is quite clear” (Nurse, 5, Westward) [20] | |
Clinical Experience | Clinical Confidence [16, 22, 25, 27, 29] -To recognise deterioration -Confidence in own ability and skills | Nurses in 1 US hospital [25]; Nurses and doctors in 8 Australian hospitals [16]; Nurses in 1 UK hospital [22]; Nurses in 1 US hospital [27] | “I’d like to think that it hasn’t made any difference to me being able to detect my patient deteriorating (FG I1)” and “I went to nursing school for three years - I know when it is time to ring the doctor” (FG A4) [16] “I never hesitate to call an RRT because I’m afraid I’ll be criticized or made to feel like I couldn’t handle a situation.” [27] |
Mainly doctors and nurses in 8 Australian hospitals [16]; Doctors and nurses in 4 Australian hospitals [17]; Year 1 interns, Senior NCHDs and nurses in 1 Irish hospital [30]; HCPs in 3 UK hospitals [19]; HCPs in 2 UK hospitals [20]; Nurses in 1 UK hospital [22]; HCPs in 1 US hospital [26]; Nurses in 1 US hospital [28] | Availability of the RRT empowered nurses who were able to obtain additional help without having to request permission. “I don’t usually hesitate to call. I notify the team of any changes, and if I feel like I need additional nursing support or if I need respiratory support right that minute, I will call an RRT” [26]. | ||
Mainly doctors and nurses in 8 Australian hospitals [16]; Doctors and nurses in 4 Australian hospitals [17]; Year 1 interns, Senior NCHDs and nurses in 1 Irish hospital [30]; HCPs in 3 UK hospitals [19]; Nurses in 1 US hospital [25] Nurses in 1 Australian hospital [18]; Nurses and doctors in 1 UK hospital [9] | Participants referred to the importance of using clinical judgement in tandem with the RRT criteria to guide their assessment and decision-making processes when deliberating whether or not to activate the RRT [17]. “She just had this sweaty clammy look and just going from previous experience again, it was like there is something really not right here.” (R1, Nurse) [23] | ||
EWS Parameters | Triage mechanism/Tool for detecting deterioration [9, 18, 20, 22, 25,26,27, 30] | Nurses in 1 US hospital [27]; Nurses in 1 Australian hospital [18]; Year 1 interns, Senior NCHDs and nurses in 1 Irish hospital [30]; HCPs in 2 UK hospitals [20]; Nurses in 1 UK hospital [22]; HCPs in 1 US hospital [26]; Nurses in 1 US hospital [25] | Doctors described using the system to gauge the severity of a patient’s condition for triaging: “When I’m contacted to review a patient, I use ‘NEWS’ to prioritise the urgency in which they need to be reviewed (NCHD 2)” [30] All staff valued the training they had received and reported that the T&T helped identify patient deterioration earlier: “We now use it on every single patient that we have on the ward and obviously they all get a score at the end of it, so I think it just rings more alarm bells if you like if a patient is unwell or is deteriorating, whereas just recording a patient’s observations, you know, you might miss something [15] It does highlight patients that are actually deteriorating quicker than you would” [22]. |