Barriers to escalation of care

Written by Tracey McLean on . Posted in Uncategorized

KEY POINT

Barriers to patient advocacy

There are many barriers people face when responding to deterioration and making a decision to escalate a patient's care. It is important to know your barriers and challenge them, as not doing so may place patient safety at risk.

EXAMPLE CHART

Patient scenario

While the doctor (registrar) was reviewing patient x, the patient complained that she felt like her heart was racing.  On palpating the patient's pulse the doctor noticed a fast, irregular pulse of 160. He asked the nurses to assist him with performing a full set of vital signs and commencing treatment.

Click the image below to view the vital signs and the score according to a scoring response chart.

HOTSPOT

"What am I thinking and what did I voice?"

Click on each hotspot below to find out what each person is thinking and voiced after the full set of vital signs has been performed and treatment has commenced.

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Possible barriers

Non-technical skill barriers

  • Ineffective non-technical skills, such as teamwork, leadership, communication and situational awareness1
  • Ineffective graded assertiveness2
  • Poor prioritisation by the medical team involved2

Further reading:

Further information about non-technical skills is available on the Crisis Resource Management (CRM) page of the Life in the Fastlane website.

Further information about Graded Assertiveness is available on the EmergencyPedia website.

Cognitive barriers

  • Factors impacting on clinical judgement (tired, distracted, stressed)1
  • Inability to recognise deteriorating conditions2,3
  • Unaware of escalation process2,3
  • Perception that sufficient action has been taken to treat patient 2,3
  • Negative emotions such as feelings of anxiety, fear, panic, looking stupid, being reprimanded or being ridiculed 1
  • Perceived limited benefit in escalating1,2,3
  • Failure to repeat abnormal observations1,2,3

Barriers around accessing support

  • Unsupported or negative reaction from colleagues
  • Critical Care team already involved in care
  • Intraprofessional hierarchies
  • Not clear who to contact / who's responsible
  • Bedside clinical team had enough experience to manage situation1,2,3
References

1. Massey, D., Chaboyer, W. and Anderson, V. (2017), What factors influence ward nurses’ recognition of and response to patient deterioration? An integrative review of the literature. Nurs Open, 4: 6–23. doi:10.1002/nop2.53. Available from: http://onlinelibrary.wiley.com/doi/10.1002/nop2.53/full

2.Roberts KE1, Bonafide CP, Paine CW, Paciotti B, Tibbetts KM, Keren R, Barg FK, Holmes JH. Barriers to calling for urgent assistance despite a comprehensive pediatric rapid response system. Am J Crit Care. 2014 May;23(3):223-9. Available from: http://ajcc.aacnjournals.org/content/23/3/223.long

3. Shearer B, Marshall S, Buist MD, et al What stops hospital clinical staff from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response system in a multi-campus Australian metropolitan healthcare service BMJ Qual Saf 2012;21:569-575. Available from: http://qualitysafety.bmj.com/content/21/7/569.long