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Improving escalation of deteriorating patients through cognitive task analysis: Understanding differences between

J Ede1, R Hutton2, P Watkinson3

  • 1Oxford University Hospital NHS Foundation Trust, Oxford, United Kingdom; School of Nursing and Midwifery, University of Plymouth, Plymouth, United Kingdom.

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Identifying patient deterioration requires effective care escalation. This study found that 28% of clinical tasks involved in escalation are cognitively challenging, highlighting key areas for improving patient safety and reducing deaths.

Keywords:
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Area of Science:

  • Healthcare delivery
  • Patient safety
  • Clinical workflow optimization

Background:

  • Effective care escalation is crucial for detecting and communicating in-hospital patient deterioration.
  • Despite existing protocols, patient deaths still occur due to failures in escalating care.
  • Understanding real-world healthcare professional practices (work-as-done) is key to addressing escalation challenges.

Purpose of the Study:

  • To develop a model of care escalation processes.
  • To identify performance variability impacting escalation.
  • To examine interdependencies within the escalation process.

Main Methods:

  • Applied Cognitive Task Analysis interviews with 30 clinical experts from various roles (nurses, physiotherapists, doctors, etc.).
  • Analysis using Framework Analysis to identify task-related elements of care escalation.
  • Representation of findings using a Functional Resonance Analysis Model.

Main Results:

  • Identified 32 tasks in work-as-done, expanding on the 8 tasks in work-as-prescribed (NEWS2 escalation).
  • 28% (9/32) of these tasks were identified as cognitively challenging with high performance variability.
  • Three interdependent tasks ('synthesizing data', 'critical escalation decision', 'identifying interim actions') represent potential failure points.
  • Poor usability of clinical information systems hinders data assimilation and increases cognitive load.

Conclusions:

  • Clinical judgment is essential and requires flexibility in escalation protocols and audits.
  • Improved information systems are needed to synthesize patient data, reduce cognitive load, and support decision-making.
  • Reducing cognitive load in data assimilation enables healthcare professionals to provide better, more creative care.