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Patient and Family Activated Escalation Systems: a systematic review.
Noémie Déom1,2, John Welch3,2, Cecilia Vindrola-Padros1,2
1University College London.
Summary
Patient and family activated escalation systems (PFAES) offer a crucial safety net for escalating in-hospital deterioration. Direct-to-response models are a safeguard, while proxy escalation is more acceptable but relies on existing systems.
Area of Science:
- Healthcare Improvement
- Patient Safety
- Health Systems Research
Background:
- Patient and Family Activated Escalation Systems (PFAES) are vital for patients and families to escalate concerns about in-hospital deterioration when standard routes fail.
- This systematic review addresses limitations of prior reviews and the context of Martha's Rule implementation in England.
- It synthesizes evidence on PFAES types, implementation, stakeholder experiences, sustainability, and equity up to 2025.
Purpose of the Study:
- To systematically review and synthesize evidence on Patient and Family Activated Escalation Systems (PFAES) up to 2025.
- To identify different PFAES models, implementation strategies, and factors influencing their success.
- To explore patient, family, and healthcare professional experiences, as well as issues of sustainability and equity.
Main Methods:
- Systematic review registered on PROSPERO (CRD420250651441) following PRISMA guidelines.
- Searches conducted across MEDLINE, Embase, Scopus, CINAHL, and Web of Science databases, supplemented by expert and citation searching.
- Thirty-five studies reporting empirical data on hospital-based PFAES were included and appraised using the Mixed-Methods Appraisal Tool (MMAT), with narrative synthesis of findings.
Main Results:
- Two primary PFAES activation routes were identified: direct-to-response team models and proxy activation within ward routines.
- Low patient and family awareness and understanding of PFAES were common, linked to poor visibility and inconsistent staff communication.
- Patients and families expressed anxiety about speaking up and a preference for healthcare professional-led escalation, while sustainability depended on governance and champions; equity was inconsistently addressed.
Conclusions:
- Direct-to-response PFAES can act as a safety net for communication failures but may be perceived as too risky by patients and families.
- Proxy escalation is more acceptable but relies on traditional systems, for which direct-to-response models serve as a safeguard.
- Future research should investigate concurrent operation of both routes (e.g., Martha's Rule) and organizational conditions for effective, equitable implementation.
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