Factors influencing clinician escalation practices for deteriorating patients in an Australian emergency department

Physiological deterioration is typically identified through clinical signs and symptoms. There is a growing adoption of emergency department-specific responses to patient deterioration. Although the effectiveness of ward-based Rapid Response Systems is well-documented in the 'failure-to-rescue' literature and widely used in acute medical and surgical wards, their implementation and factors influencing failure-to-rescue in emergency department settings are less well understood.

To explore emergency nurses' and doctors' perceptions and experiences of escalation practices for deteriorating patients, including the factors influencing these practices, in an Australian ED.

A qualitative descriptive study using semi-structured interviews and Framework Analysis. Interviews were conducted with emergency nurses and doctors who had recently cared for deteriorating emergency department patients.

Thirty-one emergency nurses (n = 22) and doctors (n = 9) participated in the interviews. Five themes were identified that influenced escalation: i) understanding deterioration and the escalation process, ii) influence of patient factors, iii) influence of environmental factors, iv) influence of staff factors, and v) organisational influences.

Clinicians' recognition of patient deterioration and decisions to escalate care transcend formal policy and are influenced by clinical expertise and judgement, interpersonal interactions, environmental pressures and organisational context.