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

BACKGROUND: 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. AIM: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.