to both understand how to escalate concerns to other appropriate healthcare professionals for expert help and how to recognise when a person’s health has deteriorated and escalate as needed (Nursing & Midwifery Council 2018a).
This chapter will develop understanding of both of these by introducing different methods for escalating concerns about patients, discussing how to escalate effectively and describing the pitfalls in communication so that these can be avoided. The NMC Code (Nursing & Midwifery Council 2018b) also contains requirements with regards to deteriorating patients and escalation. The nursing associate is required to maintain effective communication with colleagues, to make a timely referral to another practitioner when any action, care or treatment is required and to arrange, wherever possible, for emergency care to be accessed and provided promptly.
Green Flag
1 8.1 Respect the skills, expertise and contributions of your colleagues, referring matters to them where appropriate
2 13.2 Make a timely referral to another practitioner when any action, care or treatment is required
3 13.3 Ask for help from an appropriately qualified and experienced professional to carry out any action or procedure which is beyond the limits of your competence
4 15.2 Arrange, wherever possible, for emergency care to be accessed and provided promptly
The most common root cause of serious errors clinically and organisationally is related to inadequate verbal and written communication. The Institute for Innovation and Improvement (2010) notes that there are some important barriers to communication that occur across different disciplines and levels of staff. These barriers include:
Hierarchy
Gender
Ethnic background
Differences in communication styles between disciplines and individuals
Communication is more effective (and therefore patient safety) in teams where there are standard communication structures in place; Situation, Background, Assessment, Recommendation (SBAR) and Reason, Story, Vital Signs, Plan (RSVP) are examples of these standard communication structures.
Assessment and Planning Ahead
Healthcare professionals face constantly changing priorities. Consequently, when escalating a concern about a patient’s health, it is important to consider carefully the information that needs to be given and how that information can be structured into a format which conveys the intended message: that the patient needs the immediate attention of the person receiving the escalation.
It is known that ‘handover’ of information is often cognitively taxing and complex due to the amount of information and data that is known about the patient. This can lead to handovers which are unclear or miscommunicate the nursing associate’s desired outcome for the patient (Hill & Nyce 2010).
It is therefore important that when escalating concerns, the handover is planned and prepared. The focus should be on giving the essential information required to prompt the desired response and omit unnecessary information which may distract or overload the decision‐making of the recipient.
In a situation where taking a few moments to plan the escalation is not possible, it is likely that the patient requires a more immediate response where a structured communication tool is not immediately required to get help. Within an acute hospital in the United Kingdom, this will be by summoning the medical emergency team (MET) or a cardiac arrest team by calling 2222. In the patient’s own homes, general practitioner (GP) surgeries and non‐acute or community hospitals, calling 999 for an ambulance is normally required.
There are two main structures which are recommended for escalating patient care (see Table 7.1). These are the SBAR or RSVP tools.
| SBAR: | RSVP: |
| Situation | Reason |
| Background | Story |
| Assessment | Vital Signs |
| Recommendation | Plan |
Source: Resuscitation Council UK (2015).
The understanding of each term and examples of how to use each are found later in the chapter.
Planning your escalation and using one of the escalation tools are essential for ensuring an effective handover of patient information and concerns; reviewing all the information known about the patient by looking at the medical and nursing notes will enable you to plan each section of the escalation tool. It is likely that the reason escalation is required is because an assessment of the patient has already been completed; if not, utilising an Airway, Breathing, Circulation, Disability, Exposure (ABCDE) assessment will enable a systematic assessment of the patient and obtains the most up‐to‐date information about the patient’s vital signs and clinical presentation.
Red Flag
Breathing
Circulation
Disability
Exposure
The ABCDE assessment is a systematic assessment of the body systems. The systematic approach ensures that all body systems are assessed in decreasing importance to the patient’s deterioration. An intervention is required for each abnormal finding before moving onto the next element.
Completing an ABCDE assessment enables the practitioner to complete a comprehensive assessment of not only the clinical observations but also the signs and symptoms which can be found using:
Look
Listen
Feel
A great deal of patient information is held and should be used as a part of the patient assessment, as well as planning for escalation:
The medical notes – Inpatients in hospitals are ‘clerked’ at their start of their admission to hospital. This is where the admitting doctors (or other admitting clinicians) write information obtained from their first assessment of the patient, such as initial presentation, investigation findings and provisional diagnoses. The clerking is particularly useful as it will list the patient’s past medical history, their medications at the time of arrival, allergies, a social history and other information which may be useful. Review the last few entries from ward rounds and other visits from other healthcare professionals – what is the patient’s current condition? What plan of treatment is currently in place for this patient?
The observation and fluid chart – The trend of the patient’s observations is just as important as the latest single set of observations. Has the patient been declining slowly or has there been a sudden deterioration in their vital signs? Has there been any change in their urine output?
Orange Flag