Escalation of care and failure to rescue: A multicenter, multiprofessional qualitative study

Published:February 10, 2014DOI:


      The escalation of care process has not been explored in surgery, despite the role of communication failures in adverse events. This study aimed to develop a conceptual framework of the influences on escalation of care in surgery allowing solutions to facilitate management of sick patients to be developed.


      A multicenter qualitative study was conducted in three hospitals in London, UK. A total of 41 participants were recruited, including 16 surgeons, 11 surgical PGY1s, six surgical nurses, four intensivists, and four critical care outreach team members. Participants were submitted to semistructured interviews that were analyzed using grounded theory methodology.


      A decision to escalate was based upon five key themes: patient, individual, team, environmental, and organizational factors. Most participants felt that supervision and escalation of care were problematic in their hospital, with unclear escalation protocols and poor availability of senior surgical staff the most common concerns. Mobile phones and direct conversation were identified to be more effective when escalating care than hospital pager systems. Transparent escalation protocols, increased senior clinician supervision, and communication skills training were highlighted as strategies to improve escalation of care.


      This is the first study to describe escalation of care in surgery, a key process for protecting the safety of deteriorating surgical patients. Factors affecting the decision to escalate are complex, involving clinical and professional aspects of care. An understanding of this process could pave the way for interventions to facilitate escalation in order to improve patient outcome.
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      Linked Article

      • Commentary on: Escalation of care and failure to rescue: A multicenter, multiprofessional qualitative study
        SurgeryVol. 155Issue 6
        • Preview
          Failure-to-rescue (FTR), initially defined by Silber et al1 in 1992 as hospital deaths occurring after adverse events in operative patients, has been used as a measure of patient safety and hospital quality. In most studies to improve the rates of FTR mortality, authors have examined the response of organizational resources to improve rescue once a patient has been identified to be in crisis. It is now recognized, however, that most patients manifest signs and symptoms of clinical deterioration during a substantial period of time before a crisis occurs; accordingly, contemporary studies increasingly have focused on processes that precede a FTR crisis—what has been referred to as the “afferent limb of rapid response systems.”2
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      • Commentary on: Escalation of care and failure to rescue: A multicenter, multiprofessional, qualitative study
        SurgeryVol. 155Issue 6
        • Preview
          In the article “Escalation of Care and Failure to Rescue: A multicenter, multiprofessional, qualitative study,” the authors evaluate escalation of care and failure to rescue from the standpoint of barriers to effectiveness. The authors are to be congratulated on examining an important area that reveals tremendous opportunity to improve and sends a message in particular to senior residents and faculty in teaching hospitals.
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