Emergency department escalation in theory and practice: a mixed-methods study using a model of organizational resilience

Back, J., Ross, A. J. , Duncan, M. D., Jaye, P., Henderson, K. and Anderson, J. E. (2017) Emergency department escalation in theory and practice: a mixed-methods study using a model of organizational resilience. Annals of Emergency Medicine, 70(5), pp. 659-671. (doi: 10.1016/j.annemergmed.2017.04.032) (PMID:28662909)

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Study objective: Escalation policies are used by emergency departments when responding to an increase in demand (e.g., a sudden inflow of patients) or a reduction in capacity (e.g., a lack of beds to admit patients). The policies aim to maintain the ability to deliver patient care, without compromising safety, by modifying ‘normal’ processes. The study objective was to examine escalation policies in theory and practice. Methods: This was a mixed-method study, involving: i) a conceptual analysis of NHS escalation policies (n=12) and associated escalation actions (n=92); and ii) a detailed ethnographic study of escalation in situ over an eighteen-month period in a large UK emergency department (n=30 observations). Results: The conceptual analysis of NHS escalation policies found that their use requires the ability to: i) dynamically reconfigure resources (staff and equipment); ii) change workflow; and iii) relocate patients. In practice it was discovered that when the emergency department is under pressure, these prerequisites cannot always be attained. Instead, escalation processes were adapted to manage pressures informally. This adaptive need (‘work as done’) was found to be incompletely specified in policies (‘work as imagined’). Conclusions: Formal escalation actions and their implementation in practice differed and varied in their effectiveness. Monitoring how escalation works in practice is essential in understanding whether and how escalation policies help to manage workload.

Item Type:Articles
Glasgow Author(s) Enlighten ID:Ross, Dr Alastair
Authors: Back, J., Ross, A. J., Duncan, M. D., Jaye, P., Henderson, K., and Anderson, J. E.
Subjects:B Philosophy. Psychology. Religion > BF Psychology
R Medicine > R Medicine (General)
College/School:College of Medical Veterinary and Life Sciences > School of Medicine, Dentistry & Nursing > Dental School
Journal Name:Annals of Emergency Medicine
ISSN (Online):1097-6760
Published Online:26 June 2017
Copyright Holders:Copyright © 2017 American College of Emergency Physicians
First Published:First published in Annals of Emergency Medicine 70(5):659-671
Publisher Policy:Reproduced under a Creative Commons License

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Project CodeAward NoProject NamePrincipal InvestigatorFunder's NameFunder RefLead Dept
682561Centre of Excellence in Healthcare ResilienceAlastair RossGuy's & St Thomas' Foundation NHS Trust (NHSGST)GFWTAARSM - DENTAL SCHOOL