Factors Influencing Escalation of Care by Junior Medical Officers

Abstract

Patients can acutely deteriorate unexpectedly. Junior medical officers (JMOs) are often first to review patients who become unwell. Opportunities to escalate care to a senior colleague may exist prior to the need for a rapid response team review. Little is known about the factors that influence JMO decisions to escalate care. In this study, our objective was to investigate the self-reported factors that influence escalation of care by JMOs in a university-affiliated, tertiary level hospital. We designed a face-to-face questionnaire of JMOs using standardised introduction to minimise interviewer bias. Fifty JMOs participated in the study (a 100% response rate). Most (63.3%) felt that they would be able to identify a clinically deteriorating patient. They would be more likely to escalate care if they were not familiar with the patient's clinical problem. If handover plans were seen to be adequate, JMOs felt it was less necessary to escalate care. Few JMOs (12%) agreed that they limited escalation due to fear of criticism or fear of conflict with senior medical staff. Although 36% agreed that they were concerned about waking seniors overnight, only 6% feared that escalating care overnight would affect their future career prospects. Escalation of care appears to be mostly influenced by the confidence and familiarity of the JMO with the cause of deterioration. JMOs identified clear handover with documented goals of treatment and suggested actions in event of clinical deterioration as the best means by which to improve the process of escalation of care for clinically deteriorating patients.

Intermediate care to intensive care triage: A quality improvement project to reduce mortality

“…Stewart et al showed that trainees, in an effort to avoid displaying knowledge gaps or slowing down the clinical team, will only ask for help when they are convinced not doing so would harm the patient [57]. Another study reported that 30% of residents found it difficult, when they were busy, to pursue input from supervisors [58]. Thirty-six percent did not escalate care because they did not want to wake up supervisors.…”

Recognising and responding to in‐hospital clinical deterioration: An integrative review of interprofessional practice issues

“…Each study developed a new local survey tool to address specific study aims except one, which used a locally modified version of a previously developed tool (Beebe et al., ). Only four referenced other work to inform the development or administration of the instrument (McIntyre et al., ; Pusateri, Prior, & Kiely, ; Rotella, Yu, Ferguson, & Jones, ; Stevens et al., ). While all studies reported that the newly developed surveys had pretesting prior to distribution, none provided any convincing evidence of instrument reliability or validity.…”

“…Three studies provided clear justification for sample size calculations (Plowright et al., ; Sarani et al., ; Stevens et al., ), and four described representativeness of the sample (Jones et al., ; Pusateri et al., ; Sarani et al., ; Stevens et al., ), and the population sampling frame (Jones et al., ; Rotella et al., ; Sarani et al., ; Stevens et al., ). Ethics approval was noted in every study, with three exempted as local quality improvement surveys (Plowright et al., ; Salamonson et al., ; Stevens et al., ).…”

“…Importantly, no papers provided sufficient information for replication of data analysis methods. Only three noted steps for handling missing data (Jones et al., ; McIntyre et al., ; Pusateri et al., ; Rotella et al., ), two described how data entry was verified (Jones et al., ; Pusateri et al., ), and one explained response rate calculations (Rotella et al., ). None explained approaches for analysis of nonresponse error, or provided definitions for complete vs. partially completed surveys.…”

“…Only four referenced other work to inform the development or administration of the instrument (McIntyre et al, 2012;Pusateri, Prior, & Kiely, 2011;Rotella, Yu, Ferguson, & Jones, 2014;Stevens et al, 2014). While all studies reported that the newly developed surveys had pretesting prior to distribution, none provided any convincing evidence of instrument reliability or validity.…”