Barriers and facilitators to implementing a process to enable parent escalation of care for the deteriorating child in hospital

Understanding the enablers and barriers to implementing a patient-led escalation system: a qualitative study

BACKGROUND

The management of acute deterioration following surgery remains highly variable. Patients and families can play an important role in identifying early signs of deterioration but effective contribution to escalation of care can be practically difficult to achieve. This paper reports the enablers and barriers to the implementation of patient-led escalation systems found during a process evaluation of a quality improvement programme Rescue for Emergency Surgery Patients Observed to uNdergo acute Deterioration (RESPOND).

METHODS

The research used ethnographic methods, including over 100 hours of observations on surgical units in three English hospitals in order to understand the everyday context of care. Observations focused on the coordination of activities such as handovers and how rescue featured as part of this. We also conducted 27 interviews with a range of clinical and managerial staff and patients. We employed a thematic analysis approach, combined with a theoretically focused implementation coding framework, based on Normalisation Process Theory.

RESULTS

We found that organisational infrastructural support in the form of a leadership support and clinical care outreach teams with capacity were enablers in implementing the patient-led escalation system. Barriers to implementation included making changes to professional practice without discussing the value and legitimacy of operationalising patient concerns, and ensuring equity of use. We found that organisational work is needed to overcome patient fears about disrupting social and cultural norms.

CONCLUSIONS

This paper reveals the need for infrastructural support to facilitate the implementation of a patient-led escalation system, and leadership support to normalise the everyday process of involving patients and families in escalation. This type of system may not achieve its goals without properly understanding and addressing the concerns of both nurses and patients.

Opinions of Nurses and Physicians on a Patient, Family, and Visitor Activated Rapid Response System in Use Across Two Hospital Settings

BACKGROUND

Early detection of deterioration of hospitalized patients with timely intervention improves outcomes in the hospital. Patients, family members, and visitors (consumers) at the patient's bedside who are familiar with the patient's condition may play a critical role in detecting early patient deterioration. The authors sought to understand clinicians' views on consumer reporting of patient deterioration through an established hospital consumer-initiated escalation-of-care system.

METHODS

A convenience sample of new graduate-level to senior-level nurses and physicians from two hospitals in South Australia was administered a paper survey containing six open-ended questions. Data were analyzed with a matrix-style framework and six steps of thematic analysis.

RESULTS

A total of 244 clinicians-198 nurses and 46 physicians-provided their views on the consumer-initiated escalation-of-care system. Six major themes and subthemes emerged from the responses indicating that (1) clinicians were supportive of consumer reporting and felt that consumers were ideally positioned to recognize deterioration early and raise concerns about it; (2) management support was required for consumer escalation processes to be effective; (3) clinicians' workload could possibly increase or decrease from consumer escalation; (4) education of consumers and staff on escalation protocol is a requirement for success; (5) there is need to build consumer confidence to speak up; and (6) there is a need to address barriers to consumer escalation.

CONCLUSION

Clinicians were supportive of consumers acting as first reporters of patient deterioration. Use of interactive, encouraging communication skills with consumers was recognized as critical. Annual updating of clinicians on consumer reporting of deterioration was also recommended.

Paediatric family activated rapid response interventions; qualitative systematic review

BACKGROUND

Failure to recognise deterioration early which results in patient death, is considered failure to rescue and it is identified as one of the leading causes of harm to patients. It is recognised that patients and their families can often recognise changes within the child's condition before healthcare professionals. To mitigate the risk of failure to rescue and promote early intervention, family-activated rapid response systems are becoming widely acknowledged and accepted as part of family integrated care.

OBJECTIVE

To identify current family-activated rapid response interventions in hospitalised paediatric patients and understand mechanisms by which family activation works.

METHODS

A narrative systematic review of published studies was conducted. Seven online databases; AMED, CINHAL, EMBASE, EMCARE, HMIC, JBI, and Medline were searched for potentially relevant papers. The critical appraisal skills programme tool was used to assess methodological rigor and validity of included studies.

RESULTS

Six studies met the predefined inclusion criteria. Five telephone family activation interventions were identified; Call for Help, medical emergency-teams, Condition HELP, rapid response teams, and family initiated rapid response. Principles underpinning all interventions were founded on a principal of granting families access to a process to escalate concerns to hospital emergency teams. Identified interventions outcomes and mechanisms include; patient safety, empowerment of families, partnership working/ family centred care, effective communication and better patient outcomes. Interventions lacked multi-lingual options.

CONCLUSION

Family activation rapid response system are fundamental to family integrated care and enhancing patient safety. Underlying principles and concepts in delivering interventions are transferable across global healthcare system.

Clinical utility and acceptability of a whole-hospital, pro-active electronic paediatric early warning system (the DETECT study): A prospective e-survey of parents and health professionals

Background

Paediatric early warning systems (PEWS) are a means of tracking physiological state and alerting healthcare professionals about signs of deterioration, triggering a clinical review and/or escalation of care of children. A proactive end-to-end deterioration solution (the DETECT surveillance system) with an embedded e-PEWS that included sepsis screening was introduced across a tertiary children’s hospital. One component of the implementation programme was a sub-study to determine an understanding of the DETECT e-PEWS in terms of its clinical utility and its acceptability.

Aim

This study aimed to examine how parents and health professionals view and engage with the DETECT e-PEWS apps, with a particular focus on its clinical utility and its acceptability.

Method

A prospective, closed (tick box or sliding scale) and open (text based) question, e-survey of parents (n = 137) and health professionals (n = 151) with experience of DETECT e-PEWS. Data were collected between February 2020 and February 2021.

Results

Quantitative data were analysed using descriptive and inferential statistics and qualitative data with generic thematic analysis. Overall, both clinical utility and acceptability (across seven constructs) were high across both stakeholder groups although some challenges to utility (e.g., sensitivity of triggers within specific patient populations) and acceptability (e.g., burden related to having to carry extra technology) were identified.

Conclusion

Despite the multifaceted nature of the intervention and the complexity of implementation across a hospital, the system demonstrated clinical utility and acceptability across two key groups of stakeholders: parents and health professionals.

Acute clinical deterioration and consumer escalation: The understanding and perceptions of hospital staff

Introduction

Consumer escalation systems allow patients and families to escalate concerns about acute clinical deterioration. Hospital staff can impact upon the success of this process. As part of evaluation processes within a Local Health Network, where a consumer escalation system was introduced in accordance with National requirements, we sought to explore clinicians’ understanding and perceptions of consumer escalation.

Methods

Voluntary and anonymous staff surveys pre, and post, system introduction. Quantitative data was analysed using descriptive statistics, chi-square independence, and non-parametric independent samples median tests. Qualitative data was evaluated using content analysis and cross-referenced with quantitative responses.

Results

Respondent’s (pre: 215; post: 89) area of work varied significantly between survey periods. Most agreed that patients/families have a sound knowledge of a patient’s typical health status (pre: 192/215 (89.3%); post 82/88 (93.2%)) and that patients/families should be encouraged to escalate concerns of deterioration to ward staff (pre: 209/212 (98.6%); post: 85/89 (95.5%)). Respondent perceptions of patient/family ability to recognise clinical deterioration varied. Staff agreement towards local response expectations decreased as the degree of clinical requirement increased. Staff concerns of increased workloads (pre: 90/214 (42.1%); post 12/72 (16.7%), p<0.001) and conflict generation (pre: 71/213 (33.3%); post: 7/71 (9.9%), p = 0.001) decreased significantly following system introduction. However, clinician perceptions of positive system effects also decreased (patient-staff rapport pre: 163/213 (76.5%); post: 38/72 (52.8%), p = 0.001; patient centred care pre: 188/214 (87.9%); post: 53/72 (73.6%), p = 0.012; patient safety pre: 173/214 (80.8%); post: 49/72 (68.1%), p = 0.077). Only 53% of respondents (pre: 112/213 (52.6%); post: 48/88 (54.5%)) perceived that patient/family have sufficient confidence to escalate concerns.

Conclusion

Consumer escalation systems require staff support. Staff perceptions may indicate, and act as, barriers to the operation of consumer escalation processes. Further exploration in identifying and managing staff barriers is crucial to the success of consumer escalation.

Aboriginal perspectives on recognising clinical deterioration in their child and communicating concerns to clinicians

AIMS AND OBJECTIVES

To explore the perspectives of family members of Aboriginal children about a) their involvement in recognising clinical deterioration in a hospital setting and b) the effectiveness of a poster designed to promote family involvement.

BACKGROUND

To assist in the early recognition and response to clinical deterioration for hospitalised children, many escalation of care processes now include family involvement. Little is currently known about the perspectives of Australian Aboriginal families in recognising deterioration in their child and raising the alarm, or if current escalation of care systems meet the needs of Aboriginal families.

DESIGN

Qualitative pragmatist approach using semi-structured interviews.

METHODS

Seven interviews were conducted with five mothers and two grandmothers of Aboriginal children who were inpatients at a children's hospital. Thematic analysis was undertaken.

FINDINGS

Two themes were identified: Theme one was: Family role in recognising and responding to clinical deterioration, with two subthemes of knowing when to worry and communicating concerns. Participants reported that some families needed more knowledge to recognise clinical deterioration. Communication barriers between families and clinicians were identified. Theme two was: Effective visual communication with three subthemes of linguistic clarity, visual appeal and content.

CONCLUSIONS

Additional strategies are needed to promote effective communication between clinicians and families of Aboriginal children in hospital. Posters were considered effective, particularly if including a cultural connection, images and simplified language.

PRACTICE IMPLICATIONS

These insights provide important information for health professionals and health service managers to be aware that additional communication strategies are required to support Aboriginal family involvement in recognising clinical deterioration and escalation of care.

Improving Communication by Standardizing Pediatric Rapid Response Team Documentation

BACKGROUND

Rapid response teams (RRTs) have been used by multiple hospital systems to enhance patient care and safety. However, processes to document rapid response events (RRE) are often varied among providers and teams, which can lead to suboptimal communication of recommendations to both the primary medical team and family.

METHODS

A preintervention chart review was conducted from January-March 2018 and revealed suboptimal baseline documentation following RREs. A literature review and survey of RRT team members led to the creation of a standardized document with an Epic SmartPhrase which included six key elements of RRE documentation: physical examination, intervention performed, response to intervention, plan of care, communication with care team, and communication with family. A postintervention chart review was completed from April-June 2019 to assess improvements in documentation with the use of this SmartPhrase.

RESULTS

There were 23 RRE activations in the postintervention period, of which 60.8% were due to respiratory distress. The documentation of the six key elements improved (p < .05) after SmartPhrase creation and serial educational interventions.

CONCLUSIONS

Standardized RRE documentation of six key elements significantly improved with the implementation of an Epic SmartPhrase. Improved quality of documentation enhances communication between team members and can contribute to safer patient care.

Development of an evidence-based ESCALATION system for recognition and response to paediatric clinical deterioration

AIM

The aim of this study was to develop an evidence-based paediatric early warning system for infants and children that takes into consideration a variety of paediatric healthcare contexts and addresses barriers to escalation of care.

METHODS

A three-stage intervention development framework consisted of Stage 1: evidence review, benchmarking, stakeholder (health professionals, decision-makers, and health consumers) engagement, and consultation; Stage 2: planning and coproduction by the researchers and stakeholders using action research cycles; and Stage 3: prototyping and testing.

RESULTS

A prototype evidence-based system incorporated human factor principles, used a structured approach to patient assessment, promoted situational awareness, and included family as well as clinician concern. Family involvement in detecting changes in their child's condition was supported by posters and flyers codesigned with health consumers. Five age-specific observation and response charts included 10 weighted variables and one unweighted variable (temperature) to convey a composite early warning score. The escalation pathway was supported by a targeted communication framework (iSoBAR NOW).

CONCLUSION

The development process resulted in an agreed uniform ESCALATION system incorporating a whole-system approach to promote critical thinking, situational awareness for the early recognition of paediatric clinical deterioration as well as timely and effective escalation of care. Incorporating family involvement was a novel component of the system.

Challenges in the recognition and management of paediatric sepsis - The journey

Paediatric sepsis remains a leading cause of childhood death. Morbidity is high, with up to one third of children affected developing ongoing, sometimes lifelong sequelae. To address the major burden of sepsis on child health, there is need for a unified approach to care, as outlined in the Australian National Action Plan for sepsis. While the Surviving Sepsis Campaign 2020 guidelines provided evidence-based recommendations for sepsis management in hospital, additional emphasis on families, pre-hospital recognition and post-sepsis care incorporating the multidisciplinary team is paramount to achieve quality patient outcomes. The role of families, paramedics and nurses in recognising and managing paediatric sepsis remains an under-represented area in current literature. The aim of this paper is to critically discuss key challenges surrounding the journey of paediatric sepsis, drawing on contemporary literature to highlight key areas pertinent to recognition and management of sepsis in children. Application of a holistic, patient-centred focus will provide an overview of paediatric sepsis, aiming to inform future development for enhanced healthcare delivery and identify critical areas for further research.

Patient and family involvement in escalating concerns about clinical deterioration in acute adult wards: A qualitative systematic review

BACKGROUND

Despite international standards for recognition and response to deterioration, warning signs are not always identified by staff on acute hospital wards. Patient and family-initiated escalation of care schemes have shown some benefit in assisting early recognition, but are not widely used in many clinical practice areas.

OBJECTIVES

To explore (a) patients' and relatives' experiences of acute deterioration and (b) patients', relatives' and healthcare professionals' perceptions of the barriers or facilitators to patient and family-initiated escalation of care in acute adult hospital wards.

METHODS

We conducted a qualitative review using Cochrane methodology. Two reviewers independently screened studies, extracted data, and appraised the quality using a qualitative critical appraisal tool. Findings were analysed using thematic synthesis and confidence in findings was assessed using GRADE-CERQual.

SEARCH STRATEGY

MEDLINE, CINAHL, EMBASE, PsychINFO databases and grey literature from 2005 to August 2019.

INCLUSION CRITERIA

Any research design that had a qualitative element and focused on adult patients' and relatives' experiences of deterioration and perceptions of escalating care.

RESULTS

We included five studies representing 120 participants and assessed the certainty of evidence as moderate using GRADE-CERQual. Findings indicated that a number of patients/relatives have the ability to detect acute deterioration, however, various factors act as both barriers and facilitators to being heard. These include personal factors, perceptions of role, quality of relationships with healthcare staff, and organisational factors. Theoretical understanding suggests that patient and relative involvement in escalation is dependent on both inherent capabilities and the factors that influence empowerment.

CONCLUSION

This review highlights that patient and family escalation of care interventions need to be designed with the aim of improving patient/relative-clinician collaboration and the sharing of responsibility.

RELEVANCE TO PRACTICE

These factors need to be addressed to promote more active partnerships when designing and implementing patient and family-initiated escalation of care interventions.

Interventions to increase patient and family involvement in escalation of care for acute life-threatening illness in community health and hospital settings

BACKGROUND

There is now a rising commitment to acknowledge the role patients and families play in contributing to their safety. This review focuses on one type of involvement in safety - patient and family involvement in escalation of care for serious life-threatening conditions i.e. helping secure a step-up to urgent or emergency care - which has been receiving increasing policy and practice attention. This review was concerned with the negotiation work that patient and family members undertake across the emergency care escalation pathway, once contact has been made with healthcare staff. It includes interventions aiming to improve detection of symptoms, communication of concerns and staff response to these concerns.

OBJECTIVES

To assess the effects of interventions designed to increase patient and family involvement in escalation of care for acute life-threatening illness on patient and family outcomes, treatment outcomes, clinical outcomes, patient and family experience and adverse events.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP) ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform from 1 Jan 2000 to 24 August 2018. The search was updated on 21 October 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-randomised controlled trials where the intervention focused on patients and families working with healthcare professionals to ensure care received for acute deterioration was timely and appropriate. A key criterion was to include an interactive element of rehearsal, role play, modelling, shared language, group work etc. to the intervention to help patients and families have agency in the process of escalation of care. The interventions included components such as enabling patients and families to detect changes in patients' conditions and to speak up about these changes to staff. We also included studies where the intervention included a component targeted at enabling staff response.

DATA COLLECTION AND ANALYSIS

Seven of the eight authors were involved in screening; two review authors independently extracted data and assessed the risk of bias of included studies, with any disagreements resolved by discussion to reach consensus. Primary outcomes included patient and family outcomes, treatment outcomes, clinical outcomes, patient and family experience and adverse events. Our advisory group (four users and four providers) ensured that the review was of relevance and could inform policy and practice.

MAIN RESULTS

We included nine studies involving 436,684 patients and family members and one ongoing study. The published studies focused on patients with specific conditions such as coronary artery disease, ischaemic stroke, and asthma, as well as pregnant women, inpatients on medical surgical wards, older adults and high-risk patients with a history of poor self-management. While all studies tested interventions versus usual care, for four studies the usual care group also received educational or information strategies. Seven of the interventions involved face-to-face, interactional education/coaching sessions aimed at patients/families while two provided multi-component education programmes which included components targeted at staff as well as patients/families. All of the interventions included: (1) an educational component about the acute condition and preparedness for future events such as stroke or change in fetal movements: (2) an engagement element (self-monitoring, action plans); while two additionally focused on shared language or communication skills. We had concerns about risk of bias for all but one of the included studies in respect of one or more criteria, particularly regarding blinding of participants and personnel. Our confidence in results regarding the effectiveness of interventions was moderate to low. Low-certainty evidence suggests that there may be moderate improvement in patients' knowledge of acute life-threatening conditions, danger signs, appropriate care-seeking responses, and preparedness capacity between interactional patient-facing interventions and multi-component programmes and usual care at 12 months (MD 4.20, 95% CI 2.44 to 5.97, 2 studies, 687 participants). Four studies in total assessed knowledge (3,086 participants) but we were unable to include two other studies in the pooled analysis due to differences in the way outcome measures were reported. One found no improvement in knowledge but higher symptom preparedness at 12 months. The other study found an improvement in patients' knowledge about symptoms and appropriate care-seeking responses in the intervention group at 18 months compared with usual care. Low-certainty evidence from two studies, each using a different measure, meant that we were unable to determine the effects of patient-based interventions on self-efficacy. Self-efficacy was higher in the intervention group in one study but there was no difference in the other compared with usual care. We are uncertain whether interactional patient-facing and multi-component programmes improve time from the start of patient symptoms to treatment due to low-certainty evidence for this outcome. We were unable to combine the data due to differences in outcome measures. Three studies found that arrival times or prehospital delay time was no different between groups. One found that delay time was shorter in the intervention group. Moderate-certainty evidence suggests that multi-component interventions probably have little or no impact on mortality rates. Only one study on a pregnant population was eligible for inclusion in the review, which found no difference between groups in rates of stillbirth. In terms of unintended events, we found that interactional patient-facing interventions to increase patient and family involvement in escalation of care probably have few adverse effects on patient's anxiety levels (moderate-certainty evidence). None of the studies measured or reported patient and family perceptions of involvement in escalation of care or patient and family experience of patient care. Reported outcomes related to healthcare professionals were also not reported in any studies.

AUTHORS' CONCLUSIONS

Our review identified that interactional patient-facing interventions and multi-component programmes (including staff) to increase patient and family involvement in escalation of care for acute life-threatening illness may improve patient and family knowledge about danger signs and care-seeking responses, and probably have few adverse effects on patient's anxiety levels when compared to usual care. Multi-component interventions probably have little impact on mortality rates. Further high-quality trials are required using multi-component interventions and a focus on relational elements of care. Cognitive and behavioural outcomes should be included at patient and staff level.

Acute clinical deterioration and consumer escalation in the hospital setting: A literature review

BACKGROUND

Consumer escalation systems that allow patients and/or their family/carers to escalate concerns about clinical deterioration have been proposed as a way of enhancing patient safety. However, evidence to guide implementation or to support system effectiveness remains unclear.

AIM

To critically evaluate the current evidence surrounding consumer escalation within the context of clinical deterioration to identify the strengths, weaknesses and gaps in existing knowledge, essential themes, and directions for further investigation.

METHOD

Database searches were conducted within Cumulative Index of Nursing and Allied Health Literature, PubMed, and the Cochrane Library for articles directly relating to consumer escalation systems published, in English, within the previous 10 year-period. Titles and abstracts were screened and relevant full-text articles included. Content was examined to identify breadth of knowledge, essential themes, and the effectiveness of current systems.

RESULTS

27 articles, containing a mixture of both quantitative and qualitative findings, were identified. Within the context of limitations in the overall depth and quality of current evidence, four key areas (relating to consumer understanding and awareness of clinical deterioration, confidence and ability to escalate concerns, education, and staff attitudes) were identified as potentially critical to the foundation, functioning, and success of consumer escalation systems. Consumer escalation processes may contribute positive effects beyond mortality rates; however, an agreed method of assessing effectiveness remains undetermined.

CONCLUSIONS

The ability of consumer escalation processes to achieve their underlying goals is still to be adequately assessed. Further research is required to inform how to best implement, support and optimise consumer escalation systems.

The Parent Role in Advocating for a Deteriorating Child: A Qualitative Study

BACKGROUND AND OBJECTIVES

Families of children with medical complexity are experts on their child's baseline behavior and temperament and may recognize changes in their hospitalized child's health before clinicians. Our objective was to develop a comprehensive understanding of how families identify and communicate their child's deteriorating health with the hospital-based health care team.

METHODS

In this qualitative study, our multidisciplinary team recruited family members of hospitalized children with neurologic impairment. Interviews, conducted in the hospital, were audio recorded, deidentified, and transcribed. By using inductive thematic analysis, each transcript was independently coded by 3 or 4 team members. Members met regularly to reach consensus on coding decisions. Patterns observed were organized into themes and subthemes.

RESULTS

Participants included 28 family members of 26 hospitalized children 9 months to 17 years of age. Children had a mean of 9 hospitalizations in the previous 3 years. Analysis resulted in 6 themes. First, families often reported their child "writes his own book," meaning the child's illness narrative rarely conformed to textbooks. Second, families developed informal, learned pathways to navigate the inpatient system. Third, families stressed the importance of advocacy. Fourth, families self-identified as "not your typical parents" and discussed how they learned their roles as part of the care team. Fifth, medical culture often did not support partnership. Finally, families noted they are often "running on empty" from stress, fear, and lack of sleep.

CONCLUSIONS

Families of children with medical complexity employ mature, experience-based pathways to identify deteriorating health. Existing communication structures in the hospital are poorly equipped to incorporate families' expertise.

The impact of active research involvement of young children in the design of a new stereotest

BACKGROUND

Although considered important, the direct involvement of young children in research design is scarce and to our knowledge its impact has never been measured. We aim to demonstrate impact of young children's involvement in improving the understanding of a new 3D eye test or stereotest.

METHODS

After a pre-measure of understanding was taken, we explored issues with the test instructions in patient and public involvement (PPI) sessions where children acted as advisers in the test design. Feedback was collected via observations, rating scales and verbal comments. An interdisciplinary panel reviewed the feedback, discussed potential changes to the test design, and decided on the implementation. Subsequently, a post-measure of understanding (Study 1-2) and engagement (Study 3) was collected in a pre-post study design. Six hundred fifty children (2-11.8 years old) took part in the pre-measure, 111 children (1-12 years old) in the subsequent PPI sessions, and 52 children (4-6 years old) in the first post-measure. One hundred twenty-two children (1-12 years old) and unrelated adults took then part in a second series of PPI sessions, and 53 people (2-39 years old) in the final post-measure. Adults were involved to obtain verbal descriptions of the target that could be used to explain the task to children.

RESULTS

Following feedback in Study 1, we added a frame cue and included a shuffle animation. This increased the percentage of correct practice trials from 76 to 97% (t (231) = 14.29, p < .001), but more encouragements like 'Keep going!' were needed (t (64) = 8.25, p < .001). After adding a cardboard demo in Study 2, the percentage of correct trials remained stable but the number of additional instructions given decreased (t (103) = 3.72, p < .001) as did the number of encouragements (t (103) = 8.32, p < .001). Therefore, changes in test design following children's feedback significantly improved task understanding.

CONCLUSIONS

Our study demonstrates measurable impact of involvement of very young children in research design through accessible activities. The changes implemented following their feedback significantly improved the understanding of our test. Our approach can inform researchers on how to involve young children in research design and can contribute to developing guidelines for involvement of young children in research.

Parent escalation of care for the deteriorating child in hospital: A health-care improvement study

OBJECTIVE

To evaluate the implementation of an intervention for parents to escalate care if concerned about their child's clinical condition.

DESIGN

Mixed-methods health-care improvement approach guided by the Theoretical Domains Framework.

METHODS

Implementation of the 'Calling for Help' (C4H) intervention was informed by previously identified barriers and facilitators. Evaluation involved audit, review of clinical deterioration incidents, interviews and focus groups.

SETTING

Australian specialist paediatric hospital.

PARTICIPANTS

Convenience sample of 75 parents from inpatient areas during the audit, interviews with ten parents who had expressed concern about their child's clinical condition; five focus groups with 35 ward nurses.

MAIN OUTCOME MEASURES

Parent awareness and utilization of C4H, parent and nurse views of factors influencing implementation.

RESULTS

Parent awareness of C4H improved to 35% (25/75). Parent concern was documented prior to 21/174 (12%) clinical deterioration events. All interviewed parents and nurses who participated in focus groups were positive about C4H. Parents preferred to be informed about C4H by nurses, but nurses described this as time-consuming and selectively chose parents who they believed would benefit most. Parents and nurses described frustrations with and trepidation in escalating care. Nurses had used C4H to expedite urgent medical review.

CONCLUSIONS

There was an improvement in the level of parent awareness of C4H, which was viewed positively by parents and nurses alike. To achieve a high level of parent awareness in a sustainable way, a multifaceted approach is required. Further strategies will be required for parents to feel confident enough to use C4H and to address interprofessional communication barriers.

Barriers and facilitators to implementing a process to enable parent escalation of care for the deteriorating child in hospital

OBJECTIVE

To identify barriers and facilitators to implementing a parent escalation of care process: Calling for Help (C4H).

DESIGN

Audits, semi-structured interviews and focus groups guided by the Theoretical Domains Framework.

SETTING

Australian paediatric hospital where a parent escalation of care process was introduced in the previous 6 months.

PARTICIPANTS

Four children, 13 parents, 91 nurses and doctors including Medical Emergency Team (MET) members.

MAIN OUTCOME MEASURES

Parent awareness and involvement in escalating care and factors impacting implementation of C4H.

RESULTS

Two audits identified low level of parent awareness (16/88, 19% and 5/85, 6%). Parent involvement in escalation of care was documented in 11/62 (18%) events. The main facilitators included uniformly positive views that C4H was in the child's best interest, acknowledgement that parents had skills to recognize deterioration and would take action. C4H was considered to add to patient safety and being reviewed by the MET was a patient benefit. Key barriers were the low level of awareness, doubt about parent capabilities, concern about parents' information overload, anticipated overuse of resources, staff unease about possible repercussions and anticipated difficulty for parents to question staff with potential negative effects on parent-staff relationships. Overall C4H presents a challenge to traditional hospital hierarchy and culture.

CONCLUSIONS

Although there was a low level of awareness about C4H in practice, there was in-principle support for the concept. Initial strategies had primarily targeted policy change without taking into account the need for practice and organizational behaviour changes. Using a theoretical approach to identify key factors will enable a targeted approach to implementation.