Response to “RE: Escalation of Care in Surgery

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We would like to thank Dr Stevenson et al for taking the time to write their letter regarding our recently published study detailing a Healthcare Failure Mode and Effect Analysis of the escalation of care process in surgery.1 They concisely identify both strengths and limitations of the study. In the letter, Stevenson et al comment on the number of hours spent observing staff, the role of patients in the escalation of care process, the nature of controlled and uncontrolled failures in the pathway, and the overall recommendations of the study.
Regarding the number of hours that were spent observing staff, Dr Stevenson et al state that this was limited and may have led to an underestimation of process failures. However, this interpretation of the methodology is flawed. As escalation of care is an interprofessional process, it involves patients, doctors, nurses, and multiple other health professionals. This means that although the number of individual hours spent observing each staff member may seem small, during these observation periods, the observers were exposed to a plethora of hospital patients and staff. Therefore, the level of detail we were able to collect during these sessions was rich and comprehensive. Stevenson et al also query the clarification of the criteria used to identify a deteriorating patient. During the study design, we elected not to use strict criteria because all patients are different and there are multiple factors affecting the decision to escalate care.2 Two patients with the same physiological parameters may have very different outcomes depending on whether a delay in escalation of care occurs.3 Therefore, although these measurements are useful, a degree of intuition on the part of staff caring for patients will always contribute to the escalation of care decision.
Stevenson et al rightly comment on the role patients may play in alerting staff to a change in another patient's condition. This step formed part of the original flow diagram used in the study but was later removed after the participants rated it as nonhazardous. Similarly, the comments from Dr Stevenson et al regarding the distinction between controlled and uncontrolled failures are met with the same response. These were the views of the participants and not the authors. The combination of new technology (eg, an electronic vital signs chart) with human factors education is crucial if new innovations are to be successful. We agree that human factors are paramount to improving escalation of care and patient safety,4 in addition to the key role played by culture, which was identified in the original article and expanded upon in the accompanying editorial.5
Our study represents a fact-finding mission to establish the areas within the escalation of care process that have the greatest potential for successful intervention and the possible nature of these interventions. Human factors including education, process-driven care, and resource management are several of the many strategies that may be used. We hope that the study encourages both health care professionals and researchers to continue exploring and improving the escalation of care process to bring about the ultimate goal of improving care quality for patients.
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