Centre for Patient Safety & Service Quality, Department of Surgery & Cancer, Imperial College London, London, UK.
Centre for Patient Safety & Service Quality, Department of Surgery & Cancer, Imperial College London, London, UK.
Surgery. 2014 Jun;155(6):989-94. doi: 10.1016/j.surg.2014.01.016. Epub 2014 Feb 7.
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.
尽管沟通失败在不良事件中起作用，但手术过程中的护理升级并未得到探索。本研究旨在制定一个手术中护理升级影响的概念框架，以便开发出便于管理病情恶化患者的解决方案。
在英国伦敦的三家医院进行了一项多中心定性研究。共招募了 41 名参与者，包括 16 名外科医生、11 名外科住院医师、6 名外科护士、4 名重症监护医生和 4 名重症监护外展团队成员。参与者接受了半结构化访谈，使用扎根理论方法进行了分析。
决定升级的依据是五个关键主题：患者、个人、团队、环境和组织因素。大多数参与者认为他们所在医院的监督和护理升级存在问题，最常见的问题是缺乏明确的升级协议和缺乏高级外科医生。与医院寻呼系统相比，手机和直接对话被认为在升级护理时更有效。透明的升级协议、增加高级临床医生的监督和沟通技巧培训被强调为改善升级护理的策略。
这是第一项描述手术中护理升级的研究，这是保护病情恶化的外科患者安全的关键过程。影响升级决策的因素很复杂，涉及护理的临床和专业方面。对这一过程的理解可以为促进升级以改善患者结果的干预措施铺平道路。
