Back Jonathan, Ross Alastair J, Duncan Myanna D, Jaye Peter, Henderson Katherine, Anderson Janet E
Kings College London, UK.
University of Glasgow, UK.
Ann Emerg Med. 2017 Nov;70(5):659-671. doi: 10.1016/j.annemergmed.2017.04.032. Epub 2017 Jun 26.
Escalation policies are used by emergency departments (EDs) when responding to an increase in demand (eg, a sudden inflow of patients) or a reduction in capacity (eg, 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 is to examine escalation policies in theory and practice.
This was a mixed-method study involving a conceptual analysis of National Health Service escalation policies (n=12) and associated escalation actions (n=92), as well as a detailed ethnographic study of escalation in situ during a 16-month period in a large UK ED (n=30 observations).
The conceptual analysis of National Health Service escalation policies found that their use requires the ability to dynamically reconfigure resources (staff and equipment), change work flow, and relocate patients. In practice, it was discovered that when the ED 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").
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.
急诊科在应对需求增加（如患者突然涌入）或能力下降（如缺乏收治患者的床位）时会采用升级策略。这些策略旨在通过调整“正常”流程，在不影响安全的前提下维持提供患者护理的能力。本研究的目的是从理论和实践两方面审视升级策略。
这是一项混合方法研究，包括对英国国家医疗服务体系（National Health Service）升级策略（n = 12）及相关升级行动（n = 92）进行概念分析，以及对英国一家大型急诊科在16个月期间的升级情况进行详细的实地人种学研究（n = 30次观察）。
对英国国家医疗服务体系升级策略的概念分析发现，其应用需要具备动态重新配置资源（人员和设备）、改变工作流程以及转移患者的能力。在实践中发现，当急诊科面临压力时，这些先决条件并非总能实现。相反，升级流程通过非正式方式进行调整以应对压力。研究发现，政策中（“设想的工作方式”）对这种适应性需求（“实际的工作方式”）的规定并不完整。
正式的升级行动及其在实践中的实施存在差异，效果也各不相同。监测升级策略在实际中的运作情况对于理解升级策略是否以及如何有助于管理工作量至关重要。
