Title: Success Factors Facilitating Care during Escalation: The SUFFICE Study
Funder: Health Education England

Abstract: BACKGROUND (500)(734) Yearly, up to 40,000 hospital patients suffer a preventable death resulting from inadequate physiological surveillance. Strategies reducing avoidable deaths, including tools to detect illness and Rapid Response Teams have demonstrated inconsistent effects on outcomes. NHS reports recommend focusing on clinical deterioration research and improving deteriorating patient care. Previous failure to rescue studies focus on events leading to death, largely ignoring rescue. RESEARCH QUESTIONWhat factors affect successful escalation of care and how can these factors be applied effectively? SUccess Factors FacIliating Care during Escalation- The SUFFICE Study AIMS AND OBJECTIVESTo identify success factors to care escalation, creating a theory base on which to develop a scalable complex intervention, using the MRC Complex Intervention Framework. METHODS This is a multi-site, mixed-methods Exploratory Sequential design study with four phases.Phase 1 Ethnographic Observations of Escalation of Care The aim is to explore escalation events by observing medical staff and their interactions with other staff groups. Sampling medical staff will increase the number of escalations observed. Informal interviews will supplement observations, probing events, staffing levels, or actions. Data collected will include patient factors (age, admission type), escalation factors (escalation triggers, Early Warning Scores) and contextual ward factors (staffing levels). This will generate a theoretical understanding of situations that lead to an escalation of care.Phase 2 Retrospective Care Record Review (RCRR) The aim is to identify care escalation success factors by reviewing care records for 200 patients who deteriorated to the point where their condition would trigger an intensive care review (a trigger event), but ICU admission was avoided. Care records will be reviewed and given quality of care scores before, during and after the trigger event. Data collected will include patient factors (age, length of hospital stay) and care factors (care judgement scores, chronology of care pre and post trigger). Additionally, 20 care records reviews will be conducted for patients admitted to the ICU following a trigger event, but died, to capture differences in care between trigger survivors and non-survivors. Themes from care reviews will be explored in Phase 3. Phase 3 Applied Cognitive Task Analysis (ACTA) Interviews with Clinical Experts Aims are to identify escalation success factors by interviewing nursing and medical experts with greater than 4 years' clinical experience. Participants will describe how they manage the task of escalation, decisions made and why. Learning from experts is gold standard, and applying expert knowledge is important to intervention development. Phase 4 Data Analysis and Preliminary Complex Intervention Design Framework 'Following a Thread' data analysis will define areas of data convergence or divergence. Improvements to escalation will result in an intervention framework, complementing existing approaches improving failure to rescue, targeting human factors.TIMELINES FOR DELIVERYSee GANTT chart for timelines. ANTICIPATED IMPACT AND DISSEMINATIONPotential Benefit to Patients and the NHSSUFFICE will add to existing evidence, forming the basis of a complex intervention reducing in-hospital mortality and unnecessary admissions to ICU. Results from this study will be published in peer-reviewed journals, using social media to increase its impact.

Lay abstract: Yearly, up to 40,000 hospital patients suffer a preventable death because staff inadequately recognise patient illness or there are delays in requesting a review from a senior doctor (escalation of care). This widespread problem has consistently been identified in NHS care reviews and patient stories. NHS strategies reducing unnecessary patient deaths include scoring systems calculated from blood pressure and heart rate measurements, alerting staff to patient deterioration. Other strategies, not shown to reduce patient deaths, include specialist teams to help ward staff manage deteriorating patients or communication aids. The ultimate escalation of care is admission to an intensive care unit. Current research focuses on patients not rescued by hospital teams from potentially reversible illness (failure to rescue). However, further reductions to patient deaths are possible, by examining care of unwell hospital patients who are successfully treated. The aim of the SUFFICE study is to identify why some patients are successfully rescued (success factors), and use this information to make improvements to the escalation of care process. To identify escalation success factors, hospital and patient data will be collected in four stages: Stage 1: Observation of staff during care escalation events I will observe around 200 escalation of care events to understand interactions between doctors and nurses in hospital wards, their clinical input during an escalation event and identify event success factors. I will use observations to collect data on how often escalation occurs, how staff decide to escalate and how patient illness is managed. Stage 2: Patient Care Notes Reviews I will review care records (including nursing and medical documentation) of 200 ward patients who became unwell, improved and did not need to be admitted to the intensive care unit. This may indicate aspects of care contributed to the patient's condition improving (success factors). I will decide if a patient's care was good or poor and what success factors were present, by using a data collection tool used in NHS care reviews. I will also look at a number of care records for ward patients who became unwell, were admitted to intensive care unit and died. This will allow me to identify differences in care in patients who survive or die following an unwell episode. Stage 3: Staff InterviewsI will talk to 30 expert doctors and nurses to identify how they achieve escalation of care, what are escalation success factors, and how these could be applied effectively in healthcare. I will also explore the results from the first two stages during the interviews to enable greater understanding of these data. Stage 4: Development of an intervention This final stage involves looking at all the data together. I will use this knowledge to develop an intervention to help staff identify and communicate that a patient is becoming more unwell. This intervention will be tested in a future research study. DisseminationStudy results will be of interest to critical care, nursing and medical professions. I will publish 3-4 papers in well-respected medical journals, present study findings at conferences and use Twitter for study promotion. I have discussed this study with Patient and Public Involvement (PPI) representatives through a SUFFICE PPI Advisory Group. The group have contributed to this application and reviewed the plain English summary. We have planned to develop a remote PPI training package (for representatives) which can be utilised by other research studies. We agreed to meet before and at the end of each phase, discuss data analysis and the next study stages. Having a strong PPI contribution will help when disseminating results and representatives will be encouraged to co-author publications and attend public engagement events.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: GENERIC HEALTH RELEVANCE