Emergency Department Escalation in Theory and Practice: A Mixed-Methods Study Using a Model of Organizational Resilience

Jonathan Back, Alastair J Ross, Myanna D Duncan, Peter Jaye, Katherine Henderson, Janet E Anderson

Research output: Contribution to journalArticlepeer-review

47 Citations (Scopus)
840 Downloads (Pure)

Abstract

STUDY OBJECTIVE: 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.

METHODS: 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).

RESULTS: 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").

CONCLUSION: 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.

Original languageEnglish
Pages (from-to)659-671
JournalAnnals of Emergency Medicine
Volume70
Issue number5
Early online date26 Jun 2017
DOIs
Publication statusPublished - 1 Nov 2017

Keywords

  • Journal Article

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