Action 8.6

The health service organisation has protocols that specify criteria for escalating care, including:

a. Agreed vital sign parameters and other indicators of physiological deterioration

b. Agreed indicators of deterioration in mental state

c. Agreed parameters and other indicators for calling emergency assistance

d. Patient pain or distress that is not able to be managed using available treatment

e. Worry or concern in members of the workforce, patients, carers and families about acute deterioration

Intent

The health service organisation has an effective system for escalation of care to minimise risks for patients who are acutely deteriorating.

Reflective question

What protocols are used to specify the criteria for escalating care?

Key tasks

  • Work with clinical groups to agree on parameters that indicate acute deterioration and require escalation of care
  • Develop and implement protocols for escalating care when acute deterioration in a patient’s condition is detected.

Strategies for improvement

Hospitals

Delays in treatment can occur in the absence of clear criteria for escalating care.1-3 Escalation protocols provide clear, objective criteria that prompt clinicians to call for help, and endorse calling for help when clinicians, patients, family members or carers are subjectively concerned about a patient acutely deteriorating.

Identify parameters for escalation

Use a graded response system within the escalation protocol. This means that the escalation protocol includes at least two levels of response to acute deterioration:

  • An emergency response (for example, from a rapid response team) to criteria that indicate severe acute deterioration
  • At least one other level of response (for example, from the treating or on-call team) for criteria that indicate less severe deterioration.

The two levels are recommended because early treatment of acute deterioration is better – patients who trigger medical emergency calls have high mortality rates4,5, and delayed calls to medical emergency teams are associated with poorer outcomes.6,7

Work with clinical groups to agree on the criteria that indicate acute deterioration in physiological and mental state. Identify the thresholds to trigger escalation of care before acute deterioration becomes severe, and thresholds to trigger a call for emergency assistance when acute deterioration is severe. Use the escalation mapping tool available from the Commission’s website to match the thresholds and parameters that indicate acute physical deterioration to the appropriate response.

Mapping tools can also be used for developing a local escalation protocol for deterioration in a person’s mental state. Use the signs described in tools such as the mental health triage tool to set thresholds for escalation in response to observed or reported changes in a person’s mental state. Consider local clinical capacity and access to mental health expertise to decide whether the response can be implemented by the treating team, or referral should be made to a clinical psychiatry liaison or other available service. Engage the patient, and their carer and family in shared decision making about escalation of care. Patient pain and distress that are unable to be managed using available treatments may indicate acute deterioration that needs urgent treatment. Include pain and distress as a criterion for escalation in the protocol.

Patients may show signs of clinical deterioration other than those identified in the escalation protocol, and there is evidence that clinician worry or concern may precede deterioration in vital signs.8 Include clinician worry or concern as a criterion for escalation in the protocol.

Develop policies and guidance

Develop policies and provide training to guide clinicians in preventing and responding to severe aggressive behaviour and violence. When developing policies and responses to severe behavioural disturbance, provide specific guidance on appropriate responses for older patients, highlighting that:

  • Behavioural disturbances are commonly associated with delirium or dementia
  • Behavioural disturbances may be related to fear, communication difficulties or an unfamiliar setting (in which case, de-escalation strategies and involvement of family members can be successful)
  • Sedation should be avoided, and any use should be in line with age-specific evidence; over-sedation can have serious adverse effects, such as dehydration, falls, respiratory depression, pneumonia and death9
  • Clinicians should refer to specialist older people’s mental health services, if possible.

Refer to the ‘Minimising patient harm’ criterion in the Comprehensive Care Standard for further detail on preventing delirium and managing cognitive impairment; predicting, preventing and managing self-harm, suicide, aggression and violence; and minimising restrictive practices.

Localise escalation policies that consider the size, role, location and available resources of different services within the organisation. For example, escalation protocols in the emergency department may differ significantly from escalation protocols in the dialysis unit or the mental health unit. Different escalation protocols may be needed for different groups of patients – for example, children may need different escalation protocols from adults.

Escalation protocols can be complex, involving multiple steps and different communication pathways. Develop a flow diagram to summarise escalation processes and provide clinicians with a quick reference tool. Display posters of the escalation flow diagram near telephones in clinical areas, or provide clinicians with identification tag cards for quick reference.

Day Procedure Services

Delays in treatment can occur in the absence of clear criteria for escalating care.1,3 Escalation protocols provide clear, objective criteria that prompt clinicians to call for help, and endorse calling for help when clinicians, patients, family members or carers are subjectively concerned about a patient acutely deteriorating.

Identify parameters for escalation

Although there is low prevalence of episodes of acute deterioration in a person’s mental state in day procedure services, the health service organisation needs to ensure that, if a person does experience acute deterioration in their mental state, members of the workforce have the skills to initiate an immediate response to ensure safety, and communicate their concerns to relevant parties.

Use a graded response system within the escalation protocol. This means that the escalation protocol includes at least two levels of response to acute deterioration:

  • An emergency response (for example, urgent review by a consultant anaesthetist, a call to the ambulance service) to criteria that indicate severe acute deterioration
  • At least one other level of response (for example, from a senior nurse) for criteria that indicate less severe deterioration.

The two levels are recommended because early treatment of acute deterioration is better – patients who trigger medical emergency calls have high mortality rates4,10, and delayed calls to medical emergency teams are associated with poorer outcomes.6,7

Work with clinicians to agree on the criteria that indicate acute deterioration in physiological and mental state. Identify the thresholds to trigger escalation of care before acute deterioration becomes severe, and thresholds to trigger a call for emergency assistance when acute deterioration is severe. Consider the extra time necessary to transfer patients whose condition acutely deteriorates to a tertiary referral hospital when planning an escalation protocol. Use the escalation mapping tool available from the Commission’s website to match the thresholds and parameters that indicate acute physical deterioration to the appropriate response. The mapping tool can also be used for deterioration in mental state to determine what should trigger a response, and required actions to keep patients and the workforce safe.

Patient pain and distress that are unable to be managed using available treatments may indicate acute deterioration that needs urgent treatment. Include pain and distress as a criterion for escalation in the protocol.

Patients may show signs of clinical deterioration other than those identified in the escalation protocol, and there is evidence that clinician worry or concern may precede deterioration in vital signs.8 Include clinician worry or concern as a criterion for escalation in the protocol.

Escalation protocols can be complex, involving multiple steps and different communication pathways. Develop a flow diagram to summarise escalation processes and provide clinicians with a quick reference tool. Display posters of the escalation flow diagram near telephones in clinical areas, or provide clinicians with identification tag cards for quick reference.

Refer to the ‘Minimising patient harm’ criterion in the Comprehensive Care Standard for further details on preventing delirium and managing cognitive impairment; predicting, preventing and managing self-harm, suicide, aggression and violence; and minimising restrictive practices.

Examples of evidence

Select only examples currently in use:

  • Policy documents that identify agreed criteria that indicate acute deterioration in physical, mental or cognitive condition that trigger escalation of care, and the expected responses
  • Policy documents that include consideration of the organisation’s size, role, location and services provided; localised escalation strategies; and tailored escalation for specialist patient groups
  • Documented protocols that are available to the workforce for escalating care when acute deterioration in a patient’s condition is detected
  • Documented localised escalation protocols
  • Escalation flow diagrams
  • Audit results of compliance with the escalation protocols
  • Committee and meeting records in which clinicians agreed on the parameters that indicate acute deterioration for escalation
  • Resources or tools that help clinicians to use the escalation protocols.
MPS & Small Hospitals

MPSs and small hospitals will need to:

  • Work with clinical groups to agree on parameters that indicate acute deterioration and require escalation of care – delays in treatment can occur in the absence of clear criteria for escalating care 1-3
  • Develop and implement protocols for escalating care when acute deterioration in a patient’s condition is detected – escalation protocols provide clear, objective criteria that prompt clinicians to call for help, and endorse calling for help when clinicians, patients, carers or family members are subjectively concerned about a patient acutely deteriorating.

Identify parameters for escalation

Use a graded response system within the escalation protocol. This means that the escalation protocol includes at least two levels of response to acute deterioration:

  • An emergency response (for example, from a rapid response team) to criteria that indicate severe acute deterioration
  • At least one other level of response (for example, from the treating or on-call team) for criteria that indicate less severe deterioration.

The two levels are recommended because early treatment of acute deterioration is better – patients who trigger medical emergency calls have high mortality rates 4,10, and delayed calls to medical emergency teams are associated with poorer outcomes. 6,7

If appropriate, base the escalation protocol on one that was developed by the Local Hospital Network, state or territory health department or nearby larger hospital. However, it will need to be adapted to reflect the organisation’s available services and resources.

Work with clinical groups to agree on the criteria that indicate acute deterioration in physiological and mental state. Identify the thresholds to trigger escalation of care before acute deterioration becomes severe, and thresholds to trigger a call for emergency assistance when acute deterioration is severe. Consider the extra time necessary to transfer patients whose condition acutely deteriorates to a tertiary referral hospital when planning an escalation protocol. Use the escalation mapping tool available from the Commission’s website to match the thresholds and parameters that indicate acute physical deterioration to the appropriate response.

Mapping tools can also be used for developing a local escalation protocol for deterioration in a person’s mental state. Use the signs described in tools such as the mental health triage tool to set thresholds for escalation in response to observed or reported changes in a person’s mental state.  Consider local clinical capacity and access to mental health expertise to decide whether the response can be implemented by the treating team, or referral should be made to a clinical psychiatry liaison or other available service. Engage the patient, and their carer and family in shared decision making about escalation of care. Patient pain and distress that are unable to be managed using available treatments may indicate acute deterioration that needs urgent treatment. Include pain and distress as a criterion for escalation in the protocol.

Patients may show signs of clinical deterioration other than those identified in the escalation protocol, and there is evidence that clinician worry or concern may precede deterioration in vital signs.8 Include clinician worry or concern as a criterion for escalation in the protocol.

Develop policies and guidance

Develop policies and provide training to guide clinicians in preventing and responding to severe aggressive behaviour and violence. When developing policies and responses to severe behavioural disturbance, provide specific guidance on appropriate responses for older patients, highlighting that:

  • Behavioural disturbances are commonly associated with delirium or dementia
  • Behavioural disturbances may be related to fear, communication difficulties or an unfamiliar environment (in which case, de-escalation strategies and involvement of family members can be successful)
  • Sedation should be avoided, and any use should be in line with age-specific evidence; over-sedation can have serious adverse effects, such as dehydration, falls, respiratory depression, pneumonia and death11
  • Clinicians should refer to specialist older people’s mental health services, if possible.

Refer to the ‘Minimising patient harm’ criterion in the Comprehensive Care Standard for further detail on preventing delirium and managing cognitive impairment; predicting, preventing and managing self-harm, suicide, aggression and violence; and minimising restrictive practices.

Localise escalation policies that consider the size, role, location and available resources of different services within the organisation. For example, escalation protocols in the emergency department may differ significantly from escalation protocols in the dialysis unit or the mental health unit. Different escalation protocols may be needed for different groups of patients – for example, children may need different escalation protocols from adults.

Escalation protocols can be complex, involving multiple steps and different communication pathways. Develop a flow diagram to summarise escalation processes and provide clinicians with a quick reference tool. Display posters of the escalation flow diagram near telephones in clinical areas, or provide clinicians with identification tag cards for quick reference.

Action 8.7

The health service organisation has processes for patients, carers or families to directly escalate care

Intent

Patients, family members and carers can directly escalate care.

Reflective question

What processes are in place for patients, carers or families to directly escalate care?

Key task

Develop and implement a system for patients, carers and families to directly escalate care.

Strategies for improvement

Hospitals

Use the actions about health literacy from the Partnering with Consumers Standard to guide the development of a system for patients, family members and carers to access help when they are concerned that a patient is acutely deteriorating. It is important that the system enables patients, carers and family members to access help independently of the team that is directly providing care for the person of concern.

Work with consumer advisors and clinicians to identify the criteria for escalating care, the mechanism for calling for help, and the response that will be provided. Examples of criteria for escalating care are:

  • Concern about a patient who is getting worse, not doing as well as expected or not improving
  • Concern that ‘something is not right’.12

Ensure that the system can be activated easily and independently. Methods for activating the system might include calling an emergency number from internal facility telephones or from a mobile telephone, using an emergency call button, or using a designated phone number that is only for patient, carer and family escalation.

Provide written and verbal information about the system for patient, carer and family escalation on admission, and display details about when and how to use the system in public areas.

Depending on the mechanisms used for patients, carers and families to escalate care, it may be necessary to train non-clinical members of the workforce (such as ward clerks and switchboard operators) to ensure that calls are directed to the appropriate responder(s). Developing scripted questions can help non-clinical members of the workforce triage calls correctly.

Responders may need extra training to manage patient and family escalation calls. For example, skills in communication and conflict resolution may be needed to manage situations where communication between the patient, family or carer, and the team that is providing care has become problematic.

Several Australian states have established patient, carer and family member escalation systems, such as the New South Wales REACH program and Queensland’s Ryan’s Rule.

Day Procedure Services

Develop a system for patients, carers and families to obtain access to help when they are concerned that a patient is acutely deteriorating.

Work with consumer advisors and clinicians to identify the criteria for escalating care, the mechanism for calling for help, and the response that will be provided. Examples of criteria for escalating care are:

  • Concern about a patient in the service who is getting worse, not doing as well as expected or not improving
  • Concern that ‘something is not right’.13

Ensure that the system can be activated easily and independently. Methods for activating the system might include using an emergency call button, or using a designated phone number that is only for patient, carer and family escalation.

Provide written and verbal information about the system for patient, carer and family escalation on admission, and display details about when and how to use the system in public areas.

Depending on the mechanisms used for patients, carers and families to escalate care, it may be necessary to train non-clinical members of the workforce (such as reception workforce) to ensure that calls are directed to the appropriate responder(s). Developing scripted questions can help non-clinical members of the workforce triage calls correctly.

Several Australian states have established patient, carer and family member escalation systems, such as the New South Wales REACH program and Queensland’s Ryan’s Rule.

Examples of evidence

Select only examples currently in use:

  • Observation of an escalation system that supports patients, carers and families to directly escalate care
  • Consumer and carer resources that outline how they can directly escalate care
  • Relevant documentation from committees with consumer advisors and clinicians in which the criteria for, mechanism of, and response to, direct patient, carer and family escalation of care were decided
  • Evaluation of the effectiveness and usability of the patient, carer and family escalation protocol and associated quality improvement projects
  • Training documents about the system for patients, carers and families to directly escalate care, including how the non-clinical workforce should forward calls for assistance.
MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group could base the patient and family escalation protocol on one that was developed by the Local Hospital Network, state or territory health department or nearby larger hospital. However, it will need to be adapted to reflect the organisation’s available services and resources.

Small hospitals that are not part of a local health network or private hospital group should use the actions about health literacy from the Partnering with Consumers Standard to guide the development of a system for patients, carers and family members to seek help when they are concerned that a patient is acutely deteriorating.

Work with consumer advisors and clinicians to identify the criteria for escalating care, the mechanism for calling for help, and the response that will be provided. Examples of criteria for escalating care are:

  • Concern about a patient in the service who is getting worse, not doing as well as expected or not improving
  • Concern that ‘something is not right’.12

Ensure that the system can be activated easily and independently. Methods for activating the system might include calling an emergency number from internal facility telephones or from a mobile telephone, using an emergency call button, or using a designated phone number that is only for patient, carer and family escalation.

Provide written and verbal information about the system for patient, carer and family escalation on admission, and display details about when and how to use the system in public areas.

Depending on the mechanisms used for patients, carers and families to escalate care, it may be necessary to train non-clinical members of the workforce (such as ward clerks and switchboard operators) to ensure that calls are directed to the appropriate responder(s). Developing scripted questions can help non-clinical members of the workforce triage calls correctly.

Responders may need extra training to manage patient and family escalation calls. For example, skills in communication and conflict resolution may be needed to manage situations in which communication between the patient, carer or family and the team that is providing care has become problematic.

Several Australian states have established patient, carer and family member escalation systems, such as the New South Wales REACH program and Queensland’s Ryan’s Rule.

Action 8.8

The health service organisation provides the workforce with mechanisms to escalate care and call for emergency assistance

Intent

The health service organisation has mechanisms for the workforce to escalate care.

Reflective question

What mechanisms are in place for the workforce to escalate care and call for emergency assistance?

Key task

Provide the workforce with mechanisms to escalate care and call for emergency assistance.

Strategies for improvement

Hospitals

Provide mechanisms to escalate care and call for emergency assistance, and ensure that these are consistent and effective. Multiple mechanisms may be necessary in escalation systems to allow different responses to varying levels or types of deterioration. These mechanisms may include:

  • Paging systems
  • Dedicated mobile, on-call and emergency telephone numbers
  • Electronic alerting systems
  • Bedside or centralised alarms.

Consider the following issues when deciding on the mechanisms to use:

  • Avoid changes in the system at different times of the day and on different days of the week
  • Develop processes for responders to hand over shared equipment, such as pagers or mobile phones, between shifts
  • Provide backup systems in the event of equipment failure
  • Develop processes for maintaining equipment
  • Provide training about how to use the mechanisms for escalating care, including for new, casual, locum and agency members of the workforce.
Day Procedure Services

Provide mechanisms to escalate care and call for emergency assistance, and ensure that these are consistent and effective. Multiple mechanisms may be necessary in escalation systems to allow different responses to varying levels or types of deterioration. These mechanisms may include:

  • Paging systems
  • Dedicated mobile, on-call and emergency telephone numbers
  • Bedside or centralised alarms.

Consider the following issues when deciding on the mechanisms to use:

  • Avoid changes in the system at different times of the day and on different days of the week
  • Develop processes for responders to hand over shared equipment, such as pagers and mobile phones, between shifts
  • Provide backup systems in the event of equipment failure
  • Develop processes for maintaining equipment
  • Provide training about how to use the mechanisms for escalating care, including for new, casual, locum and agency members of the workforce.

Examples of evidence

Select only examples currently in use:

  • Policy documents about escalating care and calling for emergency assistance
  • Audit results of equipment functionality and maintenance, including paging systems, electronic alerting systems, alarms and dedicated mobile phones
  • Training documents about mechanisms for escalating care and calling for emergency assistance
  • Audit results of compliance with the mechanisms for escalating care and calling for emergency assistance
  • Evidence of investigations into failures of the mechanisms for escalation and emergency assistance calls, and associated quality improvement projects.
MPS & Small Hospitals

MPSs and small hospitals should provide the workforce with mechanisms to escalate care and call for emergency assistance, and ensure that these are consistent and effective. Multiple mechanisms may be necessary in escalation systems to allow different responses to varying levels or types of deterioration. These mechanisms may include:

  • Paging systems
  • Dedicated mobile, on-call and emergency telephone numbers
  • Electronic alerting systems
  • Bedside or centralised alarms.

Consider the following issues when deciding on the mechanisms to use:

  • Avoid changes in the system at different times of the day and on different days of the week
  • Develop processes for responders to hand over shared equipment, such as pagers or mobile phones, between shifts
  • Provide backup systems in the event of equipment failure
  • Develop processes for maintaining equipment
  • Provide training about how to use the mechanisms for escalating care, including for new, casual, locum and agency members of the workforce.

In remote small hospitals, it may be helpful to develop processes for obtaining emergency advice from specialist providers – such as emergency or psychiatric services, or intensive care clinicians – online or using video link.

Action 8.9

The workforce uses the recognition and response systems to escalate care

Intent

Members of the workforce take prompt action to deal with acute deterioration.

Reflective question

How does the health service organisation ensure that the workforce knows how and when to use the recognition and response systems?

Key task

Escalate care when acute deterioration is recognised.

Strategies for improvement

Hospitals

Provide orientation, education and training for the workforce so that they understand their individual roles, responsibilities and accountabilities in the recognition and response systems. Use evaluation data to identify trends and potential training gaps, so that training and education can be effectively targeted.

Topics to cover in education for non-clinical members of the workforce (such as ward clerks, porters, cleaners and food service workers) include how to escalate care if they are concerned about a patient, and how to respond if a patient or family member asks for help.

Topics to cover in education for clinicians include:

  • Recognising parameters and thresholds that indicate acute deterioration, including criteria for patient pain and distress, and clinician concern or worry
  • Identifying escalation actions when thresholds indicating acute deterioration are reached
  • Processes and mechanisms for escalating care
  • The role and capacity of responders
  • What to do if the expected response is delayed or does not adequately deal with the problem
  • Communication skills such as graded assertiveness
  • Professional behaviours in successfully operating recognition and response systems.

Effective escalation of care relies on effective communication. A large amount of information may be communicated to many clinicians when acute deterioration occurs. There are risks to patient safety if information is not comprehensive, relevant and clearly understood.14 Develop standardised and structured communication prompts and tools for clinicians to use when escalating care, in accordance with the requirements of the Communicating for Safety Standard.

Resources to support handover of critical information are available from the Commission’s website.

Provide education and training for responders about expected professional behaviours, and effective teamwork and communication skills, to foster positive experiences for members of the workforce who escalate care.

Provide processes for members of the workforce to routinely give feedback about their experiences of escalating care, and use this information to improve escalation protocols.

Day Procedure Services

Provide orientation, education and training for the workforce so that they understand their individual roles, responsibilities and accountabilities in the recognition and response systems. Use evaluation data to identify trends and potential training gaps, so that training and education can be effectively targeted.

Topics to cover in education for non-clinical members of the workforce (such as reception workforce, porters, cleaners and food service workers) include how to escalate care if they are concerned about a patient, and how to respond if a patient or family member asks for help.

Topics to cover in education for clinicians include:

  • Recognising parameters and thresholds that indicate acute deterioration, including criteria for patient pain and distress, and clinician concern or worry
  • Identifying escalation actions when thresholds indicating acute deterioration are reached
  • Processes and mechanisms for escalating care
  • The role and capacity of responders
  • What to do if the expected response is delayed or does not adequately deal with the problem
  • Communication skills such as graded assertiveness
  • Professional behaviours in successfully operating recognition and response systems.

Effective escalation of care relies on effective communication. A large amount of information may be communicated to many clinicians when acute deterioration occurs. There are risks to patient safety if information is not comprehensive, relevant and clearly understood.14 Develop standardised and structured communication prompts and tools for clinicians to use when escalating care, in accordance with the requirements of the Communicating for Safety Standard.

Resources to support handover of critical information are available from the Commission’s website.

Provide processes for members of the workforce to routinely give feedback about their experiences of escalating care, and use this information to improve escalation protocols.

Examples of evidence

Select only examples currently in use:

  • Training documents about the roles, responsibilities and accountabilities of the workforce for using the recognition and response systems
  • Examples of communication prompts and tools used for escalating care
  • Audit results of the use of communication prompts and tools when escalating care
  • Quality improvement system that includes analysis of feedback on the workforce’s experiences of escalating care, to improve escalation protocols
  • Feedback provided on the recognition and response systems
  • Audit results of compliance with the use of recognition and response systems
  • Reports on investigations into incidents associated with failure to use recognition and response systems, and associated quality improvement projects.
MPS & Small Hospitals

MPSs and small hospitals should ensure that care is escalated when acute deterioration is recognised. If possible, use the resources developed by the Local Hospital Network, state or territory health department or nearby larger hospital to support the education of clinicians working in the small hospital or MPS.

Provide orientation, education and training for the workforce so that they understand their individual roles, responsibilities and accountabilities in the recognition and response systems. Use evaluation data to identify trends and potential training gaps, so that training and education can be effectively targeted.

Topics to cover in education for non-clinical members of the workforce (such as ward clerks, porters, cleaners and food service workers) include how to escalate care if they are concerned about a patient, and how to respond if a patient or family member asks for help.

Topics to cover in education for clinicians include:

  • Recognising parameters and thresholds that indicate acute deterioration, including criteria for patient pain and distress, and clinician concern or worry
  • Identifying escalation actions when thresholds indicating acute deterioration are reached
  • Processes and mechanisms for escalating care
  • The role and capacity of responders
  • What to do if the expected response is delayed or does not adequately deal with the problem
  • Communication skills such as graded assertiveness
  • Professional behaviours in successfully operating recognition and response systems.

Effective escalation of care relies on effective communication. A large amount of information may be communicated to many clinicians when acute deterioration occurs. There are risks to patient safety if information is not comprehensive, relevant and clearly understood.14 Develop standardised and structured communication prompts and tools for clinicians to use when escalating care, in accordance with the requirements of the Communicating for Safety Standard.

Resources to support handover of critical information are available from the Commission’s website.

Provide education and training for responders about expected professional behaviours, and effective teamwork and communication skills, to foster positive experiences for members of the workforce who escalate care.

Provide processes for members of the workforce to routinely give feedback about their experiences of escalating care, and use this information to improve escalation protocols.

Last updated 30th May, 2018 at 01:46am
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References

Johnston M, Arora S, King D, Stroman L, Darzi A. Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study. Surgery 2014;155(6):989–94.

DeVita MA, Bellomo R, Hillman K. Introduction to the rapid response systems series. Joint Comm J Qual Pat Saf 2006;32(7):359–60.

DeVita MA, Bellomo R, Hillman K, Kellum J, Rotondi A, Teres D, et al. Findings of the First Consensus Conference on Medical Emergency Teams. Crit Care Med 2006;34(9):2463–78.

Jones D, Opdam H, Egi M, Goldsmith D, Bates S, Gutteridge G, et al. Long-term effect of a medical emergency team on mortality in a teaching hospital. Resuscitation 2007;74(2):235–41.

Chen J, Bellomo R, Flabouris A, Hillman K, Finfer S.. The relationship between early emergency team calls and serious adverse events. Crit Care Med 2009;37(1):148–53.

Calzavacca P, Licari E, Tee A, Egi M, Downey A, Quach J, et al. The impact of a rapid response system on delayed emergency team activation patient characteristics and outcomes: a follow-up study. Resuscitation 2010;81(1):31–5.

Calzavacca P, Licari E, Tee A, Egi M, Haase M, Haase-Fielitz A. A prospective study of factors influencing the outcome of patients after a medical emergency team review. Inten Care Med 2008;34(11):2112–6.

Douw G, Schoonhoven L, Holwerda T, Huisman-de Waal G, van Zanten AR, van Achterberg T, et al. Nurses’ worry or concern and early recognition of deteriorating patients on general wards in acute care hospitals: a systematic review. Crit Care 2015;19(1):230.

McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, et al. Confidential inquiry into quality of care before admission to intensive care. BMJ 1998;316(7148):1853–8.

Chen J, Bellomo R, Flabouris A, Hillman K, Finfer S. The relationship between early emergency team calls and serious adverse events. Crit Care Med 2009;37(1):148–53.

Peisah C, Chan DK, McKay R, Kurrle SE, Reutens SG. Practical guidelines for the acute emergency sedation of the severely agitated older patient. Intern Med J 2011;41(9):651–7.

Clinical Excellence Commission. Partnering with patients. Sydney: CEC; 2016 [cited 2016 Sep 28].

Australian Commission on Safety and Quality in Health Care. OSSIE guide to clinical handover improvement. Sydney: ACSQHC; 2010.