Exploring and improving the escalation of care process for deteriorating patients on surgical wards in UK hospitals
File(s)
Author(s)
Johnston, Maximilian Joseph
Type
Thesis
Abstract
Despite impressive progress in technical skills, the rate of adverse events in surgery remains unfavourably high. The variation seen in surgical outcomes may be dependent on the quality of ward-based surgical care provided to post-operative patients with complications, specifically, the recognition, communication and response to patient deterioration. This process can be termed escalation of care and is an under-explored area of surgical research. This thesis demonstrates the impact of delays in the escalation of care process on patient outcome. The facilitators of, and barriers to, escalation of care are then identified and described in the context of the UK surgical department. In order to prioritise areas within the escalation of care process amenable to intervention, a systematic risk assessment was conducted revealing suboptimal communication technology and a lack of human factors education as key failures. To ensure that communication technology intervention was conducted based on evidence, several exploratory studies describe the current methods of communication in surgery and explore areas of innovation and intervention. Following this, a human factors intervention bundle was implemented within a busy surgical department, which successfully improved supervision, escalation of care and safety culture. This thesis describes, for the first time, escalation of care in surgery and outlines important strategies for intervention in this safety-critical process. To date, ward-based care has been one of the most under-researched areas in surgery, despite its clear importance. The tools to improve escalation of care in surgery have been described and initial attempts at implementation have demonstrated great promise. Future use of these strategies should benefit surgeons and other clinical staff of all grades and ultimately, the surgical patient.
Version
Open Access
Date Issued
2015-04
Date Awarded
2015-09
Copyright Statement
Attribution NoDerivatives 4.0 International Licence (CC BY-ND)
Advisor
Darzi, Ara
King, Dominic
Arora, Sonal
Sponsor
National Institute for Health Research (Great Britain)
Grant Number
40490
Publisher Department
Surgery & Cancer
Publisher Institution
Imperial College London
Qualification Level
Doctoral
Qualification Name
Doctor of Philosophy (PhD)