escalation, notification, communication in the ED

see also:

• administrative aspects of Emergency Medicine in Australia

• communication, notifications and escalations of issues are critical components to safe delivery of effective healthcare in the emergency department
• care however must be given to ensure these processes do not become too complex, too time consuming or contribute to unnecessary cognitive overload
  • the recipient of any escalation notification should be clearly aware whether this is just an information notification (FYI) so that they are aware, or, it is for THEIR PERSONAL ACTION

• allocation of triage clinical urgency
• documentation of critical clinical details including alerts such as:
  • allergies
  • infectious risk
  • absconding risk
  • security risk
  • falls risk
  • language issues
• junior doctor clinical review by senior doctor
  • soon after assessment to ascertain the optimum investigation, management and disposition strategies
• clinical handover
• patient-initiated nurse call system
• patient-initiated “call for help” systems
• bedside emergency call system and response team
• nurse-initiated MET criteria abnormal vital sign escalation process
• nurse-initiated behaviour of concern (BOC) notification process
• order request documentation eg. request to have bloods or swabs taken, internal consults
• regular team huddles

• Trauma calls
• Stroke calls
• STEMI calls
• Code Blue, etc
• order request documentation eg. request to have radiology
• discharge letters to GPs
• referrals to inpatient teams, language services and outpatient requests
• requests for security attendance for a pending patient arrival who is a security risk

• regular huddles (perhaps 4 hourly) to escalate current status and issues and to look for opportunities to problem solve and address issues early
• these could be structured and routinely convey information such as:
  • General ED patient status parameters:
    • Number of patients in the ED
    • Number waiting to be seen by a doctor
    • Number waiting to be seen by a doctor more than x hours
    • Number patients presenting in past 2hrs
    • Maximal wait time
    • Number of ambulances waiting to offload and the maximal time waiting
    • Number of bed requests allocated ward beds vs not yet allocated and critical care / mental health admits
    • Number of patients mechanically restrained or intubated or requiring NIV
    • Short Stay Unit occupancy, numbers awaiting admission to the SSU, number of SSU patients awaiting a non-SSU ward bed or transfer out
  • General staffing parameters
    • this may be a traffic light system
  • Quality and safety issues
    • this may be a traffic light system
  • Environmental issues
    • this may be a traffic light system

• emergent security events
  • Code Grey
  • Code Black
  • duress alarms
• adverse event documentation and notification systems
  • eg. software such as Riskman
• system issue escalation and notifications
  • quality and safety
    • staff safety and experience
    • patient safety and experience issues
      • patient bed access / ED overcrowding issues
        • access block
        • ambulance ramping
        • excessive wait times
      • deaths in the ED
      • ISR 1 or 2 incidents
      • notable other incidents or near misses
      • absconding patients
    • legal matters
    • media requests and involvement
    • other issues of concern of which managers should be made aware
  • workforce issues
    • unexpected leave
    • staffing deficits
  • environmental issues
    • physical infrastructure
    • equipment and stores
    • ICT
• LUMPS notifications to line managers
  • LEGAL issues
    • coronial cases
    • illegal activity
    • threats of legal action
  • Up
    • up escalation of any issue to member of Executive which may have bypassed line managers
  • Media
    • someone threatening to go to the media
    • someone posting something on social media
  • Patient safety issues
    • ISR 1 or 2
    • significant patient safety issue / absconding patient
    • need to close cubicles/ beds
    • significant equipment failure
  • Staff safety issues
    • significant staff injury/reportable to Worksafe
    • other

• notification of patient expect
  • from GPs or other providers
  • from ambulance or police services
  • from wards or a hospital Code Blue response for a non-admitted person
• time-critical investigation results
  • phoned through to ED
• other abnormal investigation results
  • various notification and sign off mechanisms
• in-coming calls from inpatient teams responding to referrals
  • these may trigger an internal ED microphone communication to call the staff member to the phone if the individual staff member does not carry a phone for these purposes or is unable to answer it (performing a procedure, wearing PPE, etc)

• regular hospital Exec - HOU huddles / forums

• notification of special circumstances
  • outages or service reductions
  • Emergency Code system - eg. Code Red
  • potential infectious disease outbreaks eg. Legionella, measles
• process change notifications