. 2021 Jan 28;21:15. doi: 10.1186/s12873-021-00403-9

Table 1.

Why do healthcare professionals fail to escalate as per the EWS protocol? Study Characteristics

Author (year), Country Study setting	Study design (focus group interviews, face-to-face interviews, other) Qualitative methodology (e.g. Ethnography, narrative, phenomenological, grounded theory)	Type of healthcare professional	Outcomes assessed: Data describing the views, experiences and behaviours of HCPs and why there is a failure to escalate as per protocol with EWS	Type of EWS or RRT in operation
Astroth (2012), [25] USA 3 medical/surgical units, community hospital	Face-to-face interviews Analysis: concept analysis	Nurses (n = 15)	Facilitators and barriers to RRT activation	RRT in a 155-bed Midwestern community hospital. No other details provided.
Benin (2012), [26] USA 1 academic hospital	Face-to-face interviews Analysis: thematic analysis and the constant comparative method	49 participants: Nurses [18], primary team senior attending physicians [6], house staff members [6] RRT attending physicians [4], RRT critical care nurses [4], RRT respiratory technicians [3] administrators [8]	To create a comprehensive view of the impact and value of an RRT on a hospital and its staff, the objective of this study was to qualitatively describe the experiences of and attitudes held by nurses, physicians, administrators, and staff regarding RRTs.	Adult RRT implemented in 2005 consisting of a hospitalist physician, a critical care nurse and a respiratory therapist. The RRT was triggered by specific criteria which were not listed in the study.
Braaten (2015), [29] USA Non-teaching, acute care hospital	Cognitive work analysis. Face-to-face interviews, Document review Analysis: Directed content analysis	Nurses (n = 12) 11 female, 1 male from the medical-surgical wards	To describe factors within the hospital system that shape medical-surgical nurses RRT activation behaviour	Conducted in the medical-surgical units in a large hospital in Colorado with a well-established RRT system with a standardised policy and calling criteria, developed and implemented in 2005.
Cherry (2015), [24] UK Acute NHS hospital	Focus groups Analysis: Framework analysis technique	Nurses (n = 6) 1 focus group 1 band 7, 1 band 6 and 4 staff nurses from the AMU	To understand the attitudes of qualified nursing staff on the AMU concerning the MEWS score chart used to monitor patients.	The MEWS was in use in the AMU and the hospital, including 8 parameters (respiratory rate, oxygen saturation, inspired oxygen, heart rate, systolic blood pressure, central nervous system level using the alert, voice, pain, unresponsive (AVPU) tool, urine output and temperature. Observations were to be measured minimum 12-hourly and more frequently depending on the MEWS score.
Chua (2013), [32] Singapore 1 acute hospital	Face-to-face interviews with critical incident technique (CIT) Analysis: content analysis	Enrolled nurses (ENs) (n = 15) ENs: non-registered nursing staff provide bedside nursing care and routine vital signs monitoring and convey findings to the registered nurses	Experiences of ENs with the deteriorating patient in pre-cardiac arrest situations. Strategies to enhance the role of ENs in detecting and managing ward deteriorating patients	No system reported but vital signs were used to detect deterioration.
Elliott (2015), [16] Australia 8 different hospital sites	Focus groups (44) Analysis: thematic analysis	Staff (n = 218) (mainly nurses and doctors)	Experiences and views of staff using ORCs in clinical practice	ORCs based on the ADDS and a RRT with clear protocols for escalation.
Johnston (2014), [19] UK 3 hospitals across London	Semi-structured interviews Analysis: Emergent theme analysis	41 participants: attending/senior resident grade surgeons [16], surgical postgraduate year 1 (11), surgical nurses [6], intensivists [4], critical care outreach team members [4]	The current escalation landscape; When junior doctors and nurses should escalate care; Information required prior to senior review; Barriers to successful escalation of care; Strategies to improve the escalation process.	Escalation of care across the surgical pathway from the specialities of General Surgery, Vascular Surgery, and Urology from 3 London hospitals was examined. No other details provided.
Kitto (2015), [17] Australia 4 hospitals	Multiple case study (focus groups) Conceptual framework: Collective competence and inter-professional conceptual framework Analysis: Directed content analysis & conventional content analysis	89 participants (10 focus groups): doctors [27], nurses (62)	Medical and nursing staff experiences of RRT Explore the reasons why staff members do not activate the RRT	RRT in 4 different hospitals. No other details provided.
Lydon (2016), [30] Ireland 1 teaching hospital	Mixed Methods, semi-structured interviews Analysis: Deductive content analysis	30 participants: Interns [1st year of postgraduate training] [18], Senior NCHDs [2], Nurses [10]	To examine the perceptions of a national PTTS among nurses and doctors and to identify the variables that impact on intention to comply with protocol.	A PTTS using the NEWS and ISBAR communication tool
Mackintosh (2012), [20] UK 2 tertiary teaching hospitals **Same sample as Mackintosh (2014)	Ethnography; Observation of interactions among multi-professional healthcare staff and patient management processes; semi-structured interviews. Analysis: framework approach	150 h of observations 35 interviews: Doctors [14], Ward and critical care nurses [11], Healthcare assistants [4], Safety leads and managers [6]	To illuminate the different contextual processes which contribute to patients’ rescue trajectories and clarify the benefits and limitations of particular safety strategies within a pathway of care for the acutely ill patient.	Five strategies were in use across 2 hospitals. At Westward, an EWS, escalation protocol, communication protocol (SBAR) and CCOT (comprised of nurses, physiotherapists and intensive care physicians) were in operation. In Eastward, there was an EWS and 2 of the medical wards were piloting an intelligent assessment technology (IAT) which utilised a different scoring system to the EWS already in use in Westward and included a personal digital assistant (PDA).
Mackintosh (2014), [21] UK 2 tertiary teaching hospitals **Same sample as Mackintosh (2012)	Ethnography: - Observations - Documentary evidence- protocols and audit data - Semi-structured interviews Theoretical framework: Bourdieu - logic of practice	180 h of observations: Interactions between health care staff, recording of patients’ vital signs, ward rounds, handovers and multi-disciplinary team meetings. 35 interviews: health care assistants, nurses, physicians, critical care staff and managers	Interviews with staff focused on the management of escalation of care, the role of the RRT, and the influence of organisational contextual factors on its application.
Massey (2014), [18] Australia 1 public teaching hospital	In-depth semi structured interviews.	Registered ward nurses (n = 15)	Nurses’ experiences and perceptions of using and activating METs	A large public teaching hospital with a well-established MET, using a single parameter system with specific MET calling criteria based on vital sign observations and thresholds.
McDonnell (2013), [22] UK District general hospital	Mixed methods with semi-structured interviews. Interviews before the training and approximately 6 weeks after the introduction of new charts Analysis: thematic framework	Nurses (n = 15)	Knowledge and confidence of nursing staff in an acute hospital	A 2 tier track and trigger system using either the standard observation chart or the detailed Patient at Risk (PAR) chart. Patients could be stepped up to the PAR chart (if they triggered) or stepped down to the standard chart. A CCOT was also in place.
Pattison (2012), [23] UK Specialist hospital	Grounded theory principles. Interviews. Analysis: Constant comparative technique.	9 participants: Nurses [7], Doctors [2]	To explore referrals to CCOT, associated factors around patient management and survival to discharge, and the qualitative exploration of referral characteristics (identifying any areas for service improvement around CCOT).	MEWS and CCOT in a specialist hospital.
Petersen (2017), [9] Denmark University hospital	Focus groups Analysis: Content analysis	Nurses (n = 18) 5 focus groups (3–5 participants in each) (2 male, 16 female from the medical and surgical acute care wards)	To identify barriers and facilitators related to three aspects of the EWS protocol: 1) adherence to monitoring frequency; 2) informing doctors of patients with an elevated EWS (≥3), and 3) call for the MET	A modified version of the NEWS has been in use in hospitals in the Capital Region of Denmark since 2013. Parameters included: respiratory rate, oxygen saturation, supplemental oxygen, temperature, systolic blood pressure, heart rate, and level of consciousness. Clear protocol for action based on EWS trigger scores in operation.
Stafseth (2016), [31] Norway University hospital	Semi-structured focus group interviews Analysis: Thematic analysis	Nurses (n = 7) 2 focus groups of 3 and 4 nurses.	Registered nurses’ experiences with the early detection and recognition of vital function failures and experiences with the use of the MEWS and the MICN.	A track and trigger system comprised of the MEWS and a 24-h on-call MICU, which was a nurse-led support service (not a team). MICU nurses were registered nurses with two years postgraduate education in critical care nursing and extensive experience in critical care.
Stewart (2014), [27] USA Acute care hospital	Mixed-methods; Focus groups Analysis: Thematic analysis	Nurses (n = 11) 5 focus groups with between 1 and 4 attendees, providers.	Perceptions of barriers and facilitators to the use of MEWS at the bedside	The MEWS scoring system was implemented in the hospitals electronic medical record system in 2011 where a RRT also exists.
Williams (2011), [28] USA Community hospital	Focus groups Analysis: Content analysis	Nurses (n = 14) 6 focus groups Staff nurses [6], Nurse clinicians [2] Supervisor/educators [6]	Thoughts and feelings about shared and “lived” experiences surrounding RRT use.	156-bed community hospital with a nurse-led RRT implemented in 2005. RRT consisted of an ICU registered nurses, an emergency department registered nurse and a respiratory therapist. Hospitalists often responded to RRT calls but were not obliged to according to hospital protocol.

Author (year), Country
Study setting

Study design (focus group interviews, face-to-face interviews, other)
Qualitative methodology (e.g. Ethnography, narrative, phenomenological, grounded theory)

Type of healthcare professional

Outcomes assessed:
Data describing the views, experiences and behaviours of HCPs and why there is a failure to escalate as per protocol with EWS

Type of EWS or RRT in operation

Astroth (2012), [25] USA

3 medical/surgical units, community hospital

Face-to-face interviews

Analysis: concept analysis

Nurses (n = 15)

Facilitators and barriers to RRT activation

RRT in a 155-bed Midwestern community hospital. No other details provided.

Benin (2012), [26] USA

1 academic hospital

Face-to-face interviews

Analysis: thematic analysis and the constant comparative method

49 participants: Nurses [18], primary team senior attending physicians [6], house staff members [6] RRT attending physicians [4], RRT critical care nurses [4], RRT respiratory technicians [3] administrators [8]

To create a comprehensive view of the impact and value of an RRT on a hospital and its staff, the objective of this study was to qualitatively describe the experiences of and attitudes held by nurses, physicians, administrators, and staff regarding RRTs.

Adult RRT implemented in 2005 consisting of a hospitalist physician, a critical care nurse and a respiratory therapist. The RRT was triggered by specific criteria which were not listed in the study.

Braaten (2015), [29] USA

Non-teaching, acute care hospital

Cognitive work analysis. Face-to-face interviews, Document review

Analysis: Directed content analysis

Nurses (n = 12)

11 female, 1 male from the medical-surgical wards

To describe factors within the hospital system that shape medical-surgical nurses RRT activation behaviour

Conducted in the medical-surgical units in a large hospital in Colorado with a well-established RRT system with a standardised policy and calling criteria, developed and implemented in 2005.

Cherry (2015), [24] UK

Acute NHS hospital

Focus groups

Analysis: Framework analysis technique

Nurses (n = 6)

1 focus group

1 band 7, 1 band 6 and 4 staff nurses from the AMU

To understand the attitudes of qualified nursing staff on the AMU concerning the MEWS score chart used to monitor patients.

The MEWS was in use in the AMU and the hospital, including 8 parameters (respiratory rate, oxygen saturation, inspired oxygen, heart rate, systolic blood pressure, central nervous system level using the alert, voice, pain, unresponsive (AVPU) tool, urine output and temperature. Observations were to be measured minimum 12-hourly and more frequently depending on the MEWS score.

Chua (2013), [32] Singapore

1 acute hospital

Face-to-face interviews with critical incident technique (CIT)

Analysis: content analysis

Enrolled nurses (ENs) (n = 15)

ENs: non-registered nursing staff provide bedside nursing care and routine vital signs monitoring and convey findings to the registered nurses

Experiences of ENs with the deteriorating patient in pre-cardiac arrest situations.

Strategies to enhance the role of ENs in detecting and managing ward deteriorating patients

No system reported but vital signs were used to detect deterioration.

Elliott (2015), [16] Australia

8 different hospital sites

Focus groups (44)

Analysis: thematic analysis

Staff (n = 218)

(mainly nurses and doctors)

Experiences and views of staff using ORCs in clinical practice

ORCs based on the ADDS and a RRT with clear protocols for escalation.

Johnston (2014), [19] UK

3 hospitals across London

Semi-structured interviews

Analysis: Emergent theme analysis

41 participants:

attending/senior resident grade surgeons [16], surgical postgraduate year 1 (11), surgical nurses [6], intensivists [4],

critical care outreach team members [4]

The current escalation landscape; When junior doctors and nurses should escalate care; Information required prior to senior review; Barriers to successful escalation of care; Strategies to improve the escalation process.

Escalation of care across the surgical pathway from the specialities of General Surgery, Vascular Surgery, and Urology from 3 London hospitals was examined. No other details provided.

Kitto (2015), [17] Australia

4 hospitals

Multiple case study (focus groups)

Conceptual framework: Collective competence and inter-professional

conceptual framework

Analysis: Directed content analysis & conventional content analysis

89 participants (10 focus groups):

doctors [27], nurses (62)

Medical and nursing staff experiences of RRT

Explore the reasons why staff members do not activate the RRT

RRT in 4 different hospitals. No other details provided.

Lydon (2016), [30] Ireland

1 teaching hospital

Mixed Methods, semi-structured interviews

Analysis: Deductive content analysis

30 participants:

Interns [1st year of postgraduate training] [18], Senior NCHDs [2], Nurses [10]

To examine the perceptions of a national PTTS among nurses and doctors and to identify the variables that impact on intention to comply with protocol.

A PTTS using the NEWS and ISBAR communication tool

Mackintosh (2012), [20] UK

2 tertiary teaching hospitals

**Same sample as Mackintosh (2014)

Ethnography; Observation of interactions among multi-professional healthcare staff and patient management processes; semi-structured interviews.

Analysis: framework approach

150 h of observations

35 interviews: Doctors [14], Ward and critical care nurses [11], Healthcare assistants [4], Safety leads and managers [6]

To illuminate the different contextual processes which contribute to patients’ rescue trajectories and clarify the benefits and limitations of particular safety strategies within a pathway of care for the acutely ill patient.

Five strategies were in use across 2 hospitals.

At Westward, an EWS, escalation protocol, communication protocol (SBAR) and CCOT (comprised of nurses, physiotherapists and intensive care physicians) were in operation.

In Eastward, there was an EWS and 2 of the medical wards were piloting an intelligent assessment technology (IAT) which utilised a different scoring system to the EWS already in use in Westward and included a personal digital assistant (PDA).

Mackintosh (2014), [21] UK

2 tertiary teaching hospitals

**Same sample as Mackintosh (2012)

Ethnography:

- Observations

- Documentary evidence- protocols and audit data

- Semi-structured interviews

Theoretical framework: Bourdieu - logic of practice

180 h of observations: Interactions between health care staff, recording of patients’ vital signs, ward rounds, handovers and multi-disciplinary team meetings.

35 interviews: health care assistants, nurses, physicians, critical care staff and managers

Interviews with staff focused on the management of escalation of care, the role of the RRT, and the influence of organisational contextual factors on its application.

Massey (2014), [18] Australia

1 public teaching hospital

In-depth semi structured interviews.

Registered ward nurses (n = 15)

Nurses’ experiences and perceptions of using and activating METs

A large public teaching hospital with a well-established MET, using a single parameter system with specific MET calling criteria based on vital sign observations and thresholds.

McDonnell (2013), [22] UK

District general hospital

Mixed methods with semi-structured interviews.

Interviews before the training and

approximately 6 weeks after the introduction of new charts

Analysis: thematic framework

Nurses (n = 15)

Knowledge and confidence of nursing staff in an acute hospital

A 2 tier track and trigger system using either the standard observation chart or the detailed Patient at Risk (PAR) chart. Patients could be stepped up to the PAR chart (if they triggered) or stepped down to the standard chart. A CCOT was also in place.

Pattison (2012), [23] UK

Specialist hospital

Grounded theory principles. Interviews.

Analysis: Constant comparative technique.

9 participants:

Nurses [7], Doctors [2]

To explore referrals to CCOT, associated factors around patient management and survival to discharge, and the qualitative exploration of referral characteristics (identifying any areas for service improvement around CCOT).

MEWS and CCOT in a specialist hospital.

Petersen (2017), [9] Denmark

University hospital

Focus groups

Analysis: Content analysis

Nurses (n = 18) 5 focus groups (3–5 participants in each)

(2 male, 16 female from the medical and surgical acute care wards)

To identify barriers and facilitators related to three aspects of the EWS protocol: 1) adherence to monitoring frequency; 2) informing doctors of patients with an elevated EWS (≥3), and 3) call for the MET

A modified version of the NEWS has been in use in hospitals in the Capital Region of Denmark since 2013. Parameters included: respiratory rate, oxygen saturation, supplemental oxygen, temperature, systolic blood pressure, heart rate, and level of consciousness. Clear protocol for action based on EWS trigger scores in operation.

Stafseth (2016), [31] Norway

University hospital

Semi-structured focus group interviews

Analysis: Thematic analysis

Nurses (n = 7)

2 focus groups of 3 and 4 nurses.

Registered nurses’ experiences with the early detection and recognition of vital function failures and experiences with the use of the MEWS and the MICN.

A track and trigger system comprised of the MEWS and a 24-h on-call MICU, which was a nurse-led support service (not a team). MICU nurses were registered nurses with two years postgraduate education in critical care nursing and extensive experience in critical care.

Stewart (2014), [27] USA

Acute care hospital

Mixed-methods; Focus groups

Analysis: Thematic analysis

Nurses (n = 11)

5 focus groups with between 1 and 4 attendees, providers.

Perceptions of barriers and facilitators to the use of MEWS at the bedside

The MEWS scoring system was implemented in the hospitals electronic medical record system in 2011 where a RRT also exists.

Williams (2011), [28] USA

Community hospital

Focus groups

Analysis: Content analysis

Nurses (n = 14)

6 focus groups

Staff nurses [6], Nurse clinicians [2] Supervisor/educators [6]

Thoughts and feelings about shared and “lived” experiences surrounding RRT use.

156-bed community hospital with a nurse-led RRT implemented in 2005. RRT consisted of an ICU registered nurses, an emergency department registered nurse and a respiratory therapist. Hospitalists often responded to RRT calls but were not obliged to according to hospital protocol.

Legend: ADDS: Adult Deterioration Detection System; AMU: Acute Medical Unit; CCOT: Critical Care Outreach Team; CIT: Critical Incident Technique; EN: Enrolled Nurses; EWS: Early Warning System; HCP: Health Care Professional; MEWS: Modified Early Warning System; MET: Medical Emergency Teams; MICN: Mobile Intensive Care Nurse; NCHD: Non Consultant Hospital Doctor; ORC: Observation Response Chart; PTTS: Physiological Track and Trigger System; RRT: Rapid Response System; RRT: Rapid Response Team