Purpose: Our objective was to understand the culture of escalating acute medical issues to hospitalist attendings on our resident teaching service and develop a policy to standardize escalation of care.
Description:
We administered surveys to residents and hospitalists to better understand the culture of escalation at our hospital. We received 63 responses from 138 residents (45.7%) and 26 responses from 49 hospitalists (53.1%). While a majority of residents agreed or strongly agreed that they are expected to notify hospitalists on acute changes in patient condition (80.7%) and that hospitalists are available throughout the day (91.2%), only 52.4% of residents indicated that they frequently or always notify their attending of acute changes. Only 52.0% of hospitalist respondents agreed that residents know which clinical conditions require attending notification. When asked which clinical conditions require attending notification, there was discordance between hospitalists and residents. Only 28.8% of residents believed unanticipated mental status change requires notification within 1-2 hours, compared to 79.2% of hospitalist respondents. Similarly, only 25.4% of residents believed new admissions requiring a stepdown unit require early attending notification compared to 79.2% of hospitalists, and only 25.4% of residents believe new significant vital sign abnormality requires early escalation compared to 70.8% of hospitalists. Likely contributing to these discrepancies, only 43.9% of residents and 60.0% of hospitalists agreed that clear instructions were given to notify attending physicians for specific clinical situations.
To improve the consistency in which appropriate changes in clinical condition are escalated to attendings, a work group comprised of residents, hospitalists attendings and quality managers drafted an escalation policy (figure). The policy delineates 12 clinical conditions in which residents are expected to notify attending physicians and document that discussion in the electronic medical record. The protocol was introduced to hospitalists and residents at multiple forums, including emails, conferences, faculty meetings, and ward orientation at rotation changes. The policy was also publicized and made available through cards, posters, and online applications. Hospitalists review the escalation protocol with their resident teams at the start of each rotation.
Conclusions: The survey found that both residents and hospitalists expect certain clinical conditions to be escalated to an attending physician, yet fail to achieve this escalation consistently in practice. The results suggest that this discrepancy is due to lack of clear expectations set by hospitalist attendings, including a lack of formal instruction to escalate and clarity on the specific patient conditions requiring escalation. Through a workgroup with both resident and hospitalist representation, a list of escalation criteria was developed and implemented to standardize practice. Performance will be regularly assessed and the impact on patient outcomes will be tracked.