Why do escalation pathways fail? A human factors perspective on early warning systems in acute Irish hospitals

Early Warning Systems (EWS) enhance patient outcomes by reducing mortality, cardiac arrests, unplanned critical care admissions, length of stay, and serious adverse events. The Irish National Early Warning System (INEWS) V.2, launched in 2020, requires nurses to monitor vital signs and trigger responses via an escalation protocol involving physicians of varying seniority. While escalation pathways are clearly defined, barriers persist that hinder appropriate escalation of care, resulting in a ‘failure to escalate,’ which increases the likelihood of ‘failure to rescue’: failure to deliver the interventions needed to mitigate patient deterioration. To identify and evaluate the barriers and enablers influencing nurses and physicians in escalating care for deteriorating patients in acute Irish hospitals. A mixed-methods empirical study underpinned by a human factors’ perspective. Semi-structured, stakeholder-specific focus groups were conducted with nurses, junior and senior physicians at two Irish hospitals. One focus group for each stakeholder per hospital resulting in a total of six focus groups. Thematic analysis of focus group data was guided by a human factors’ sociotechnical systems framework. Insights were subsequently used to design a survey aimed at quantifying key barriers and enablers across a broader sample of healthcare staff. Three key emerging themes are reported: governance, teamwork, and communication. A notable enabler was the concept of "home-base wards" (home wards), which facilitated better teamwork, communication, and escalation of care. These findings align with international literature on escalation of care. This study underscores the value of a human factors approach in addressing barriers and enablers to care escalation. Home wards were identified as a critical enabler with potential to enhance teamwork, communication, and patient safety. Future research should explore the broader impact of home wards on escalation processes, with particular attention to their role in fostering effective teamwork and communication.