Medical emergencies in hospital: The role of treatment escalation plans in out-of-hours decision-making.

Abstract

Out-of-hours medical emergencies are common in acute hospitals, and are often attended by staff who are unfamiliar with the patient's clinical background. Information in the hospital notes may or may not include guidance about how best to deal with clinical deterioration. The use of Treatment Escalation Plans (TEPs) attempts to address these deficiencies. This was an observational, questionnaire-based evaluation of the experience of trainee hospital doctors who attended out-of-hours medical emergencies. Sixty-five medical emergencies were evaluated by a total of 38 doctors. Thirty patients had a TEP, attended by 20 doctors, and 35 without a TEP were attended by 27 doctors. Information from medical notes to facilitate decision-making was deemed sufficient by the attending doctor in 77% of patients with a TEP, compared to 54% of patients with no TEP. Only 10% of patients with a TEP had their treatment escalated at the time of the call, whereas this occurred in 20% of patients without a TEP (NS). A TEP was deemed 'somewhat' or 'very' helpful by trainees in 21/30 of the cases who had one. In 27/35 cases who did not have a TEP, trainees deemed that it would have been helpful to have had one. Twelve of 38 participants (32%) considered that there was a discrepancy between what was 'expected' and what they considered to be 'right' when managing out-of-hours emergencies. TEPs have an important role in delivering key information that shapes out-of-hours decision-making in deteriorating patients. Both objective outcomes and the subjective quality of medical decision-making are enhanced when a TEP is available.