Escalation Process Research Articles

Reflections on NHS Wales' escalation process: applying the observe, orient, decide and act loop

Reflections on NHS Wales' escalation process: applying the observe, orient, decide and act loop

The Art of Diplomacy in Modern Military Conflicts

The article reflects the process of forming a new world order in the context of the Global Hybrid War unleashed by the United States and NATO and the active use of its tools against the victims of aggression. The role of diplomacy in managing the processes of escalation and containment of modern military confl icts is shown. The author draws attention to the increasing threat of a global thermonuclear confl ict, the probability of which increases in the context of the use by Western countries of a proxy war strategy, which opens the way to large-scale aggression, including against nuclear states. The article highlights the urgent need to review the Russian strategy of nuclear deterrence in order to adapt it to the realities of our time.

Implementation and improvement of a routine suicidal ideation screening process for an ambulatory, academic NCCN-designated center.

294 Background: From May – August 2021, outpatient suicidal ideation-related safety events nearly doubled from the three years prior at an academic NCCN center. This rise in events challenged staff and revealed improvement opportunities for suicide prevention, such as routine screening for suicidal ideation (SI) in the ambulatory setting. In addition, the COVID pandemic introduced an added layer of vulnerability to cancer patients, who are at an increased SI risk compared to the general population. Methods: From August 2021 - 2023, a multidisciplinary team developed and implemented a routine SI screening, intervention and escalation process that included a staff education program, a process-aligned EHR build, a metric dashboard, and a quality improvement-control plan. The vision was to identify all patients experiencing SI and support them with timely and compassionate care. A step-up metric target approach was used to set quarterly goals. The overarching goal was to screen at least 70% of eligible patients by the end of fiscal year 2024. The new process went live organization-wide on July 31, 2023. Following implementation, various improvement opportunities were identified with indicators including performance metrics, process audits, patient case reviews, and stakeholder feedback. Initial improvement efforts focused on clinics and sites that were screening < 25% between FY24 Q1 and Q2. Continued collaboration between Quality Improvement and clinic leaders revealed improvement opportunities in identifying eligible patients and staff screening practices. Impactful interventions addressed patient identification and staff coaching. Results: As a new process, the overall screening rate started at 0% and increased to 48% over FY24*. Conclusions: Overall, a new SI screening process was successfully implemented, and improved with diligent PDSA work, yet metric goals were not achieved. Many factors may have contributed to underperformance. Ongoing evaluation and collaboration with stakeholders are crucial for continued improvement. Beyond these efforts exists the social and cultural stigma of suicide, which may have limited the impact of improvement endeavors. Results may demonstrate further need for open and supportive discussion with staff, patients, and the larger healthcare community. Data time range: 7/31/23-5/21/24.* FY24 + Quarter Metric Goal Screening Rate Q1 40% 35.7% Q2 50% 34.5% Q3 60% 41.2% Q4 70% 47.8%

Positive beliefs about cross-partisan empathy can strengthen Americans' support for democracy.

Undemocratic practices, such as voter suppression and election interference, threaten democracies worldwide. Across four studies (N = 4,350), we find that informational and motivational factors drive Americans' support for such practices. Partisans drastically overestimate how much opponents support undemocratic practices, which decreases people's willingness to defend democracy themselves (S1-S2). One remedy for this dynamic is to inform people about the extent to which their rivals actually support democracy, but in polarized contexts, people are incurious about the true beliefs of outpartisans. To address this, we test a new method for improving democratic attitudes-changing beliefs about cross-party empathy. Empathizing across disagreements can improve connections and boost persuasion. When people learn about these valued consequences of empathic engagement, their curiosity about outpartisans increases (S3), and they choose to learn about opponents' support for democracy, which reduces their own support for undemocratic practices and politicians (S4). Our findings suggest that fostering support for democracy requires not just informational strategies but also motivational ones. The power of our combined approach comes in that-instead of presenting people with information about outpartisans-it induces them to seek out that information themselves. Together, these results highlight how cross-party empathy beliefs can increase people's curiosity about those they disagree with and disrupt processes of political escalation.

Escalation process of critical values when these cannot be communicated on first attempt: A hospital-wide process improvement project.

Since laboratory critical values reflect such an abnormal pathologic state that there is imminent danger to the patient, it is crucial to deliver the result upon initial call with an escalation process when the initial call cannot occur. In our 8-hospital system, one of the hospitals used the escalation procedure twice as frequently compared with the other hospitals. This work presents hospital-wide quality improvement processes that decreased escalation of critical value calls so as to reach the same proportion of escalated calls compared to other hospitals in the system. The laboratory met weekly with leaders of different hospital areas and quality management; they presented the interventions they implemented, and the laboratory monitored their progress. Monitoring and reviewing with providers the importance of critical values decreased temporarily escalated calls from 25% to 18%. Having a dedicated phone to call critical values in each hospital area decreased the calls in a sustained fashion, which now fluctuate between 9% and 14%. Other interventions, including having a dedicated person receiving critical value results, did not decrease escalated critical value calls. Having a dedicated phone in each hospital area that receives the initial critical value call simplifies and standardizes the process.

Let's Talk Safety - Data from the Neonatal Intensive Care Unit Safety and Bed Capacity Huddles.

Huddles are brief team meetings designed to communicate essential information. Safety huddles provide a forum to identify and review patient safety events. In a just culture, everyone is accountable for patient safety. The purpose of this project is to discuss safety issues/events at the twice daily bed capacity huddles in a Level IV Neonatal Intensive Care Unit (NICU) utilizing a just culture model. Having daily discussions of patient safety and the escalation process for follow-up promotes a just culture. The aims are to improve the unit's culture of safety and learn from patient safety issues. A just culture model was adopted to promote discussion of safety events during the huddles. A structured checklist of safety events was utilized along with a script of ground rules. Twice a day, a multidisciplinary group gathers to huddle. Nurse leaders facilitate the discussion, track the results, and provide follow-up. The structured safety huddle began in May of 2020 and continues twice daily. All required staff attend. The escalation process is defined and has prevented recurrence of some safety issues. The NICU experienced a 14% increase in favorable results on the Agency for Healthcare Research and Quality (AHRQ) culture of safety survey since the inception of the structured safety huddles. Safety huddle discussions have impacted the culture of safety on this unit. Tracking of discussions can help to identify trends, improve processes, and impact patient safety.

Diplomacy in the context of escalating challenges and threats in world politics

The article reflects the most important factors determining the effectiveness of Russian diplomacy in the context of new challenges and threats associated with the development of processes of escalation of tension in the international situation. The relevance of the article is determined by Washington’s intensifi ed desire for dominance in the escalation of military and non-military methods of pressure on Moscow in order to achieve its stated geopolitical goals, the priority of which is inflicting strategic military defeat on Russia, fragmentation and destruction of our country.The novelty of the article lies in the author’s attempt to explore the vectors of development of the military-political situation in Ukraine in the direction of both vertical and horizontal escalation. Based on the analysis of the results obtained, the author substantiates the need for a signifi cant revision of the curricula of Russian universities in order to adapt them to the military-political realities of our time.

THE SPECTER OF NUCLEAR WEAPONS USE IN UKRAINE: THE NUANCES OF NUCLEAR WAR RISK

The essence of Russian security policy is composed of the combined use of conventional and unconventional threats both in war and peacetime. Russia is trying to dominate the process of escalation, especially by frequently threatening nuclear war in Ukraine. It tries to maintain the strategic initiative superiority, thereby forcing its enemies to act under its control. Put differently, by means of manipulating the fear of nuclear war in Ukraine, it tries to prevent other states from directly intervening in the battlefield and to prevent military aid to its enemies from becoming strategic. Methodologically, Russia's effort to gain dominance in escalating tensions through nuclear risk has been studied as a case study. The nuclear risk hinges on uncertainty of nuclear deterrence. The nuances of this often-ignored uncertainty are explained. Since such uncertainty poses credible risk of nuclear war, absolute victory is not possible. No party will get everything it wants, and therefore the only solution is diplomatic compromise through negotiation. The importance and implications of this article lie in the fact that the problems and warnings examined here are likely not only in Ukraine, but also in a possible future crisis over Taiwan and in future conflicts involving nuclear powers.

Opinions of Nurses and Physicians on a Patient, Family, and Visitor Activated Rapid Response System in Use Across Two Hospital Settings

Early detection of deterioration of hospitalized patients with timely intervention improves outcomes in the hospital. Patients, family members, and visitors (consumers) at the patient's bedside who are familiar with the patient's condition may play a critical role in detecting early patient deterioration. The authors sought to understand clinicians' views on consumer reporting of patient deterioration through an established hospital consumer-initiated escalation-of-care system. A convenience sample of new graduate-level to senior-level nurses and physicians from two hospitals in South Australia was administered a paper survey containing six open-ended questions. Data were analyzed with a matrix-style framework and six steps of thematic analysis. A total of 244 clinicians-198 nurses and 46 physicians-provided their views on the consumer-initiated escalation-of-care system. Six major themes and subthemes emerged from the responses indicating that (1) clinicians were supportive of consumer reporting and felt that consumers were ideally positioned to recognize deterioration early and raise concerns about it; (2) management support was required for consumer escalation processes to be effective; (3) clinicians' workload could possibly increase or decrease from consumer escalation; (4) education of consumers and staff on escalation protocol is a requirement for success; (5) there is need to build consumer confidence to speak up; and (6) there is a need to address barriers to consumer escalation. Clinicians were supportive of consumers acting as first reporters of patient deterioration. Use of interactive, encouraging communication skills with consumers was recognized as critical. Annual updating of clinicians on consumer reporting of deterioration was also recommended.

Implementing a Digital Deteriorating Patient Pathway to improve the safety and effectiveness of care of the adult deteriorating patient.

Identification, escalation and clinical review of the deteriorating patient is essential for a safe and effective hospital. We present a deteriorating patient pathway developed within our electronic patient record, including implementation of a digital escalation and senior review process, triggered from a logic algorithm and vital signs. The pathway is activated by an average 43 patients per day with median mortality of 13.3%. Our Trust has seen a significant improvement in escalation and senior review and increased use of treatment escalation plans. The pathway has facilitated a cultural shift in the Trust towards the deteriorating patient. The new pathway is transferrable to both other digital Trusts as well as maternity and paediatric practice.

The Front Lines: A Space of Violence. Characteristics, Mechanisms, and Contexts of Military Violence in the First World War between Containment and Escalation

AbstractThis article deals with the war crimes committed during the First World War. Whereas in historiography the presence of franc-tireurs, the new industrial warfare or the specific military and radicalised command culture of individual armies often served as explanatory patterns for the escalation of violence, this contribution attempts to introduce a different perspective into the discussion. The focus is on the specific violence of mobile warfare, which was articulated in the context of military “forward panics” (Randall Collins) on the Eastern and Balkan fronts and was responsible for a considerable part of the war crimes committed there. The article therefore deals with the nature and character of these military forward panics. Starting with a description of the spatial characteristics of the front as a specific space of violence, the role of military orders and the significance of the front as a soldierly space of imagination, the article analyses above all the structural violence of forward panics. In this context, the article discusses three factors that played an essential role in this escalation process: first, the special soldierly frame of reference of combat in mobile warfare, which continuously lowered the inhibition thresholds for the escalation of violence; second, the escalation-forcing dynamics that the swift advance or the flight-like retreat of the troops brought with it for the process of violence; and finally, third, the significance of soldierly group pressure for the process of escalation of violence.

From Threatening Chaos to Temporary Order through a Complex Process of Adaptation: A Grounded Theory Study of the Escalation of Intensive Care during the COVID-19 Pandemic.

To ensure high-quality care, operationalize resilience and fill the knowledge gap regarding how to improve the prerequisites for resilient performance, it is necessary to understand how adaptive capacity unfolds in practice. The main aim of this research was to explain the escalation process of intensive care during the first wave of the pandemic from a microlevel perspective, including expressions of resilient performance, intervening conditions at the micro-meso-macrolevels and short- and long-term consequences. A secondary aim was to provide recommendations regarding how to optimize the prerequisites for resilient performance in intensive care. A grounded theory methodology was used. First-person stories from different healthcare professionals (n70) in two Swedish regions were analyzed using the constant comparative method. This resulted in a novel conceptual model (including 6 main categories and 24 subcategories), and 41 recommendations. The conclusion of these findings is that the escalation of intensive care can be conceptualized as a transition from threatening chaos to temporary order through a complex process of adaptation. To prepare for the future, the components of space, stuff, staff, system and science, with associated continuity plans, must be implemented, anchored and communicated to actors at all levels of the system.

Non-elective inpatient anti-cancer therapy for solid tumors: To treat or not to treat?

234 Background: Administration of anti-cancer therapy to hospitalized patients is associated with greater treatment-related complications and reduced quality of life. We designed and implemented a standardized process to review all non-elective systemic anti-cancer therapy in solid-tumor patients with the goal of reducing aggressive end of life care and improving quality. Methods: A multidisciplinary group of quality and safety, pharmacy, physician, and nursing leadership designed a workflow to standardize the review of all inpatient anti-cancer treatment requests for non-elective solid-tumor (NEST) patients. Our NEST process begins with a formal pharmacy and nursing review, which can flag a case for further physician review. The pharmacist reviews for adequate hematologic counts, hepatic function, creatinine clearance as well as any active infections requiring IV antibiotics. Then the nursing review assesses treatment plan parameters, patient’s performance status, recent vital signs, and other clinical concerns. If either review flags one or more criteria, the case then goes to physician review. The NEST escalation process includes two levels of physician review – a single reviewer and a committee. If the review determines that there are more potential benefits than risks associated with administering anti-cancer treatment, the treatment can be approved for inpatient administration. However, if the formal review estimates significantly greater risk than potential benefit, the treatment will not be approved for inpatient administration. Results: A total of 58 requests for inpatient anti-cancer therapy occurred between initial implementation (10/31/2022) through 3/31/2023. 82.8% (48/58) were reviewed by both pharmacy and nursing and 45.8% of those were approved without need to escalate. The remaining requests had baseline patient characteristics that triggered physician review - with 13 reviewed by a single physician and 3 requiring committee review. Of the cases requiring further review, 5 did not receive their requested therapy (either denied or the family decided to not pursue treatment). 36.2% (21/58) of NEST patients died within 60 days of process initiation, 22.4% (13/58) died within 30 days, and 13.8% (8/58) died within 10 days. These outcomes were more common in individuals where NEST was denied or inpatient treatment was not pursued (77.8% died within 60 days, 44.4% died within 10 days; note 2 patients discharged to hospice with no death date on record). Conclusions: We designed a formal review process for anti-cancer therapy to be administered in the inpatient setting to solid tumor patients. This multi-disciplinary review led to 15.5% of requests not being administered to patients. Ongoing continuous improvement work focuses on further developing review criteria, exploring options for hard stops prior to treatment administration and increasing earlier goals of care discussions.

Insurance Approval Delay of Biologic Therapy Dose Escalation Associated with Disease Activity in Patients with Inflammatory Bowel Disease.

Dose escalation of self-injectable biologic therapy for inflammatory bowel diseases may be required to counteract loss of response and/or low drug levels. Payors often require completion of a prior authorization (PA), which is a complex approval pathway before providing coverage. If the initial PA request is denied, clinic staff must complete a time and resource-intensive process to obtain medication approval. This study measured time from decision to dose escalate to insurance approval and evaluated impact of approval time on disease activity. This was a single-center retrospective analysis of adult patients with IBD prescribed an escalated dose of biologic therapy at an academic center with an integrated specialty pharmacy team from January to December 2018. Outcomes included time to insurance approval and the association between approval time and follow-up C-reactive protein (CRP) and Short Inflammatory Bowel Disease Questionnaire (SIBDQ) scores. Associations were tested using linear regression analyses. 220 patients were included, median age 39, 53% female, and 96% white. Overall median time from decision to dose escalate to insurance approval was 7days [interquartile range (IQR) 1, 14]. Approval time was delayed when an appeal was required [median of 29days (IQR 17, 43)]. Patients with a longer time to insurance approval were less likely to have CRP improvement (p = 0.019). Time to insurance approval did not significantly impact follow-up SIBDQ scores. Patients who had a longer time to insurance approval were less likely to have improvement in CRP, highlighting the negative clinical impact of a complex dose escalation process.

A conflict escalation comparison: Couples from the general population and couples engaged in high‐intensity conflict

AbstractObjectiveThe purpose of the present study was to test a model that examines the characteristics of the escalation process among heterosexual couples. It also examined how women's use of verbal and physical violence is associated with a sense of danger in men.BackgroundThe prevalence of intimate partner violence (IPV) is a critical concern for public health. IPV has serious physical and mental health consequences on the victim.MethodsParticipants were 165 women. The first subsample (n = 70, 42.42%) comprised women from the general population, and the second (n = 95, 57.57%) was composed of women living in relationships characterized by high‐intensity conflict (research population). Structural equation modeling was performed to assess the hypothesized model and to test the research hypotheses.ResultsAnalysis indicates that the use of violence (verbal and/or physical) by one partner was positively correlated to the use of violence by the other partner. The analysis also shows that the woman's use of violence positively affects the man's sense of danger only for couples from the general population. Finally, the man's sense of danger is related to his violence toward the woman.ConclusionIn a high‐conflict relationship, violence is less reciprocal but escalates more easily, whereas in the general population, violence is more reciprocal but more moderate. In addition, emotions are an essential component of marital conflict and influence the development and management of conflict. Emotional components, such as a sense of danger, may be a risk factor in the escalation of conflict to violence.

Evaluating the role of the diagnostic radiographer in identifying child safeguarding concerns: A knowledge, attitude and practice survey approach

IntroductionChild safeguarding and the appropriate identification of suspected victims represents a global phenomenon. Diagnostic imaging is acknowledged as a contributory diagnostic service but the role of the radiographer in the identification and escalation process is less well understood. MethodA Knowledge, Attitude and Practice (KAP) survey was constructed to evaluate knowledge base in the context of the patient–radiographer interaction, the shaping of attitude towards child safeguarding and attitudes held towards their role plus the actual practical experiences of managing child safeguarding concerns. ResultsRespondents demonstrated a inconsistent knowledge base with respect to physical, social and radiographic signs and symptoms of child safeguarding concern. A positive attitude towards the role of the radiographer in child safeguarding was demonstrated but one that was shaped more by experience than pre-registration education.Assessment of concerns was chiefly influenced by clinical history and appreciation of aetiology. Practically, radiographers have infrequent involvement with the identification and escalation of concerns. Whilst some statistically significant relationships between responses and demographics did exist, these were either sporadic or argued to be a result of natural variation. ConclusionAssessment of physical and social signs of child safeguarding concern are argued to be becoming more challenging. Radiological signs continue to be visible to radiographers but with increasing use of other imaging modalities these signs are becoming more varied in nature and are providing new challenges. Radiographers are capable of escalation when required to do so. Implications for practiceTo maximise the contribution of the profession, education needs to account for imaging modality worked with, in combination with an understanding of related aetiology. Previously existing concerns with respect to escalating processes are no longer in evidence and radiographers are both willing and able to contribute to that process.

The escalation process of workplace bullying: A scoping review

The escalation process of workplace bullying: A scoping review

An action-reaction cycle in the Sino-Indian rivalry?

ABSTRACT The Sino-Indian rivalry traces its origins to the founding of each state in the late 1940s. Over the past decade Indian concerns over Chinese activities in South Asia have significantly increased. While New Delhi has sought to counter Beijing in South Asia, a key question is to what extent has China responded to India in the same region? Do we find evidence of a tit-for-tat rivalry escalation process in South Asia where both China and India are actively trying to counter each other? The central argument in this article is that China is not actively engaging in a direct form of rivalry reciprocity with India. While certain activities by Beijing in the region are designed to enhance Chinese influence and power, there is less evidence that these are a direct response to India. This is in contrast to New Delhi’s behavior in the region where we do find evidence of Indian leaders directly responding to China. This articles’ main contribution is to demonstrate that maintenance in asymmetrical positional rivalries does not require clearly identifiable points of escalation, or follow a linear path of a tit-for-tat action-reaction cycle.

Uncertainties and their treatment in the quantitative risk assessment of domino effects: Classification and review

Domino accidents are typical low-frequency and high-consequence events in chemical process industries. Applying quantitative risk assessment (QRA) in domino accident assessment is challenging due to the uncertainties in the escalation process. Meanwhile, the outcomes of QRA are subject to a certain degree of unreliability due to the inappropriate representation of uncertainty. This paper reviews the literature in the field of QRA of domino accidents that may happen in the chemical process industries. Firstly, the sources of uncertainty in risk assessment of domino effects are identified and categorized based on a fundamental structure of uncertainty and a QRA framework. Furthermore, the current methodologies and approaches applied for handling various uncertainties (input uncertainty, model parameter uncertainty, and model structure uncertainty) in the QRA related to domino effects are reviewed. Based on the literature review results, current challenges with respect to uncertainty handling in QRA of domino accidents are discussed, and recommendations for future research are given before the conclusions are presented. This study helps researchers to get insights into the interface between uncertainty fundamentals and the QRA framework and the current status of uncertainty handling in the QRA of domino effects. Furthermore, this study promotes the development of new approaches for handling uncertainty in domino accident analysis.

465 - Development and Implementation of an Escalation Process to Address Psychosocial Support Needs Identified in the Pre-Transplant Phase

465 - Development and Implementation of an Escalation Process to Address Psychosocial Support Needs Identified in the Pre-Transplant Phase