Development and Implementation of an Escalation Protocol for Internal Medicine Trainees

Abstract

Background: Overnight, physicians in training receive less direct supervision. Decreased direct supervision requires trainees to appropriately assess patients at risk of clinical deterioration and escalate to supervising physicians. Failure of trainees to escalate contributes to adverse patient safety events.

Objective: To standardize the evaluation of patients at risk of deterioration overnight by internal medicine residents, increase communication between residents and supervising physicians, and improve perceptions of patient safety at a tertiary academic medical center.

Methods: A multidisciplinary stakeholder team developed an overnight escalation-of-care protocol for residents. The protocol was implemented with badge buddies and an educational campaign targeted at residents, supervising physicians, and nursing staff. Residents and supervising physicians completed anonymous surveys to assess the use of the protocol; the frequency of overnight communication between residents and supervising physicians; and perceptions of escalation and patient safety before, immediately after ("early postintervention"), and 8 months after ("delayed postintervention") the intervention.

Results: Seventy-five (100%) residents participated in the intervention, and 57-89% of those invited to complete surveys at the various time points responded. After the intervention, 82% of residents reported using the protocol, though no change was observed in the frequency of communication between residents and supervising physicians. After the implementation, residents perceived that patient care was safer (early postintervention, 47%; delayed postintervention, 72%; P = 0.02), and interns expressed decreased fear of waking and being criticized by supervising physicians.

Conclusion: An escalation-of-care protocol was developed and successfully implemented using a multimodal approach. The implementation and dissemination of the protocol standardized resident escalation overnight and improved resident-perceived patient safety and interns' comfort with escalation.

Keywords: clinical deterioration; communication; escalation of care; patient safety; residency training.

Figure 1.

NF escalation-of-care protocol badge buddy. Notification implies that residents must, at minimum, contact the appropriate supervising physician by page. AMA = against medical advice; Hgb = hemoglobin; MICU = medical intensive care unit; NF = night float; PACU = postanesthesia care unit; Plt = platelets; PRN = pro re nata (as needed); R2 = second-year internal medicine resident; R3 = third-year internal medicine resident; SOB = shortness of breath.

Figure 2.

Framework and timeline of the study. The clinical quality improvement study occurred in three phases: 1) development of the intervention (escalation-of-care [EoC] protocol), 2) implementation of the intervention, and 3) dissemination of the intervention. The EoC protocol was developed over the course of six months. The initial implementation involved distributing educational materials to interns and supervising physicians over the course of one month, three months after which delayed dissemination or scale-up to all residents and nursing staff occurred over the course of one month.