Escalating deteriorating patients’ care in the Emergency Department: Characteristics and safety culture

Mr Cliff Connell1, Professor Ruth Endacott1, Professor Simon Cooper2

1Monash University, Frankston, Australia, 2Federation University, Churchill, Australia

Background: Physiological deterioration in patients is often heralded by clinical features such as abnormal vital signs and declining conscious state. Rapid Response Systems (RRS) have evolved to help recognise and stabilise patients experiencing clinical instability in general acute medical and surgical wards. More recently, there has been an increasing uptake of emergency department (ED) specific responses to patient deterioration. The prevalence of deterioration and the effectiveness of ward based RRS are well documented in the ‘Failure to Rescue’ (FTR) literature. However, the characteristics affecting FTR in ED specific RSS is are largely unknown.

Aim: To describe the relationships between dynamic ED characteristics (workload, skillmix and casemix), organisational culture (safety climate) and the care of the deteriorating ED patient.

Methods: Mixed methods comprising a safety climate survey, retrospective medical record review and staff interviews.

Results: Failure to rescue deteriorating ED patients is influenced by i) the safety culture within the ED, ii) the experience and expertise of the person documenting signs of deterioration, iii) staff self-confidence and confidence in others, iv) communication and team interaction, v) the ED area in which the patient is being cared for, vi) the interpretation and implementation of care based on the health services and national performance indicators, vii) education which is provided to support ED staff efforts to recognise and manage deteriorating patients, and viii) the vital sign which indicates physiological deterioration.

Conclusion: This study provides key recommendations for emergency practice and research priorities for recognising and managing deteriorating ED patients. These recommendations include i) site specific cultural evaluation and change, ii) educational strategies which include regular interprofessional in situ simulation based on ED specific deterioration scenarios, and iii) recommendations for the roles and responsibilities of ED response teams, and an ED specific track and trigger system befitting the ED patient profile.


With more than 30 years nursing experience, Cliff Connell has spent the last 20 years as an emergency nurse, ED clinical nurse educator, university lecturer and researcher. Currently a Monash Nursing and Midwifery lecturer and PhD candidate, Cliff’s research interests focus on patient safety, deteriorating patient outcomes, emergency care and evidence-based education.