Humanising the Escalation of Care: Developing COURAGE as a Tool for Patient Safety

Working in the ICU can be stressful, especially when the stakes are high, patients' conditions are complex and deteriorating, and life or death decisions need to be made quickly. Many challenges to patient safety can and do arise, often engaging one of the most difficult tasks: the need to escalate. Failures to escalate are a significant cause of errors and compromises to patient safety. Our goal is to describe a new approach through the lens of humanising the ICU and what escalation requires: COURAGE.

Introduction: Challenges to Patient Safety in the ICU

“Two roads diverged in a wood, and I—

I took the one less traveled by,

And that has made all the difference.”

― Robert Frost

“Never be bullied into silence. Never allow yourself to be made a victim. Accept no one’s definition of your life; define yourself.”

― Robert Frost

Patient safety is a fundamental part of care and is needed to provide the best quality of care for the sickest patients. Safety is particularly challenging in the ICU given the complexity and severity of illness, the use of ever-changing advanced life support technologies and the increased risk of complications. Challenges that are known to place patient safety at risk include but are not limited to: complexity of care (patient comorbidities, hospital-acquired infections, invasive procedures, polypharmacy), technology-related issues (complexity of the electronic medical records use, alarm fatigue, new or changed equipment/technologies, cybersecurity issues), patient and family related issues as well as ethical and legal concerns (such as end of life discussions/decision-making, assessments of consent and autonomy to make decisions, cultural and religious variability) and failures to escalate (Hang et al. 2023; Lintern 2017).

Failure to Escalate: A Safety Concern

Failure to escalate care in the ICU is usually a consequence of a complex interplay between human, organisational and systemic factors. Junior healthcare workers, no matter their professional background, those who have been recently hired because of staff shortages, are often more intimidated at the thought of questioning and/or feel reluctant to challenge senior or more experienced workers due to lack of confidence, patient variability, fears of being judged, fears of being perceived to lack knowledge, fears of being rejected or disliked, desire to avoid conflicts in the working environment, so they opt to remain silent (O'Neill et al. 2021). On other occasions, overconfidence and having high cognitive bias can lead to misdiagnosis or unanticipated clinical deterioration for patients (O'Neill et al. 2021). Failures to escalate are not, however, limited to less experienced staff. Poor team dynamics and the lack of proper interdisciplinary communication during handover between the different members of the care team (doctors, nurses, and other care providers), intra and inter-team tensions and poor leadership, delay decision-making and thus escalation of care (Ede et al. 2019; Liu et al. 2022). From an organisational perspective, the lack of proper clinical mentorship, communication training, and escalation protocols create a further challenge to patient safety. Moreover, from a system perspective, the hierarchical nature of the workplace, the presence of a blame culture and the lack of psychological safety all constitute further threats to proper patient care (Walton 2006; Law and Chan 2015; Mackintosh and Sandall 2010).

What Has Been Done So Far?

With the goal of optimising patient care and creating a culture of safety, efforts have been made to address the importance of escalation of care, to improve team dynamics and develop skills among junior healthcare workers and teams by creating a shared mental model that focuses on core competencies such as leadership, mutual support, situation monitoring and communication. An example of this is TeamSTEPPS, which consists of communication guidelines and training that have focused on topics such as closed-loop communication, situation monitoring, team-centred discussion, patient-centred communication, conflict management and clear respectful communication (Hassan et al. 2024). Another example is CUS, which is a tool developed to set a common nomenclature for healthcare workers to adopt when a safety concern is identified. C: first state the concern, U: to state why they are uncomfortable, and S: If the conflict is not resolved, state that there is a safety issue.

Literature has shown that implementation of escalation pathways does lead to perceptions of increased patient safety (Babroudi et al. 2021). So, why do people still fail to escalate despite the presence of safety concerns? Although those tools are standardised and have been proven to be effective in various settings, they are not always culturally accepted, especially when the psychological safety of the person who has identified the safety issue is not guaranteed in highly hierarchical, punitive and toxic work cultures, whether such work culture is real or perceived as such. What if people feel unsafe or intimidated when speaking up? What if they perceive their actions or failures to act are contributing to the patient's current safety issue? What if the system approach to patient safety is known to engage hospital-based critical incident or root cause analysis reporting and review, and they fear being judged and blamed (even though statements are made that the goals of such reviews are not to assign blame)? What if workplace gossip is prevalent? TeamSTEPPS and CUS tools are great as prompts, yet they fail to consider the very human nature of what escalation of concerns means for the healthcare professionals on whom they depend. If they speak up, does it guarantee that the receiver will acknowledge and act appropriately? What if their concern is ignored and not attended to? Or worse, what if they are devalued for asking questions or raising concerns? Creating a culture of safety is the goal; however, its execution often remains elusive due to leadership, inclusivity and psychological safety issues (Curry et al. 2018; Hebles et al. 2022; Nembhard and Edmondson 2006; Liu et al. 2022). Addressing such issues is fundamental to improving patient safety. Put simply, addressing such issues is core to humanising the ICU for healthcare professionals.

The Human Factor as a Safety Concern: Humanising the ICU

Healthcare workers, whether junior or senior, are subject to immense levels of stress while working under high pressure in the ICU. Having to deal with uncertainty, dying patients, grieving family members, staffing shortages, long working hours, poor sleep and eating habits, those workers are functioning on tasks with little to no attention given to their own well-being (Lin et al. 2021; Nakweenda et al. 2022). Recent data has shown increased level of health workers chronic fatigue and burnout (De Hert 2020). Although healthcare workers should care for patients with the utmost professionalism and highest scientific objectivity, burnout and fatigue remain prevalent despite wellness initiatives which are often only periodic in nature, may not be feasible to perform in an ICU environment, do not promote systematic approaches to well-being, do not address issues of psychological safety or leadership and place the onus on healthcare workers themselves without addressing organisation and systemic challenges.

Healthcare is fundamentally humans trying to help other humans through illnesses and through periods of vulnerability greater than their own. While being trained to work in a professional context and to perform in some standardised forms, forgetting these healthcare professionals are first and foremost humans with diverse backgrounds, training, psychological and personal experiences, and outlooks dehumanises them. To be reduced to a set of roles and responsibilities in many ways devalues the richness of care and empathy that is brought to their caring role - the care they provide to critically ill patients and their families - simply through sharing their common humanity. Burned-out nurses, doctors and other allied health professionals, working in workplaces they perceive or experience as toxic, are at an increased risk of committing medical errors and risk impaired rational judgement, fear and anxiety when it comes to prompt decision making and to the escalation of their concerns, compromising patient safety (Tawfik et al. 2018). It is past time to change such workplaces, and consistent efforts should be taken to build psychologically safe work environments that will close the gap between being "professional" and being "human". Humanising the ICU is currently a "hot topic" in critical care medicine. In the context of patient safety, unless such humanisation happens, efforts to promote patient safety will remain static and may even be curtailed as most ICUs around the world rebuild their teams by welcoming less experienced new physicians and inter-professional team members in this post-pandemic period.

As part of these efforts to humanise the ICU, we are proposing to acknowledge and name what the ask is of the healthcare worker faced with the need to escalate a patient safety concern in order to continue to move our common goal of providing the best quality of patient care forward: the ask is to display COURAGE (Table 1).

As a proposed new algorithm to address ongoing failures to escalate by incorporating a humanising lens, COURAGE draws on well-established concepts from TeamSTEPPS and CUS. COURAGE adds some additional concepts, requiring all who seek to promote patient safety to understand what is required of the healthcare worker involved. This new approach also seeks to appeal to the human in the healthcare professional by asking them to understand the importance of trusting their feelings and judgement that there are issues of patient safety at stake, and of understanding that asking for help is not an option based on their fiduciary duties for they must put their patient's interests above their own. COURAGE goes farther, though, in acknowledging that the ask may be difficult, the response may not be what it should be, and the expected and needed help may not be provided. Arising from the question of what the potential consequences for the patient of the perceived safety event are, COURAGE appeals to both the human and the healthcare professional with respect to the need to escalate further. Such escalation may differ according to organisational practices and policies. The point is that it is acceptable once again to ask for help and to analyse from the personal healthcare worker's perspective if they received the help they were seeking.

COURAGE: A QI Tool in Simulation-Based Education

In our innovative simulation-based teaching of new ICU interprofessional team members at Toronto Western Hospital, University Health Network (Toronto, Canada), we are using COURAGE as a tool to promote the appropriate escalation of care to break through the clinical challenges and assure improved patient safety. Without research into its effectiveness, COURAGE will only remain as a theoretical nomenclature with no clear clinical significance. Through high-fidelity simulation-based education sessions taught by one of the authors (FT) with experienced nursing faculty, COURAGE was trialled at our centre to train and debrief a newly hired small group of ICU nurse. The goal was to teach them when and how to escalate care when faced with adversities and challenging clinical contexts. Initial feedback was very positive: new nurses who participated in these sessions have indicated that they feel now more comfortable working with uncertainty and that escalating concerns feels less stressful. Further structured research is, of course, required, and we would welcome broader worldwide participation in such QI initiatives to better evaluate the effectiveness of the COURAGE approach we propose. We hypothesise that applying a humanising lens to escalation will decrease failures to escalate within teams and across organisations. Quality improvement initiatives with simulation-based training are needed, and future interdepartmental collaborations are welcomed to have this tool extrapolated and evaluated in different clinical settings.

Conclusion

To address the ongoing patient safety issues that arise from failures to escalate, we propose the incorporation of a humanising lens to previously developed approaches such as TeamSTEPPS and CUS. While they have been effective, failures to escalate persist and efforts to decrease such instances through policies, "cultures of safety" and "no blame" approaches have not achieved the anticipated success. Combining the success of TeamSTEPPS and CUS, with naming the very human ask required, we propose a new approach, that of COURAGE.

It has been five years now since our field was changed by the COVID-19 pandemic and its aftermath. While what we do is fundamentally the same, critical care teams have undergone many changes in who we are, how we work, and we continue to evolve. At the start of the events that would propel these changes, one of the slogans, meant initially to encourage and acknowledge, that subsequently became a rallying cry was "not all heroes wear capes". Many of us felt very uncomfortable being labelled or self-identifying as a hero for what we are trained to do. Many of us still do. Yet... whether heroes wear capes or scrubs, what they do have in common is COURAGE, the courage to stand up for what is right.

Conflict of Interest

None.