Failure to Escalate by Jillian Fickenscher

Failure to escalate. That is one of the many concepts in Patient Safety that stood out to me today during the first day of our conference. I find this concept especially challenging in the environment of academic medicine. Unfortunately, a hierarchy as well as “tribes” or “silos” still do exist, as this has been so long-engrained in the culture of academic medicine. And this culture may often create a barrier to escalation.

I found myself thinking back to my first night of cross-covering the Family Medicine inpatient service at one of the community hospitals where our residents work. This hospital is a bit different than the University Hospital where there is always both an intern and a supervising resident in-house, and access to multiple specialists at all times. Because this is a smaller, community hospital, there is one resident (that night –me!) covering all the patients on our service, including all of the Med-Surg patients as well as those in the small ICU. There are no residents from any consulting services around. And if anything is needed, you call the attending physician directly.

I received “hand off” on my patients, and was thankful that we had only one patient in the ICU for my first night. I was told that he was improving overall and would likely transfer to the floor in the morning. However, a couple of hours into my shift, I received a page from his nurse, who was concerned. The patient had a new issue, unrelated to the reason he was hospitalized in the first place. He had hit his lower leg on a car door the day prior to his admission, which hadn’t been a concern that I was aware of – until tonight. The patient was having a significant amount of leg pain and per the nurse, seemed to be delirious, though neither she nor I knew very well what his prior baseline mental status was, as he was unfamiliar to us. I told her I would be right down, and quickly reviewed his chart again. I noticed that when he came in, his INR was supratherapeutic. His Coumadin was held, and he had received one dose of Vitamin K in an attempt to reverse this, but bleeding was not his acute issue, so nothing more aggressive was done.

When I arrived at his bedside, I met his nurse, and agreed that the patient was altered. We reviewed the medications he had received, his vitals, and I examined his leg. He was in severe pain and would groan and pull away from me if I touched it. It was red and swollen tight. I had to use a Doppler to find a distal pulse. Of course, I hadn’t heard anything about this issue in checkout, but did see that the leg injury was noted in his progress notes, but thought to be a non-issue to the day team. After my exam and discussion with his nurse, I decided to call my attending (who was home and in bed – OK per the rules of the community hospital). I thought to myself, this is either nothing (a “non-issue” like I had read) and I would feel stupid waking her up, or it could be the worst thing – a rapidly expanding hematoma due to his elevated INR, potentially leading to compartment syndrome and maybe even loss of function of his leg.

So, I called my attending and discussed my findings and concerns. We came up with a reasonable plan, including giving FFP to quickly reverse his anticoagulation status (“just in case,”) and to call surgery for evaluation. Again, that meant calling an attending physician directly (and a surgeon, nonetheless!) in the middle of the night. Regardless, I spoke with him and he agreed with giving the FFP but told me he would wait until morning to see the patient. After some time and continued checks on my patient, the nurse and I still felt unease with waiting, and decided to call my staff physician again. I was so relieved when she said, “I appreciate your concern about this patient; I will be right in.”

Although I was relieved, I also felt extremely guilty. Here I was bothering not one, but two attendings in the middle of the night, and now one had to get out of bed and come in. Maybe I would be deemed as incompetent or not confident or not prepared for this. But Dr. Chang was extremely understanding and compassionate. She again assessed the patient with me, reviewed any new information we had, discussed my concerns, then decided to call the surgeon herself, who then came in, and yes – performed an emergency surgery on the patient’s leg.

Thankfully this was a good outcome, thanks to many members of this patient’s care team being willing to speak up and step up and do what’s right. However, as I am now farther along in my training, I had to pause today to reflect. First, why should I feel such guilt and anguish over calling an attending physician? Thankfully Dr. Chang was wonderful and caring and told me that it was the right thing to do, but I know that many other attendings would not be that way. That culture needs to change. I also wondered, perhaps more importantly, whether at this point, perhaps with more confidence or more to lose if I made the “wrong” call, if I would have done the same thing. I wonder if during the situation I described, I escalated the patient’s care simply because I was younger, less experienced, and honestly didn’t know the right answer or the right steps. Today, would I have talked myself out of escalating care due to having more experience, and not wanting to seem like I couldn’t manage his case overnight? I hope not, but it made me think. And I plan to be extremely mindful of the risk of Failure to Escalate in the future. As Carol Hemmelgarn said today, “trust your gut.” And I will try to continue to do just that.