• Jonathan Back, Alastair J Ross, Myanna D Duncan, Peter Jaye, Katherine Henderson, and Janet E Anderson.
• Kings College London, UK. Electronic address: jonathan.back@kcl.ac.uk.
• Ann Emerg Med. 2017 Nov 1; 70 (5): 659-671.

Study ObjectiveEscalation policies are used by emergency departments (EDs) when responding to an increase in demand (eg, a sudden inflow of patients) or a reduction in capacity (eg, a lack of beds to admit patients). The policies aim to maintain the ability to deliver patient care, without compromising safety, by modifying "normal" processes. The study objective is to examine escalation policies in theory and practice.MethodsThis was a mixed-method study involving a conceptual analysis of National Health Service escalation policies (n=12) and associated escalation actions (n=92), as well as a detailed ethnographic study of escalation in situ during a 16-month period in a large UK ED (n=30 observations).ResultsThe conceptual analysis of National Health Service escalation policies found that their use requires the ability to dynamically reconfigure resources (staff and equipment), change work flow, and relocate patients. In practice, it was discovered that when the ED is under pressure, these prerequisites cannot always be attained. Instead, escalation processes were adapted to manage pressures informally. This adaptive need ("work as done") was found to be incompletely specified in policies ("work as imagined").ConclusionFormal escalation actions and their implementation in practice differed and varied in their effectiveness. Monitoring how escalation works in practice is essential in understanding whether and how escalation policies help to manage workload.Copyright © 2017 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

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