Failure to escalate: What stops junior doctors asking for help when they need it?

Worldwide, recognition of and response to clinical deterioration is a key safety issue in hospitals. Within this, issues which prevent the most senior available decision makers from being involved in decisions about managing a patient's clinical deterioration may contribute to poor outcomes. This study was undertaken to understand the reasons why medical trainees do not always escalate concerns to more senior staff when a patient shows signs of clinical deterioration. This was done through an online survey of medical trainees at a large tertiary Health Service in Melbourne, Australia. 51% of trainees completed the survey. The trainees identified the following top barriers to escalation: - Perceived issues accessing more senior staff - Existence of factors that impact on judgement and decision-making re escalation (eg, lack of situational awareness, competing demands) - Feeling that it is not always clear who to contact or who's accountable for the patient's care - Perception that junior trainees are not always able to identify when a patient requires escalation - Concern about a negative response from more senior staff to escalation concerns. The trainees also provided feedback on system changes that may enable better escalation. Conclusions: This research identifies a number of system issues that medical trainees report contribute to them not escalating clinical concerns. The survey provides excellent guidance for our organisation about what our trainees feel are barriers to escalation and how we might respond to these.