Co-design of a patient and family-initiated escalation of care intervention to detect and refer patient deterioration in the acute adult ward setting 

Student thesis: Doctoral ThesisDoctor of Philosophy


Despite the introduction of rapid response systems internationally to improve the recognition and response to patient deterioration, warning signs are not always identified by staff on acute hospital wards. Patient and family-initiated escalation of care schemes have shown some benefit in assisting early recognition, but are not used widely in many clinical practice areas and there is lack of robust evidence examining this area, particularly in the adult setting.

The aim of this research study is to co-design a patient and family-initiated intervention to improve the detection and escalation of patient deterioration on acute adult hospital wards across Ireland using an Implementation Science approach. This approach is particularly relevant when implementing changes in practice as it considers stakeholder engagement, behaviour change and contextual factors as central to understanding and addressing the factors that influence implementation in specific settings.

The design is a collective case study approach including a sample of medical and surgical wards in an acute hospital in Northern Ireland and the Republic of Ireland using an adapted co-design approach and Medical Research Council framework guidelines. The study was conducted over three phases using a variety of methods to collect data to inform the development and implementation of a patient and family-initiated escalation of care intervention.

-Phase 1 established the evidence base by undertaking a systematic review and creating the steering group.
-Phase 2 involved collecting data from key stakeholders, patients [n=12], relatives [n=11] and healthcare professionals [n=32], using individual and focus group interviews. A review of patients’ records also informed the development of a co-designed patient and family escalation of care intervention and implementation plan.
-Phase 3 involved co-ordinating the co-design of the intervention and implementation plan through steering group meetings and by undertaking feedback interviews with key stakeholders, patients [n=5], relatives [n=4] and healthcare professionals [n=20], from each hospital site and undertaking a cost analysis.

The study findings highlighted that patients and relatives can detect deterioration however calling for help can be challenging for some. To address these challenges a co-designed intervention was developed to provide greater signposting regarding the main signs of deterioration and the key steps to take when calling for help. Feedback interviews on the developed intervention were positive, indicating that most participants felt that it was a valuable and empowering resource for patients and relatives. However, there was clear evidence that deeply embedded socio-cultural, organisational, and economic constraints may influence its introduction into practice. These factors were considered in the development of an implementation plan and cost analysis to promote future uptake and sustainability of the intervention in the clinical setting.

Thesis embargoed until 31 December 2026.

Date of AwardDec 2021
Original languageEnglish
Awarding Institution
  • Queen's University Belfast
SponsorsHealth Service Executive & Northern Ireland Public Health Agency
SupervisorJennifer McGaughey (Supervisor), Donna Fitzsimons (Supervisor) & Bronagh Blackwood (Supervisor)


  • Clinical deterioration
  • family-initiated escalation of care
  • rapid response systems
  • patient and family escalation of care
  • patients
  • relatives
  • healthcare professional

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