Interventions to increase patient and family involvement in escalation of care for acute life-threatening illness in community health and hospital settings



There is now a rising commitment to acknowledge the role patients and families play in contributing to their safety. This review focuses on one type of involvement in safety ‐ patient and family involvement in escalation of care for serious life‐threatening conditions i.e. helping secure a step‐up to urgent or emergency care ‐ which has been receiving increasing policy and practice attention. This review was concerned with the negotiation work that patient and family members undertake across the emergency care escalation pathway, once contact has been made with healthcare staff. It includes interventions aiming to improve detection of symptoms, communication of concerns and staff response to these concerns.


To assess the effects of interventions designed to increase patient and family involvement in escalation of care for acute life‐threatening illness on patient and family outcomes, treatment outcomes, clinical outcomes, patient and family experience and adverse events.

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP) and the World Health Organization (WHO) International Clinical Trials Registry Platform from 1 Jan 2000 to 24 August 2018. The search was updated on 21 October 2019.

Selection criteria

We included randomised controlled trials (RCTs) and cluster‐randomised controlled trials where the intervention focused on patients and families working with healthcare professionals to ensure care received for acute deterioration was timely and appropriate. A key criterion was to include an interactive element of rehearsal, role play, modelling, shared language, group work etc. to the intervention to help patients and families have agency in the process of escalation of care. The interventions included components such as enabling patients and families to detect changes in patients’ conditions and to speak up about these changes to staff. We also included studies where the intervention included a component targeted at enabling staff response.

Data collection and analysis

Seven of the eight authors were involved in screening; two review authors independently extracted data and assessed the risk of bias of included studies, with any disagreements resolved by discussion to reach consensus. Primary outcomes included patient and family outcomes, treatment outcomes, clinical outcomes, patient and family experience and adverse events. Our advisory group (four users and four providers) ensured that the review was of relevance and could inform policy and practice.

Main results

We included nine studies involving 436,684 patients and family members and one ongoing study. The published studies focused on patients with specific conditions such as coronary artery disease, ischaemic stroke, and asthma, as well as pregnant women, inpatients on medical surgical wards, older adults and high‐risk patients with a history of poor self‐management.

While all studies tested interventions versus usual care, for four studies the usual care group also received educational or information strategies. Seven of the interventions involved face‐to‐face, interactional education/coaching sessions aimed at patients/families while two provided multi‐component education programmes which included components targeted at staff as well as patients/families. All of the interventions included: (1) an educational component about the acute condition and preparedness for future events such as stroke or change in fetal movements: (2) an engagement element (self‐monitoring, action plans); while two additionally focused on shared language or communication skills.

We had concerns about risk of bias for all but one of the included studies in respect of one or more criteria, particularly regarding blinding of participants and personnel. Our confidence in results regarding the effectiveness of interventions was moderate to low.

Low‐certainty evidence suggests that there may be moderate improvement in patients’ knowledge of acute life‐threatening conditions, danger signs, appropriate care‐seeking responses, and preparedness capacity between interactional patient‐facing interventions and multi‐component programmes and usual care at 12 months (MD 4.20, 95% CI 2.44 to 5.97, 2 studies, 687 participants). Four studies in total assessed knowledge (3,086 participants) but we were unable to include two other studies in the pooled analysis due to differences in the way outcome measures were reported. One found no improvement in knowledge but higher symptom preparedness at 12 months. The other study found an improvement in patients’ knowledge about symptoms and appropriate care‐seeking responses in the intervention group at 18 months compared with usual care.

Low‐certainty evidence from two studies, each using a different measure, meant that we were unable to determine the effects of patient‐based interventions on self‐efficacy. Self‐efficacy was higher in the intervention group in one study but there was no difference in the other compared with usual care.

We are uncertain whether interactional patient‐facing and multi‐component programmes improve time from the start of patient symptoms to treatment due to low‐certainty evidence for this outcome. We were unable to combine the data due to differences in outcome measures. Three studies found that arrival times or prehospital delay time was no different between groups. One found that delay time was shorter in the intervention group.

Moderate‐certainty evidence suggests that multi‐component interventions probably have little or no impact on mortality rates. Only one study on a pregnant population was eligible for inclusion in the review, which found no difference between groups in rates of stillbirth. In terms of unintended events, we found that interactional patient‐facing interventions to increase patient and family involvement in escalation of care probably have few adverse effects on patient’s anxiety levels (moderate‐certainty evidence).

None of the studies measured or reported patient and family perceptions of involvement in escalation of care or patient and family experience of patient care. Reported outcomes related to healthcare professionals were also not reported in any studies.

Authors’ conclusions

Our review identified that interactional patient‐facing interventions and multi‐component programmes (including staff) to increase patient and family involvement in escalation of care for acute life‐threatening illness may improve patient and family knowledge about danger signs and care‐seeking responses, and probably have few adverse effects on patient’s anxiety levels when compared to usual care. Multi‐component interventions probably have little impact on mortality rates. Further high‐quality trials are required using multi‐component interventions and a focus on relational elements of care. Cognitive and behavioural outcomes should be included at patient and staff level.

Plain language summary

How effective are strategies to help patients and their families secure emergency medical care when a health condition becomes life‐threatening?

Medical emergencies

A life‐threatening condition is a medical emergency. The faster a person secures the right medical care, the better their chances of surviving. When patients and their families know the signs of a life‐threatening medical emergency and how best to communicate concerns around a deterioration in health, they can act quickly to seek emergency care and work with staff to ensure a timely response.

Increasing patient and family involvement

Education and coaching are available to help patients and their families, and healthcare professionals work together to make sure patients and families can secure emergency care when needed. These strategies focus on:

‐ helping patients and their families to notice changes in a patient’s condition and tell healthcare staff about them;

‐ empowering patients and families to feel confident about arranging for urgent or emergency care;

‐ healthcare staff giving patients and families a chance to talk about their concerns, and actively listening to them during an emergency consultation; and

‐ training healthcare staff to respond appropriately when patients and their families raise concerns about a patient’s condition.

Why we did this Cochrane Review

We wanted to find out if education and coaching strategies could help patients and families to recognise when changes in a health condition are life‑threatening and act to help secure emergency care.

What did we do?

We searched for studies that tested strategies to involve and empower patients and their families in seeking emergency care for a life‐threatening medical condition. We also included studies where the strategy included a component targeted at enabling staff response.

We looked for studies in which the strategies people received were decided at random. This type of study usually gives the most reliable evidence about the effects of a strategy.

Search date: we included evidence published up to 21 October 2019.

What we found

We found nine relevant studies in different healthcare settings in which 436,684 patients and family members took part. Seven of the strategies studied involved face‐to‐face education or coaching sessions for patients and families, and two involved education programmes aimed at healthcare staff as well as patients and their families. All strategies had an educational part and an engagement part (for example, self‐monitoring; using action plans); two strategies additionally focused on communication skills and using shared language.

All studies compared usual care against receiving strategies to increase involvement of patients and their families in seeking emergency care. In four studies, people in the usual care group also received information or educational strategies. The studies varied in design and in their assessments, making it difficult to compare all their results.

We did not find any studies that looked at patients’, or their families’, satisfaction with care, or what they thought of their involvement in seeking emergency care.

What are the results of our review?

Compared with usual care, strategies to improve involvement in securing emergency care:

‐ may help patients and their families to know which danger signs to look for, and to know the right action to take (4 studies; 3086 people);

‐ probably have little to no effect on stillbirth in pregnancy (1 study; 409,175 people); and

‐ probably do not increase anxiety levels in patients and their families (1 study; 2,597 people).

We are uncertain if the strategies affected:

‐ peoples’ confidence in recognising and reporting worsening in a health condition (2 studies; 217 people); or

‐ the time between the start of life‐threatening symptoms and receiving emergency treatment (4 studies; 27,023 people).

Our confidence in our results

We are moderately confident about the effect of the strategies on anxiety levels and on stillbirth, although these results might change with further evidence. We are less confident about our other findings, which are likely to change with further evidence. Some of the studies we compared had small numbers of people taking part, so their results may have been unreliable.


Strategies to help patients and their families to secure emergency care may improve their knowledge about life‐threatening conditions, and probably don’t increase their anxiety more than usual care

Authors’ conclusions

Implications for practice

Our review identified some positive indications; notably that interactional patient‐facing interventions and multi‐component programmes to increase patient and family involvement in escalation of care for acute life‐threatening illness may improve patient and family knowledge about danger signs and care‐seeking responses, and probably have little adverse effect on patient’s anxiety levels when compared to usual care. We were pleased to see the lack of adverse effects of patients being proactively and interactionally involved in escalating health concerns. We note that the sparsity of evidence may certainly be a factor in this finding, which needs to be confirmed further by studies addressing it as an explicit endpoint and also by further qualitative research. Patient‐focused interventions that facilitate the patient to be proactively engaged with healthcare providers and/or services at the very least appear to result in better informed patients – which, from an ethical and health policy perspective, is a positive aspect of the reviewed interventions.There were also many outcomes for which there was no indication of an effect and/or the evidence was too sparse or of low quality, meaning that effects are uncertain. Changes in knowledge and preparedness were not translated into effects on time to treatment or clinical outcomes (morbidity; mortality) when compared to usual care. The evidence is insufficient for us to attribute effects to particular strategies, intensity and duration of the intervention, or timing of delivery in relation to application when an episode of patient deterioration in condition occurs. The evidence on treatment outcomes, and clinical outcomes is limited and uncertain. While the interventions may be beneficial for a wide range of acute life‐threatening illnesses, the evidence identified in this review was too limited to recommend any change in current practice.From our included studies, it is clear that interventions to improve escalation of care are complex interventions which need to include a number of different components. Our review highlights the need for policy makers and practitioners to understand escalation of care as a form of negotiated boundary work within the complex social system of healthcare (Shojania 2019). The reframing of this concept has potential implications for the organisation and delivery of care, in terms of understanding how escalation of care operates within the wider context of services, pathways and routes into urgent care (see Figure 3). The interventions emphasised personal deficits of patients and families (e.g. lack of knowledge about signs and symptoms, lack of engagement with services or inappropriate use of services), and staff (e.g. lack of person‐centred care). Organisational and service limitations to the exercise of individual (patient, family or staff) knowledge and behaviours were not acknowledged, which we believe needs addressing. Our review also found insufficient information about the different communication elements of escalation of care strategies. Such evidence is needed to guide the levels of training or support required to meet the different needs of diverse populations to produce patient benefit.

Implications for research

Our review highlights the finding that escalation of care involves a number of different components, but further research is required to establish fidelity of form (i.e. which of these components are required to have impact at patient, staff and service level) and the significance of relationships between the components. Further research broadening the focus of interventions beyond individual behaviour change to dialogic reciprocal relationships is required. This could usefully examine use of cognitive aids (such as mnemonics) and communication strategies (Denham 2008Mackintosh 2010) and how these might contribute to improvements e.g. in patients’ self‐efficacy, as noted by See 2014. Future research is also needed to understand the influence of diverse populations, conditions and connectedness to services with regard to escalation of care. A focus on generic self‐management and communication skills may be more important in some populations than others; similarly provision of technical warning signs may have greater impact in some conditions (e.g. stroke) than others (e.g. childhood illness). This may be linked to the degree of uncertainty (e.g. the indeterminacy of future outcomes associated with fetal movement, compared to chest pain, and symptoms of a stroke).Further studies are needed to establish effectiveness around time of delivery of the intervention and its application with regard to recognition and response behaviours to deterioration. The follow‐up periods for those patient educational interventions focusing on stroke and acute coronary events were relatively short (maximum of two years). We need to better understand the significance of different levels of engagement with services as a mediator of escalation of care, and the role of continuity of care models in this process.There are also implications for future researchers in terms of using consistent terminology and thinking about the same outcome categories and outcome measures to enable further comparison of results. Our review highlights the need to include cognitive, behavioural and clinical outcomes. The danger with relying solely on cognitive measures such as knowledge is that this does not necessarily translate into change in behaviours. Similarly, deaths and delays may not accurately reflect any underlying behaviour change and subsequent intervention (based on escalation of care) because the course of the illness may be fundamentally difficult to predict. We believe there is a greater need to highlight and measure staff‐based and relational elements in escalation of care (Bosk 2019), together with measurement of patient access to and use of response pathways. Studies should report adverse effects of the intervention, for both patients (and family members) and staff, with effects on health systems and what any changes in usage mean clearly defined. Lastly, we would encourage researchers to include implementation outcomes when assessing the effects of these outcomes. These need to include data on the fidelity of the interventions, their reach and uptake, and their acceptability to patients, families and staff.
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