Enacting patient safety on the frontline: an ethnographic study of rescue work with acutely illpatients
International concerns over ‘failure to rescue’ acutely ill patients on hospital wards have led to the widespread implementation of rapid response systems. Despite these system level changes, management of deterioration in such patients’ conditions remains problematic. Rescue is a complex process and only partially understood. This study aims to explore the nature of ‘rescue work’, drawing on theoretical insights from medical sociology to illuminate relationships between organisational systems, department and individual level processes. Data collection involved ethnographic fieldwork over a 12 month period in two UK NHS Trusts, including observations (180 hours), interviews (35) with health care assistants, nurses, doctors and managers, and documentary analysis. The findings expand understandings of rescue beyond reified, linear trajectories to include overlapping structural, technological and diagnostic influences. The thesis draws attention to the adaptability and intelligence displayed by frontline staff to handle clinical uncertainty, and the significance of hidden articulation work for minding gaps in patient trajectories. Technological monitoring tools open up aspects of rescue work for scrutiny, facilitating the development of a shared management approach for caring for acutely ill patients. Tools such as the track and trigger system perform a valuable bridging function between occupations. However, these tools also reinforce hierarchies and occupational boundaries. Relations between the domains of critical care, medicine and management influence the organisation and provision of services, and organ specialism assumes a hierarchical superiority over generalist services. Structural processes such as access to critical care, and transfer of responsibility between medical firms influence patient pathways. This thesis helps to explain why organisations struggle to effectively manage acutely ill patients on the ward. The analysis suggests that priorities and solutions for the acutely ill should include greater recognition of the significance of the mundane routine of rescue work, structural and professional influences and inequalities, and diagnostic categorisation regarding escalation of care.
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