To the Editors,

I express gratitude to Dr. Iftah Amith for his valuable Letter to the Editor,1 and to JAHM for the opportunity to respond.

Dr. Amith highlights the discrepancy between the definition of escalation provided by Ko et al2 and by ourselves,3 and I agree that there is need for a consensus definition. Dr. Amith’s Letter then moves past this issue to propose his escalation audit framework, but I would like to explore this discrepancy further.

I agree with Ko et al that an escalation is an “unplanned transfer to the BAM hospital.” Ko et al further specify that an escalation must involve an overnight BAM admission, but this requirement is superfluous.

Escalations are of interest for many reasons: they put patients at risk of harm, they consume an inordinate amount of resources, and they can cause a type of moral injury to HaH staff. But it’s not all bad: escalations prove that HaH is fulfilling its mandate by caring for acutely ill patients, a percentage of whom will inevitably decompensate. Whether an unplanned transfer to the BAM hospital involves an overnight stay does not change the fact that the transfer carries risk of harm to multiple parties while also demonstrating that HaH is in the business of providing acute care.

Ko et al may have added the overnight admission requirement to filter out returns to hospital to access BAM-based resources only, without handing over responsibility for the patient’s care. To avoid this type of confusion, we include a transfer of care requirement in our definition of escalation, namely, An escalation is any unplanned transfer of care to the BAM hospital.

The majority of Dr. Amith’s letter is devoted to his proposed escalation audit framework, which appears to be an excellent tool for standardizing the analysis of escalations (and we appreciate that the framework includes non-overnight BAM transfers). I would suggest that he remove the third domain (“Planned versus unplanned transfer”) because of the apparent consensus that escalations are, by definition, unplanned.

Lastly, I would ask the HaH Community to reflect upon where unplanned deaths belong in quality reviews. As stated in our original paper, we believe that escalations and unplanned deaths represent the same phenomenon, namely, a decompensation that HaH could not stabilize. Should HaH create a broader “decompensation” metric that includes both escalations and unplanned deaths? One without the other can mask what is really going on, and both provide the same opportunity for quality improvement.

Conflict of Interests

None

Corresponding Author

Shauna Tierney, shauna.tierney@gmail.com
Mailing address: 1955 Cochrane St, Victoria, BC, Canada, V8R 3H4.Phone: 250-634-6426