Improving escalation of deteriorating patients through cognitive task analysis: Understanding differences between work-as-prescribed and work-as-done.

"Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: PW provides consultancy for Arcturis and holds share in the company."

"Funding JE is funded by the National Institute for Health and Care Research [Clinical Doctoral Research Fellowship (NIHR300509)]. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. PW is funded by the National Institute for Health and Care Research (NIHR), UK and the NIHR Biomedical Research Centre. RE is employed by the National Institute for Health and Care Research."

"This work reports methods from the published protocol paper () and used the COREQ checklist (). This study forms part of a larger research study: the SUFFICE study. Ethical approval was provided by the Queen Square London Research and Ethics committee (REC Ref 20/HRA/3828; CAG-20CAG0106) and the study was registered with the International Standard Randomised Controlled Trial Number (ISRCTN 38850). All experts were aware that participating in the study was voluntary and signed a consent form. All collected data were stored in a password-protected computer and anonymised. Conclusion: Our data support the emphasis on the need to retain clinical judgement and suggest that future escalation protocols and audit guidance require in-built flexibility, supporting staff to incorporate their expertise of the patient condition and the clinical environment. Improved information systems to synthesise the required data surrounding an unwell patient to reduce staff cognitive load, facilitate decision-making, support the referral process and identify actions are required. Fundamentally, reducing the cognitive load when assimilating core escalation data allows staff to provide better and more creative care.: Study registration (ISRCTN 38850) and ethical approval (REC Ref 20/HRA/3828; CAG-20CAG0106)."