Patient and Family Activated Escalation Systems: a systematic review

BACKGROUND: Patient and family activated escalation systems (PFAES) enable patients and families to escalate concerns about in-hospital deterioration and trigger urgent clinical review when standard escalation routes fail. Given limitations of prior reviews and the rollout of Martha's Rule in England, this systematic review synthesised evidence on PFAES up to 2025, including system types, implementation, stakeholder experiences, sustainability and equity. METHODS: The protocol was registered on PROSPERO (CRD420250651441) and reporting followed Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). The databases MEDLINE, Embase, Scopus, CINAHL and Web of Science were searched (June 2025), with expert input and backward citation searching. Screening was undertaken in Rayyan. Studies reporting empirical data on hospital-based PFAES were included and appraised for quality using the Mixed-Methods Appraisal Tool (MMAT). Findings were synthesised narratively. RESULTS: Searches initially identified 6,129 papers. Thirty-five studies met the inclusion criteria. PFAES clustered into two activation routes: direct-to-response team models and proxy activation embedded in ward routines. Low awareness (16/35) and limited understanding (15/35) among patients and families were frequently reported and were linked to limited visibility, reliance on written materials, and inconsistent staff explanations under workload pressure. Patients and families commonly described anxiety about speaking up and fear of harming relationships with staff, alongside a preference for healthcare professionals' led escalation due to concerns about bypassing them, viewing activations as outside their patient role, or simply trusting their care team to perceive and escalate deteriorations. Sustainability was associated with governance support, champions, and ongoing promotion, while equity was inconsistently addressed despite language and communication barriers being recurrent. CONCLUSIONS: While only published studies were included in this review, its broader scope and up-to-date coverage identified additional studies and defined two activation models. Direct-to-response team escalation can be a safety net to interprofessional communication failures but often feels too risky or confrontational for patients and families to use. Proxy escalation appears more acceptable yet depends on traditional staff escalation systems, for which direct-to-response team PFAES models are a safeguard. Future research should examine stakeholder perceptions where both routes operate concurrently, such as Martha's Rule, and determine the organisational conditions that support effective implementation. Implementations should embed equity and cultural safety to ensure vulnerable groups can access and use PFAES.