Tiago Marçal Pedro
Duarte de Brito , Maria Pacheco Pereira and Humberto S
Machado
Introduction: Failure to Rescue (FTR) is the failure to prevent a patient’s death after a complication. It measures the ability of a hospital to prevent the death of patients who develop one or more complication that was not present at the time of admission. Therefore, the aim of this study is to review the factors that contribute to FTR, and the measures and strategies that can be applied to prevent the FTR events, in order to discuss the best way to improve patient outcomes in the hospital setting. Methods: A search was conducted on PUBMED retrieving a total of 464 articles. A review of the selected articles’ bibliography was conducted to find other relevant articles. Sixty studies were reviewed in this paper. Results: Patient factors as increasing age, comorbidities and frailty increase the risk of FTR, as well as an increasing number of complications. Several hospital factors, nursing care, and microsystem also influence FTR. Some track and Trigger Systems (TTS) and Early Warning Scores (EWS) have been shown to predict clinical deterioration. On the other hand, machine learning systems have outperformed EWS. Rapid response teams have become the standard approach to delivery and escalation of care, and cognitive aids and crisis checklists also have potential to help reduce FTR. Conclusion: Patient and hospital factors are often non-modifiable; thus, microsystem factors could be a target for improvement. Creating clinical pathways can improve surveillance, and communication tools like SBAR can help relay information. EWS, machine learning models and continuous monitoring are strategies that can help detect clinical deterioration. In the efferent limb rapid response teams have shown to reduce FTR.
Failure
to Rescue (FTR) was first described in 1992 by Silber et al as the failure
to prevent death after a complication in the surgical patients. According to
Silber et al, there were only 2 formal attempts to develop a medical FTR metric
before their own in 2018 [1-4]. It measures the ability of a hospital to
prevent the death of patients who develop one or more complication that was not
present at the time of admission by identifying and successfully managing it
[4-6].
Failure to rescue is an important metric to measure the quality of care
of an hospital and it is different from the in-patient
mortality, which describes all patients deaths during hospitalization [5,7,8].
On the other hand, FTR rate is calculated using the number of patients with a
complication as a denominator and as a numerator the number of patients that
died following a complication [8].
The definition of FTR has evolved with time and various definitions have
been posted in the literature, with different specific complications for each
one, based on the subpopulation it was applied to [2,4,8]. In 2002, Needleman
et al described a version that was
nursing sensitive, with complications that related to nursing interventions (pneumonia,
shock, gastrointestinal bleed, cardiac arrest, sepsis and deep venous thrombosis),
and was later termed as FTR-N by Silber [8,9]. In 2007 the Agency for
Healthcare Research and Quality used this last definition, adding one other
complication (renal failure), as a patient safety indicator to measure and
grade hospital care and was labeled as FTR-A [2,10]. Having various versions of
this metric, created for different subpopulations, although it can alter the
calculation of the FTR based on which definition is used, can be helpful to
evaluate the occurrence of this event in different settings, with different
particularities, more accurately [8]. Even so, having a common definition would
serve to use and measure it as a common metric for all hospitals [1].
Failure to rescue is a multifaceted and complex problem, with several
risk factors contributing to it [2]. Those factors can be divided into macro
system factors such as hospital type (academic and critical access), size and
volume, technology, resources or staffing ratio and microsystem factors such as
intensive care units and rapid response teams composition, hospital
culture on teamwork and communication or psychological safety [3,8,11,12].
Furthermore, there are also patient factors that can have an impact on failure
to rescue, since complications are primarily associated with their
characteristics [2,3,8]. Increased age and frailty have shown to contribute to
failure to rescue, also preexisting comorbidities and the condition of
admission, as well as the performance status at the time of a surgery, can
influence the outcome [3,8,13].
In the macro system factors, high-volume hospitals are associated with
lower rates of FTR, although they are not associated with lower complication
rates8, and so was surgeon volume [3,8,4,14]. These hospitals are usually
teaching hospitals, although the teaching status itself was not clearly
associated to a reduction on the FTR rate [14]. The hospitals with high technology
were also related to lower FTR rates [1].
The staffing of the hospital also plays a role in the FTR rate8. It is
common in hospitals to have decreased staffing during the night or at weekends,
particularly in unmonitored units, leading to treatment delays and worse
outcomes [8,15]. Specifically, the nursing staff and nurse-patient ratios have
been one of the most consistent factors associated with FTR [8]. Also, the
nurse’s education has been shown to have an impact on FTR, hospitals with
higher proportions of nurses with bachelor’s degree or higher have a lower FTR
rate [10,16].
When it comes to the microsystem factors, closed Intensive Care Unit (ICU)
settings with a larger proportion of certified intensivists have also shown to
reduce FTR [1,17]. Also in the microsystem factors, the hospital culture on
teamwork and communication, as well as the psychological safety of the team
contribute to better outcomes, including FTR [14]. Communication is a very
important factor in the quality of care and the nurses and junior physicians
must feel comfortable communicating with senior physicians about their concerns
[14]. It is important that the healthcare environment culture supports those in
direct contact with the patients to provide opportunities for better and timely
care to be provided3. Teamwork also plays a major role in responding well to
complications, by taking advantage of the cognitive diversity of the team
members and abolishing traditional hierarchies [12]. Psychological safety is
important to reassure confidence to the care providers to speak up, report
mistakes, question others and express concerns to higher hierarchic members
without fear of any adverse effect [12].
The failure to rescue events can be broken down into a progression from a
complication that can be either identified and communicated by an afferent limb
to the efferent limb that provides the escalation of care the patient needs, or
that can progress to death due to a failure at any point in this circuit [2,8].
The nursing factors and attributes focus mainly on the afferent limb, and the
physician factors are mostly on the efferent limb [2]. This concept is the
basis of the rapid response systems, whose principles are early recognition and
prompt and appropriate intervention, where the afferent
limb refers to the measures that focus on identifying the deteriorating
patient, and the efferent limb refers to the interventions to rescue the
patient [18].
Patients who require ICU admission from the ward can have changes in
measurable clinical variables, like vital signs, up to 48 hours before
transfer20. The identification of this changes and thus patient deterioration
is part of the afferent limb [18].
There are systems that help nurses to know when to escalate care and also
detect changes prior to deterioration, such as early warning scores (EWS), also
known as Track
and Trigger Systems (TTS) [8,10,19,20]. There are various types of these systems
that can be divided into single parameter, multiple parameter or aggregate
weighted systems. The single parameter systems rely on any single deviation of
vital signs, laboratory values, and urine output or oxygen saturation to
trigger a response. Multiple parameter systems are expanded versions of the
single parameter ones, using a combination of abnormal signs to trigger a
response. The aggregate weighted systems assign points to the degree of
deviation of individual physiological variables, combining them to a score,
which has thresholds for triggering [19]. In addition, many systems include the
facility for triggering on a subjective basis, recognizing the importance of
clinical intuition in patient assessment [18].
Another strategy to improve the detection of patients that can be
deteriorating is the use of continuous
monitoring in general wards, that can provide dynamic information about the
patterns of the vital signs of the patient, and there can also be achieved an
automation of the calculation of scores to trigger an escalation of care [20-24].
These automated programs also can be used in the ICU context, where is already
continuous monitoring to help prevent FTR events in this setting [25]. In this setting, an implementation of
telemedicine ICU nursing can also help improve the outcomes of the patients [26,27].
The efferent limb is just as important as the afferent limb, as it is the
response to the trigger and initiates the escalation of care [19]. For this,
the implementation of Rapid Response Teams (RRT) or Medical
Emergency Teams (MET) arose as a method to provide care to patients that
were deteriorating or at risk of deteriorating at their bedside [28]. The
continuation of the pathway for some patients is the ICU setting, where, as
said before, FTR can also occur [8]. The development of crisis-checklists can
also help the team that is usually with the patient manage an emergency while
escalation to a RRT occurs [29].
The afferent and efferent limbs work as a continuous pathway, being both
essential for the patient safety and prevention of FTR events [2,3].
In this paper, the aim is to review the factors that contribute to FTR, and the measures and strategies that can be applied to prevent the FTR events, both in detecting and in the process of escalation of care, in order to discuss the best way to improve patient outcomes in the hospital setting.
A search was conducted on PUBMED using the following keyword
combinations: "failure to rescue health care statistics and numerical
data"; "failure to rescue quality"; "failure to rescue
rates"; "failure to rescue health care"; "failure to
rescue" AND rapid response system; "medical care" AND
"failure to rescue"; "failure to rescue" AND deteriorating
patient; "failure to rescue" AND general ward; rapid response team
AND "failure to rescue"; hospital staffing AND "failure to
rescue"; early warning score* AND "failure to rescue"; medical
emergency team* AND "failure to rescue"; track and trigger AND
"failure to rescue"; "failure to rescue" AND continuous
monitoring; "failure to rescue" AND telemedicine; concept OR
definition AND "failure to rescue". A review of the bibliography of
the articles selected was conducted to find other relevant articles.
A total of 464 articles were found using the mentioned keywords. 60 articles were selected to this revision. Inclusion criteria include English language publication, review articles, systematic reviews, retrospective or prospective studies, quantitative and qualitative studies. Exclusion criteria include articles published in other language than English, studies about pediatric or obstetric population, articles where FTR was not the main or one of the main topics, articles comparing surgical procedures or their outcomes, studies about specific clinical or surgical interventions. Timeline: articles were included from the search since 2015 till 2020. 1 article cited in the reviewed studies was included.
In a systematic review by Johnston et al in 2015, the values of FTR in
the articles reviewed varied from 0,03% to 16,9%. Studies suggest that, in the
United States, between 22 000 to 200 000 avoidable deaths occur in hospitals
per year [5,30].
Figure 1: Inclusion/exclusion criteria for articles inclusion in the review
Patient factors, such as increasing age, increase the risk of FTR. In a
study of trauma population, the risk of FTR increased in a stepwise fashion
with increasing age, reaching almost 28-folder higher risk for patients with
over 90 years old, and the risk increased significantly from 66 years and
higher. The FTR patients in this study also had more commonly comorbidities
such as cardiac disease and bleeding disorders. Increased age is also
associated with the development of more complications [31]. In another study,
contributors to both development of adverse events and FTR were 70 or more
years of age, renal disease, and penetrating mechanism of injury, decreased Coma
Glasgow Score, and increased Injury Severity Score [32].
Frailty has also been associated with higher risk of FTR [1,13]. There is
an association with increasing frailty and number of complications, and also
FTR. Although the increase in FTR can be mediated by the increasing number of
complications, frailty increases the occurrence of FTR by itself. This
association is present not only in high-risk surgeries, but also in lower risk
operations, although in a smaller scale [13].
Despites an increase in the number of complications being related to a
higher risk of FTR, the type of complication can also have an impact [31,33-35].
In addition to age, Injury Severity Score, Charlson Comorbidity Index and
number of complications, complications like sepsis, pneumonia,
acute respiratory distress syndrome and cardiovascular complications
independently increased the risk of FTR [35]. Moreover, the impact of having a
respiratory and an infectious complication combined is synergistic [34].
Hospital performance is another factor that is associated with FTR.
Hospitals with higher performance have lower FTR rates [36-38]. In a cohort
using the Japan Trauma Data Bank, hospitals with higher performance had fewer
complications and lower FTR rates, whereas high-mortality hospitals had both
more complications and higher FTR rates, indicating that in trauma patients,
complications and rescue from a complication can be related to better
performance in these hospitals [36]. In a study of patients undergoing
non-cardiac surgery
in Veterans Affair hospitals the FTR rate was also higher in the high-mortality
hospitals, while the complication rates were not statistically different [37]. Sheetz
et al also found a correlation between high-mortality hospitals and higher FTR
rates in a study to determine the effect of hospital characteristics on failure
to rescue after high-risk surgery [38].
Hospital volume was also associated as a factor that affects FTR rates in
several articles [3,7,14,30,35,39]. In a study using data from 27 countries
from patients undergoing surgery in low, middle and high-income countries,
hospitals were ranked by volume of surgical procedures and by complication
rates. Hospitals with higher volume had lower FTR rates than lower volume ones,
and the hospitals with the highest complication rates were not the ones with
highest FTR rates [7]. Level 1 trauma centers were also associated with lower
FTR rates35. Indeed, according to Slim et al, “studies of hospital and surgeon
volumes found a statistically significant reduction of 29-77% of FTR”.
Hospital factors such as teaching status, high hospital technology, and
increasing nurse-to-patient ratio and presence of an ICU larger than 20 beds
influenced FTR rates, offering a survival advantage for patients undergoing
major surgery [38]. Regarding trauma patients, bed size over 600 and teaching
status, besides being a level 1 center, were independently associated with
lower FTR rates [35]. In a study that analyzed FTR in a medical population
after acute myocardial infarction, major teaching hospitals displayed 19% lower
odds of FTR than non-teaching hospitals, and hospitals with a good nursing mix
and staffing, cardiac
technology and teaching status displayed 33% lower odds of FTR than
hospitals without these characteristics4. The teaching intensity has also been
related with better FTR rates [10]. The participation of residents in surgical
procedures has also been related with lower FTR rates, especially in
cardiothoracic procedures where the residents were more likely to be
senior-level residents [33].
Failure to rescue is an outcome that is highly sensitive to nursing care
[10]. Implementation in the United States of minimum nurse staffing levels has
reduced the FTR rates and in the United
Kingdom its use as a nurse sensitive quality indicator has been supported
by lower FTR rates in hospitals with better staffing by lower patient-nurse
ratios [10]. An increasing of nurse staffing by 10% reduced FTR rates by 4% and
hospitals with higher proportions of bachelor’s degree also had reduced rates
of FTR [10,16]. In addition to the staffing levels, when nursing surveillance
is performed 12 or more times a day, compared with less than 12 times a day,
there is a significant decrease in FTR [10].
In a qualitative study, abilities of enrolled and registered nurses in
recognizing clinical deterioration were found to be influenced by their
knowledge of patients, past experiences with clinical deterioration, patient
assessment, workload and staffing levels. Furthermore, having an adequate
number of experienced nurses on each shift was considered essential, as well as
having a supportive ward culture,
where nurses have no fear to consult each other or seek for help. Ineffective
nursing relationships between enrolled and registered nurses from suboptimal communication
and teamwork and ineffective delegation skills can have undesirable
consequences for deteriorating patients [40].
Higher levels of staffing are associated with reduction in FTR, both in
surgical and medical patients, although the association is not as strong in medical
patients [9]. Furthermore, a greater number of hours of nursing care is
associated with a reduction in FTR rates [3,9]. In addition, favorable nursing
environments, with effective communication between nurses and physicians have
lower risk of FTR [3,9,41]. The teamwork between physicians and nurses has even
more effect when there is better nurse staffing and education [41]. Nurse
autonomy is also associated with a reduction in FTR, and higher education of
nurses is associated with an enhanced predisposition to exercise their
professional judgment in decision making [42].
There have been developed many track and trigger systems. Single
parameter systems shown reductions in patient adverse outcomes in small,
single center and nonrandomized studies, both in medical and surgical wards,
however a large randomized control trial of such a system did not show these
benefits [19].
The most reviewed and validated early warning scores are the aggregate
weighted scoring systems [19]. These are popular in the United Kingdom and
allow a graded response depending on the total score [18]. The NEWS
(National Early Warning Score), published by the Royal College of Physicians of
London in 2012, has been shown to be a good predictor of deterioration leading
to ICU admission or death and to be superior to 33 aggregate weighted scoring
systems for detecting mortality, cardiac arrest and anticipated ICU transfers
[18,19,43]. Also, many track and trigger systems include the possibility to
trigger escalation on a subjective basis, when staff, family or patient were
worried. Analyses of these subjective activations suggests most were due to
respiratory observations, where deterioration was too subtle to trigger on a
physiologic basis [18].
The Modified Early Warning Score (MEWS) is another aggregate weighted
scoring system, which have been reported to have a positive relationship with
earlier detection of clinical
deterioration, however it has limitations. If one of the physiologic
parameters is unassessed, ignored, or unreported the patient remains at risk of
deterioration, or in comparison, inappropriate trigger scores can activate
unnecessary calls, which decrease this tool’s effectiveness and increases
workloads of bedside nurses, physicians, and rapid response team members [44].
Although these addictive scores like the NEWS or the MEWS are easy to
apply and interpret, their accuracy is precluded by using static variable
thresholds for a small number of parameters [20]. Also, recording the vital
signs on a paper chart has significant potential for inaccuracy, with studies
demonstrating that almost 20% of NEWS scores were calculated incorrectly [19].
Prediction tools from electronic medical records have also been used to
predict a patient’s probability of clinical deterioration up to 2 to 48 hours
in advance, and can decrease false alarms by 50% [19]. The electronic Cardiac
Arrest Risk Triage that was developed using regression coefficients
outperformed MEWS and NEWS in a retrospective analysis of postoperative
surgical patients [20]. In a study by Kia et al a machine learning model of
patient deterioration was developed that included demographics, vitals, lab
results and physical exam findings that had significantly better performance
than MEWS and could warn about patient deterioration 6 hours prior to the event
and help clinicians make timely interventions, using not only “point in time”
measurements, but also prior data and trends.
Continuous monitoring of patients can also improve the early detection of
patient’s deterioration [20,22]. In a 2016 study, it was demonstrated that
continuous multi-parameter monitoring could be performed on medical and
surgical units with a small and appropriate level of audible alerts, and that
it may have initiated nurse interventions that prevented failure to rescue
events. On other study, 2 types of continuous monitoring technologies were
studied, one not necessitating direct patient contact and another one direct
patient contact, found that both accurately predicted patient deterioration [22,45].
Another technology
described in another study was the cVSM (continuous Vital Sign Monitoring),
which was different than simply telemetry monitoring, that sounds an alarm
anytime a parameter breaches a threshold, this has programed delays that allow
vital-signs to self-correct to prevent unnecessary alarms, that can lead to
staff distraction and alarm fatigue. Nurses were able to identify signs of
deterioration early and intervene more quickly, improving patients outcomes.
The incidence of FTR using this technology declined to zero and the
complication rate decreased from 22% to 5.9% [20].
Another strategy that can improve the afferent limb is the telemedicine
ICU implementation, whose nursing interventions have been studied by Williams
et al, identifying that consultation, education and mentoring by the nurses in
this setting helped reduce FTR. On the contrary, physiological
interventions were associated with more cases of FTR, indicating likely late
interventions from the tele-ICU or the ICU team.
In the efferent arm, rapid response teams and medical emergency teams
have become the standard approach to prevent FTR [18]. In many European
countries, these teams are represented by ambulance resuscitation teams [14].
There are often variations of the composition of the team, and while earlier
studies indicated that the team’s structure was not related with the outcomes,
more recent evidence suggests that intensivists on RRTs are predictors of
better performance and can reduce FTR [10].
Rapid response teams or medical emergency teams are often presented as a
factor in hospitals with lower FTR rates [1,16]. In a study that measured the
outcomes after the implementation of a rapid response system on a large
healthcare jurisdiction, it was found that cardiopulmonary
arrests, and related deaths, mortality and FTR decreased but at the same rate
as before the implementation; however, the mortality in the low-mortality
diagnostic-related group subpopulation decreased significantly. Other articles
also report that RRTs have reduced hospital mortality, unplanned ICU transfers
and unexpected cardiac arrests [19,27,46,47].
The use of cognitive aids can also help the team in the critical management of the deteriorating patient, with one study in a simulation environment reporting a decreasing in the percentage of omitted critical management steps of 70% [48]. Besides cognitive aids, the use of checklists structuring responses to clinical deterioration has potential to improve patient care and outcomes, since the first responders on the efferent limb are frequently an assembly of available providers of care with limited experience in managing emergency situations [28].
Besides the variation of FTR observed in various studies, it’s relation
with the mortality rate can also be different depending on the care setting
that is being analyzed [14,49]. It depends on the precedence of deaths
occurring in the studied setting, with precedence being a complication
occurring after the admission. In the trauma setting precedence is lower than
30% [49,50], whereas in elective surgery and emergency general surgery the
precedence rate is about 85% [49]. The lower value of precedence in the trauma
setting can be explained by the death of some patients due to the injury that
led them to that service before any complication can occur [50].
Factors
that affect FTR
Regarding patient factors that can affect FTR, age has been shown in
several studies and in several healthcare settings to be associated with FTR,
particularly in trauma populations [1,8,14,31,32,50,51]. Besides being
associated independently with FTR, increasing age also relates with the risk of
developing a cluster of complications, which also increases the risk of FTR [31].
In a trauma patients’ study, Earl-Royal et al aimed to identify pre-existing
conditions as risk factors for adverse events and FTR. They found that each
decade above 60 years had a higher risk of developing adverse events, and that
above age 70 the risk of FTR also increased. Theories linking the increasing
age with increasing mortality in trauma patients relate to decreased physiological
reserve, polypharmacy and frailty [32]. Some strategies to minimize the impact
of complications in the geriatric population in trauma care are a
multidisciplinary approach to care of these patients, with early geriatric
consultation, early admission to a highly monitored setting or having
availability of a trauma bed in the surgical ICU for elderly trauma patients,
as well as a higher nurse-to-patient ratio for this patients, in order to
recognize the potential complications early and preventing them [31].
Besides age, frailty is also associated with FTR, and some authors argue
that it can be a more reliable risk factor for FTR than age itself [1,8,13]. It is important to identify these patients,
that are not necessarily all elderly, since patients in the highest strata of
frailty can also be under 55 years, to increase attentiveness to them and
improve FTR rates [1,3,8]. Also, prehabilitation programs have shown to be
effective in reducing postoperative complications
in these patients, although it has not yet been demonstrated they reduce FTR [3,13].
The comorbidities are also an important factor, since they contribute to
the occurrence of complications41; 51, but also to FTR [3,14,31,32,41,50,51].
In trauma
patients, the comorbidities associated with FTR are not consensual between
studies, in a study the comorbidities associated with FTR were cardiac disease
and bleeding disorders, whereas in another study, several comorbidities were
associated with the development of complications, but only renal disease, liver
disease and coagulopathy were associated with FTR, and reported that in other
studies diabetes was also a risk factor for FTR [31,32].
The traditional FTR metric only accounts for one complication, and if
there are multiple occurrences, only the first is counted [8,34,50]. Yet, the
risk of FTR increases in a stepwise fashion with the number of complications and
besides, the traditional approach may miss differences in what followed the
index complication and lead to death [31,33-35]. Certain index
complications have been shown to be related to an increased risk for
particular secondary complications, as myocardial infarction followed by
cardiac arrest, and there is significant variation between some index
complications and the following secondary complications [3,34]. Secondary
complications play an important role between the first complication and
mortality, therefore it is important that an initial complication signals a
potentially important change in the patient status and timely and appropriate
treatment is initiated to reduce the risk of additional complications and
mortality [3]. In a cohort of emergency general surgery, Hatchimonji et al
found that among the patients who died with more than 1 complication, 82.5% had
a respiratory and 77.5% had an infectious complication. Having increased
attention to specific complications such as respiratory, infectious or
cardiovascular complications may also be important, since these independently
increase the risk for FTR [34,35].
Hospital performance, in terms of
mortality, is also related to FTR, being high-mortality hospitals associated
with higher FTR rates [36-38]. Massarweh et al found that there were no
significant differences in complication rates across the performance quintiles
of hospitals in their study, however the FTR rate was lower in better
performing hospitals, suggesting that these hospitals can be associated with
better management and rescue from complications.
Higher hospital volume and surgeon volume is associated in several
articles with lower FTR rates, and Rosero and colleagues also found that
hospitals with lower procedure volume for major abdominal surgery were
associated with higher FTR rates [3,7,8,14,30,35,39]. In addition, level 1
trauma centers, which are more likely to have a higher annual volume, were
associated with lower FTR rates in the Roussas et al study [35]. This may be
related to the infrastructures, care protocols, both formal and informal,
nursing staff being familiar with determined patient populations, procedures
and complications, and the surgeons’ experience with common postoperative
complications that require timely attention and intervention [8]. The
centralization or regionalization of care can contribute to reducing FTR, due
to this relation between volume and FTR and possibly by reducing variations in
practice [14,35].
Several other hospital factors have been shown in several studies, across
different settings, to reduce the risk of FTR [4,10,17,33,35,38]. Hospitals
with lower FTR rates tend to have more board-certified intensivists and a
closed model ICU, higher rates of employing hospitalists, advanced practice
providers, residents and presence of overnight coverage and use of rapid
response teams, in a study by Ward and colleagues [17]. However, these factors,
along with the patient
factors, do not completely explain the variation of FTR between hospitals [1,8,12].
On top of that, many of these hospital factors are often not easily alterable,
because of financial constraints [12].
Other factors that can help explain the occurrence of FTR are the
microsystem factors, that relate to human individual factors, for example the
staff behavior and attitudes, and the safety culture at the institution level,
that relates to the values, beliefs, norms, and traditions of the organization
[3,38,39]. These microsystem factors can
act as barriers in proper escalation of care that comprises the identification
of deterioration, effective communication, and an adequate response [39, 52,53].
The identification of deterioration can be negatively affected by clinical
inexperience, high workload, and overconfidence, whereas communication and be
impaired by hierarchical barriers, fear of criticism, a desire for independence
and frequent interruptions in clinical work [39]. In a study by Smith et al, 5
microsystem characteristics were identified as being important to the rescue of
surgical patients: teamwork; action taking; psychological safety; recognition;
and communication. Despite emerging evidence that suggests that focusing on
improving these factors may be a more prosecutable way to improve care, even in
large scale interventions, there is still few data about their contribution to
reduce FTR [1, 12,14,17,38,39,54].
Team resource management, that derives from crew resource management
training in aviation, aims to improve the teamwork and communication in
healthcare by addressing communication principles for speaking up, leadership
support, teamwork, evidence-based practices, just culture and patient
centeredness, and it also involves simulation training where the whole team
train in simulated crisis scenarios [2,5,10].
Simulation training is a growing practice in healthcare, and has
potential in help preventing FTR, by allowing to identify and review
contributing factors and practice skills to prevent FTR. Additionally, teamwork
strategies practiced in these trainings
help nurses to see the whole picture in a determined situation, and communicate
within hierarchical structures. Also, simulation sessions that are
interdisciplinary help build a safety culture between disciplines, improving
teamwork [2]. Besides improvements in the perception of teamwork by healthcare
practitioners, improved patient outcomes have also been shown when
multidisciplinary safety programs are implemented [10].
Afferent
limb
The nursing care has also been consistently associated with FTR [1-3,
8-10]. A better nurse staffing has been shown to improve FTR, not only in
quantity of nurses, but also in the nurses’ education, being higher proportions
of nurses with bachelor’s degree associated with lower FTR rates [1,10,16,41].
The nursing skill mix, or the proportion of registered nurses, also has an
impact on FTR, being a higher proportion also associated with a reduction in
FTR [4,55]. It is important to state that the quantity of staff for itself may
not be sufficient to improve patient outcomes, as demonstrated in a study by Twigg
et al, where the addition of assistants to nurse
care in an acute ward setting actually increased FTR, thus emphasizing the
importance of quality nursing care [56]. There is also an association with
increased surveillance and decreasing FTR, with more than 12 nurse assessments
reducing FTR. In order to improve surveillance, creation of clinical pathways
may be a strategy to implement [10].
Staffing levels, workload, past experiences with clinical deterioration
and knowing a patient have been associated with the ability to recognize
deterioration by nurses. A strategy that may improve the recognition of
clinical deterioration is assigning nurses to care for the same group of
patients on a regular basis, reducing their workload and the need to learn
about the patient, and also help them develop a connection with the patients [40].
The teamwork and communication are also important in what comes to
nursing care, both with registered and enrolled nurses, and also in the
nurse-physician relationship [3,9,40,41]. This last can be optimized in various
ways, by implementing interactive multidisciplinary rounds, maintaining
professional standards and using conflict resolution strategies [10].
Furthermore, using tools like SBAR, that stands for Situation, Background,
Assessment and Recommendation, helps relay information in a structured and
succinct form, and improves confidence when managing emergent situations and
calling for help [2,10]. Some centers have also introduced the ISBAR that
contains an Introduction to make sure that those who are participating in the
handover and the patient are well identified [10].
In a study from 2016 analyzing four case scenarios, Jones and Johnstone
reported that in attentional blindness – the failure to things that are in
plain sight due to being unexpected – could be a salient yet overlooked human
factor in FTR across critical care [57]. This study highlighted the difficulty
of maintaining attention and watchfulness while repeatedly performing a task,
even to expert clinicians.
There is contradictory evidence in the literature regarding the use of
early warning scores, while some authors claim they are not reliable in
determining those patients who will deteriorate and those who will not, and
others say they have led to a reduction in preventable adverse outcomes and are
well established across the globe [8,47]. Many track and trigger systems have
been developed, making it hard to compare them and validate them with each
other and across different hospital
systems [19].
Although single parameter systems have shown reductions in patient
adverse outcomes in small, single center and nonrandomized studies, both in
medical and surgical wards, they were unable to show these results in a large randomized
control trial [19].
Aggregate weighted scoring systems, like NEWS and MEWS, also have
limitations, since the scores are usually defined manually, alarm triggers are
based on empirically chosen values, and the thresholds are usually defined to
capture the most clinically relevant events, which can result in non-specific
alerts and false alarms generating alarm fatigue [19,58]. In addition,
regarding NEWS, the response that is triggered with 3 points in any component
triggers the same response as an aggregate value of 5 points, on the other
hand, the latter indicates a significantly higher risk. This alarm triggering
increases the workload with discrete improvements in detection of
deterioration, increasing the risk of alarm fatigue and diversion of medical
care from patients who could potentially have a greater need. Alternatives to
improve this would be either defining more extreme values for scoring 3 points
based on levels at which the risk is similar to an aggregate score of 5 or increasing
the frequency of observation of patients with 3 points on a single component
rather than immediately escalate care [43]. It was also hypothesized that the
occurrence of a derangement was more important than its degree, and that a
binary EWS, that only scores 1 or 0 could be more effective than traditional
EWS, however the binary NEWS, the best performing of the binary systems, was
still outperformed by the traditional EWS and although they could lead to
earlier detection, providing more time for interventions, the number of early
false alarms could result in latter triggers being ignored [59].
Implementing digital handheld devices for electronic charting can be a
good strategy to improve the performance of TTS, since that recording vital
signs on a paper chart has potential for inaccuracy and errors in calculation.
These devices have shown to allow for a faster and more accurate calculation of
EWS, and the automatic calculation and embedded alerts was associated with an
increase in accuracy and attendance to patients with high EWS scores [19].
Electronic medical records can be used by prediction tools and automated
detection programs, as machine learning models, to calculate the probability of
clinical deterioration before it happens and send an alert to a clinician [19,20,25,58].
Machine learning models have shown to outperform EWS systems, as NEWS and MEWS,
as they may allow for better early identification of decompensating patients [1,20,58].
Notwithstanding, these models depend on the quality and quantity of the data
used to train them, and may promote a false sense of security, over-triage, or
recommend ineffective or harmful treatment if the training is poorly done, and
an errant model could harm a great number of patients, while clinicians errors
only affect one patient at a time [20].
Continuous monitoring of vital signs can improve early detection of
clinical deterioration and help initiate interventions that prevent FTR [20-22,45].
In a study by Watkins et al, the nurses surveyed in the study agreed that
continuous vital sign monitoring would help enhance patient safety. There are
various technologies that can be used, with direct or not direct patient
contact, or that delay the alarm set off, providing some time to deviations in
vital signs to normalize to prevent alarm fatigue and distractions [21,22].
There are some barriers for the implementation of such technologies, as
inadequate training or unfamiliarity
with them, challenges in incorporating them into the clinical workflow, or
budget restrictions, but there are also facilitators such as education to these
systems, valuing how these technologies worked in the hospital they are being
implemented in, tailoring them and integrating them into existing workflows and
receiving regular feedback about progress [22]. There is still needed research
in this area about which parameters should be captured, or if all patients
should be monitored or specific types of patients [23].
There is evidence that incorporation of telemedicine ICU nurses in best
practice initiatives in the ICU can reduce hospital length of stay and improve
adherence to practices that avoid FTR. In order to further prevent FTR, it may
be useful to clarify the tele-ICU nurse’s role in order to prevent delays and
support proactive clinical practice, and also further study their impact on
patient outcomes [27].
Efferent
limb
The efferent limb can be divided into 2 systems: ramp-up or ramp-down
systems. In the ramp-up systems the magnitude of the initial response is linked
with the severity of the patient’s physiological deviation. The ramp-down
systems mobilize maximum resources initially and then can de-escalate, once the
triage of the patient and the situational needs are assessed [18].
Rapid response teams and medical emergency teams have become the standard
approach to the efferent arm, becoming more prevalent in hospital systems
overtime [19]. Their constitution may vary in different institutions, but they
are typically multidisciplinary and comprise a critical care physician, a
critical care nurse and a respiratory therapist at minimum [8,46]. Evidence
also shows that intensivists used on rapid response teams are predictors of
high performance and may improve FTR [8,10].
According to Fernandez-Moure et al, the medical emergency teams are more
directed to a specific diagnosis, like cardiac arrest or stroke, and are
arranged around those medical diagnoses,
as opposed to the rapid response teams, that have to often respond to a medical
emergency of unclear origin [60]. A surgical rescue team can also be important
and has shown improved outcomes. Medical patients can also have emergent
surgical pathology, that can have a mortality of 100% if they don’t undergo
surgery, so the concept of surgical rescue can be extended to those patients
and acute care surgeons can be established as the surgical RRS for medical
patients [11].
Cognitive aids aim to improve communication, teamwork and leadership and
the surgical safety culture and accelerate escalation of care and optimize resuscitation
by lowering omitted management steps, and therefore have potential to reduce
FTR [48]. Despite the potential benefit in implementing this strategy to reduce
FTR, there is still not a widespread use in clinical practice [48].
Implementation of crisis checklists also has the potential to improve patient
outcomes by structuring the responses to clinical deterioration by the first
responders in the management of common emergencies while escalation to rapid
response teams occur [14].
Key
Learning Points
In conclusion, there are several
strategies that may help prevent the occurrence of FTR.
Patient and hospital factors are many
times hard to modify, therefore a focus on improving microsystem factors
through team resource management training, simulation sessions and
implementation of multidisciplinary safety programs may be a way of reducing FTR.
Even so, additional investigation to the microsystem factors contribution for
FTR would be interesting to further understand their importance.
Furthermore, the creation of clinical
pathways and assignment of the same group of patients consistently to nurses
may contribute to improve nursing surveillance and recognition of clinical
deterioration, and the use of communication tools like SBAR may help relay
information and improving confidence in managing emergent situations and
calling for help.
Regarding track and trigger systems,
there is contradictory information in the literature, and the amount of EWS
makes it difficult to compare them and validate them. Nonetheless, aggregate
weighted systems are the most reviewed and validated ones, despite their limitations.
Howbeit, machine learning systems have shown to outperform
EWS systems and could be a good strategy to prevent FTR. In that matter,
studies to understand the best machine learning model and its applicability to
different settings of care could be interesting.
Continuous monitoring could also be a
strategy to improve patient outcomes by detecting early clinical deterioration,
however there is still need for insight on which patients would benefit this
type of monitoring and which parameters should be assessed.
In the efferent limb, rapid response
teams have become the standard and have shown to help reduce FTR.
Finally, randomized trials to assess the benefits of cognitive aids and crisis checklists could also be important to assess their benefits and if they are proven, using them more widely in clinical practice in order to prevent and reduce FTR.
Humberto
S Machado, Anesthesiology Service, University
Hospital Center of Porto
Largo Professor Abel Salazar, 4099-001 Porto,
Portugal, Tel: +351935848475, E-mail: hjs.machado@gmail.com
Duarte de Brito TMP, Pereira
MP and Machado HS. Failure to rescue, what can be done to prevent
it? (2021) Edel J Biomed Res Rev 3: 30-38
Failure to Rescue, Early Warning Score, Rapid
Response Team, Continuous Monitoring
