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Tackling the Underlying Problems of Failure to Rescue

From: The Hospitalist, Mar/Apr 2005

by Richard Kremsdorf, MD

A recent HealthGrades Quality Study titled Patient Safety in American Hospitals (July 2004) highlighted the frequency of patients dying from complications that develop while in hospitals. Failure to rescue, according to the 3-year study, accounts for 60,000 deaths each year in Medicare patients under the age of 75.

Based on my experience as a pulmonary and critical care physician, this statistic quantifies an important problem. Deaths from complications of illness, or care, during a hospital stay happen more than we’d like to admit. However, the good news is that by identifying the underlying problem and deploying some targeted, systemic changes, hospitalists can begin to handle decompensation quickly, proactively, and before it’s too late.

Moving forward, hospitals need to build an effective patient safety net, which requires three important elements: point-of care tools for caregivers, proactive clinical surveillance, and real-time process monitoring.

FIGURE 1. Catastrophe Timeline - Review of the patient's chart revealed instability had been developing for hours before a 'code' was called
FIGURE 1. Catastrophe Timeline — Review of the patient's chart revealed instability had been developing for hours before a "code" was called

Reasons for Failure to Rescue

A huge effort, and amount of money, has been focused on finding errors that lead to harm. Unfortunately, we’re tackling the wrong errors. New tools like barcode medication administration or CPOE tackle errors of commission. These errors might occur when a doctor or nurse administers a wrong dose or wrong medication. Errors of commission are much easier to identify and solve, but clinically significant errors of commission that cause harm are relatively rare events and don’t affect overall hospital mortality.

Errors of omission, however, are much more insidious. An error of omission is an error that occurs when an action is not taken or an important step in the process is left out. Examples of an error of omission include sub-optimal patient care resulting from the inadequate availability of patient information for decision-making, or a more blatant example, when a patient’s vital signs indicate decompensation but the clinical response is inadequate or delayed.

Errors of omission continue in today’s hospitals for two very important reasons: First, we lack a systematic way to handle clinical decompensation. While we have “code” teams, their efforts often come into play too late. Second, lacking a way to recognize and respond to the issue, we have accepted that failure to rescue is in some ways inevitable and excusable.

The basic, first step is to replace the inherently unreliable paper patient chart. Paper patient charts get misplaced, information is sometimes missing and/or illegible, and they make it impossible for a team effort to optimize care.

Hospitals need to get patient data such as vital signs and medication usage in electronic form. That way, it is effortless and time-efficient to determine a patient’s status and check up on patients even when not physically near them. Making this change alone, even in only one hospital unit, hospitalists can begin to effect significant positive changes in patient safety outcomes.

Catastrophes Aren’t Inevitable

Often, the first time physicians become aware of a problem is when they receive a frantic call to come to the bedside. The patient is decompensating and needs immediate, dramatic intervention to save their life. However, when we take the time to look back at the patient chart and “connect the dots,” we see that instability had been developing for hours before an urgent summons for assistance.

Even with the best care, patients’ clinical needs often change after admission. Patient status can change rapidly, so a perfect assessment earlier in the day can quickly become dated. Further, bedside staff have many other patients, and staffing assignments don’t build in “slack time” to permit paying extra attention when problems develop. Consequently, signs of clinical deterioration are often missed or not acted upon until there’s a code on the unit and dramatic measures are needed to save a life.

Proactive clinical surveillance tools are the second big step in creating a safety net for patients. With patient data in electronic form, hands-on caregivers, nurses, and supervisors can use specially designed “dashboard views” to quickly identify which patients are exhibiting warning signs of clinical decline and exactly where they are located.

To be most effective, staff should view clinical surveillance information in a variety of useful ways:

  • Hospital–wide for a big picture of where the trouble spots are
  • By unit, to scan through patients and see the values that are triggering an alert
  • By provider, so doctors and nurses can scan their list of patients and see which have triggered alerts
  • By patient, drilling into all the details of that patient’s current status and previous care
  • By patient, drilling into all the details of that patient’s current status and previous care

tion, which are out of range or trending in the wrong direction, should automatically highlight patients. With the complete clinical record on-line, staff can prioritize which patients to visit next and what type of supplemental resources might be needed to enhance care.

For hospitalists, clinical surveillance tools save an immense amount of time and help prioritize patient care. Typically hospitalists manage a large number of patients who are scattered around the hospital. Determining where to start rounds and which patients should be seen first is often difficult. Even worse, patients’ conditions suddenly change for the worse soon after you’ve checked on them. There are just too many patients to continually be looking at patient charts and relying on verbal information: that’s why there are computers!

Supervisory staff can provide an additional safety net, if they have the tools to do so effectively. Typically, they rely on “report” and walking around, visiting staff, looking for an opportunity where their intervention could be helpful. By referring to “hot spots” indicated on a clinical surveillance dashboard view, they would know where they’re needed and spend their time helping, rather than prospecting.

Some hospitals have formalized their response to the failure to rescue problem by creating “rapid response teams.” Such teams can also rely on clinical surveillance tools to identify patients in need, rather than waiting for a phone call from an overwhelmed primary caregiver.

FIGURE 2. Clinical surveillance information may be seen in 'dashboard views' by unit or provider, to scan through patients and see values that triggered an alert.
FIGURE 2. Clinical surveillance information may be seen in "dashboard views" by unit or provider, to scan through patients and see values that triggered an alert.

Making Best Practices Work

Organizational performance can be dramatically improved when patient outcomes and staff activity can be measured and analyzed. Traditionally, this has been done retrospectively.

By evaluating outcomes of patients and compliance with processes, many sites have been able to improve processes for future patients. However, because reporting has been periodic, results become available only months later, and implementation of care enhancements are delayed.

With comprehensive patient data in electronic form, real-time monitoring of compliance with intended processes and best practices becomes possible. For example, if there is a consensus that the head of the bed of ventilated patients should be elevated to reduce the incidence of ventilator-associated pneumonia, then the monitoring system can show, by ICU, the percentage compliance with that protocol at any given moment.

Since the report is available real-time, non-compliance can be addressed immediately, benefiting the patient and directing education about the protocol precisely when and where it is needed for maximum impact.

Creating a Reliable Patient Safety System

An electronic medical record forms the very foundation of a patient safety system. This electronic data provides the capability for proactive clinical monitoring and much more sophisticated process analysis that happens in days or weeks, not over a course of months or years.

Capture patient data electronically, set up a set of effective alerts based on hospital-defined triggers, and enact process monitoring to improve outcomes and fix problems as they occur. With these three elements, hospitals have the best antidote for failure to rescue and are able to create a safety net for patients.

Dr. Kremsdorf can be contacted at cdlong@ntelos.net.


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