Essay on a Critical Evaluation of ‘Failure To Rescue’ As It Relates to the Deteriorating Patient in the Acute Healthcare Environment

Introduction

This essay will critically evaluate ‘failure to rescue’ as it relates to the deteriorating patient in the acute healthcare environment. The essay will discuss the incidence of adverse events linked to failure to rescue in the Australian acute healthcare environment, and evaluate the consequences of failure to rescue for different stakeholders. The essay will then evaluate two nursing strategies, rapid response systems and systematic staffing reviews, that have the potential to prevent registered nurses from failing to rescue the patient and maintain patient safety.

The concept of ‘failure of rescue’

‘Failure to rescue’, in an acute healthcare environment, refers to the inability of healthcare providers to prevent a clinically critical deterioration, such as death or disability, in patients with complications from surgery, medical care or underlying illness, or healthy patients who developed complications. For example, a patient with underlying hypertension and chronic kidney disease may be admitted for elective dilatation and curettage for postmenopausal bleeding, and reported slight abdominal pain, elevated creatinine levels and an elevated breathing rate. The patient later suffered atrial fibrillation, abdominal pain, and deteriorated into a state of serious hematemesis, eventually dying of gastrointestinal bleeding. This represents a failure to rescue.

‘Failure to rescue’ has been used as a quality service metric to evaluate the standards of a hospital’s healthcare provision, and is typically defined as the total number of deaths resulting from a complication from a medical procedure, although more restricted definitions such as FTR-N and FTR-A have been used with lower reliability and validity. (Silber et al, 2007)

‘Failure to rescue’ is often linked to both patient factors, such as age and comorbidities, as well as healthcare and hospital factors such as negligence in monitoring of patient symptoms, identification of patient signs, adequate healthcare staffing and timely intervention. ‘Failure to rescue’ most frequently occurs in surgical procedures with higher risk of adverse events, which include procedures such as general, vascular and thoracic surgical procedures. (Massarweh et al, 2017)

The incidence of adverse events linked to failure to rescue in the Australian acute healthcare environment

Adverse events such as post-surgical complications, infection, treatment rejection and reactions to medication may be linked to failure to rescue, and are evident to varying degrees in the Australian acute healthcare environment. This can range from small errors in the application of routine medications and anaesthetics, to neglect of post-operative symptoms such as breathing difficulties and tachycardia, which may be indicative of more serious conditions such as pulmonary embolism.

Incidence of adverse events in the Australian acute healthcare environment vary significantly. A study by Assareh et al (2014) had found that the incidence of adverse events linked to failure to rescue in the Australian acute healthcare environment was marked by significant geographical variance. (Assareh et al, 2014) Based on a population based study of 4.3 million elective surgical admissions across New South Wales, Australia from 2002-2009, Assareh et al (2014) found that of 153 local government areas, about 20% (31 areas) featured patients who were exposed to excessive adjusted failure-to-rescue risk of 10 to 50%, while about another 20% had a lower adjusted failure-to-rescue risk of 10%, when compared with the national risk level of 14%. (Assareh et al, 2014) This may be explained by the findings of Ghaferi et al (2009), who had concluded that incidence of adverse events did not directly result in failure to rescue and death, and that rather, it was the inability to quickly identify and respond to the deterioration caused by such adverse events that led to failure to rescue. (Ghaferi et al, 2009) A similar study also found that hospitals with high complication and adverse incidence rates tend to have lower failure to rescue rates in Australia, likely because nursing staff in high adverse incidence rate environments have the experience and situational awareness developed to prevent failure to rescue incidents. (Ghaferi et al, 2011)

The variance in such incidence of failure to rescue across Australian acute healthcare is a result in the quality and adequacy of healthcare practitioner staffing in these areas. For example, insufficient staffing results in nurses having to manage the needs of a larger number of patients, resulting in monitoring using indirect electronic surveillance rather than direct and frequent bedside interaction. (Simpson, 2016) This may result in issues such as the inability for nurses to handoff patients to other nurses properly, or assuming care of multiple patients during critical phases such as epidural labor, anesthesia and blood transfusions, which may result in a lower quality of care and a higher risk of maladministration of medical procedures. (Simpson, 2016)

Consequences of failure to rescue for the patient, families and the healthcare system

The consequences of failure to rescue are severe, and may result in complications, disability and death for the patient, significant emotional and financial harm for the families, and reduced healthcare service quality and higher financial liability for the healthcare system.

For patients, failure to rescue may lead to significant post-surgical complications, disability and even death. For example, failure to care in birthing procedures may result in issues such as postpartum hemorrhage, newborn suffocation and postpartum distress. (Simpson, 2016) The families of these patients may suffer significant emotional trauma, as well as higher healthcare costs, as a result of these complications and failure to rescue incidents.

For the healthcare system, failure to rescue may result in lower healthcare service quality, lower trust in the healthcare system, and financial damages resulting from patient lawsuits, litigation trials and compensation. Healthcare practitioners and nurses may also suffer from post-traumatic stress disorder, job stress and burnout. Healthcare system costs may also rise as a result of failure to rescue. As demonstrated by Chen et al (2018), for a study of hepato-pancreato-biliary surgery patients, failure to rescue resulted in higher average Medicare payments during index hospitalization, when placed in comparison with successful rescue (on average, USD $53,500, as compared to $44,600), while total hospitalization payments were on average $14,500 higher for failure to rescue cases compared to successful rescue cases. (Chen et al, 2018)

Evaluation of two nursing strategies that can be used to prevent failure to rescue and maintain patient safety

Rapid response systems and systematic staffing reviews are two nursing strategies that can be used to prevent failure to rescue and maintain patient safety. Foremost, as proven by Subbe and Welch (2013), rapid response systems would allow for healthcare practitioners to conduct high-quality monitoring of vital signs, identify aberrant pathological patterns in routine patient interactions, and escalate any anomalies to a dedicated rapid response team who can respond in a timely manner. (Subbe and Welch, 2013) This would involve the division of the nursing team into two sections: a general care team, and a rapid response team, of which the latter would be exclusively responsible for responding in a swift manner to any escalations of adverse events, in order to prevent failure to rescue.

Rapid response teams may, however, feature significant drawbacks. Foremost, hospitals are often reluctant to specifically assign a team of rapid responders, as it leads to a decline in the nurse staffing ratio, while the team of rapid responders may not be actively deployed to their ful capacity. This is especially significant, given that most hospitals already face insufficient staffing of nurses. Hospital management teams may also regard broad-based training in adverse event identification as sufficient to manage adverse events, given that adverse events and failure to rescue are not seen as sufficiently frequent incidents to warrant the deployment of a special rapid response team. Furthermore, rapid response teams may be more effective in hospitals with higher complication rates, because those hospitals have a suitable environment for training rapid response nurses in recognizing and responding to complications as they develop, while hospitals with lower complication rates typically have less opportunities for nurses to develop symptom identification and rescue skills. (Ghaferi et al, 2009)

Secondly, systematic staffing reviews of training and operations would help to maintain patient safety. Such reviews would allow nurses to streamline communications, conduct resuscitation training, adequately equip themselves with knowledge of pathological symptoms, and implement effective escalation protocols. (Johnston et al, 2015) This would allow nurses to contribute more effectively to the prevention of avoidable harm, by equipping them with sufficient resources, staffing and knowledge to escalate potential failure-to-rescue cases ahead of time and surface them for targeted intervention. (Johnston et al, 2015)

These staffing reviews would also allow for nurses to undergo simulation training in order to close their skill and knowledge gap, which Cooper et al (2011) showed to be successful in eliminating failure to rescue. (Cooper et al, 2011) In particular, Audet et al (2018) conducted a literature review of studies from 1996 to 2017 on the impact of nurse education in an acute care setting on nursing response to adverse events, and found that higher levels of nurse education were associated with lower risks of failure to rescue and mortality in 75% of the reviewed studies. (Audet et al, 2018) This demonstrated that higher nurse education helps to reduce the risks of death from failure to rescue, and that nurses need to be equipped to properly recognize and handle adverse events.

In conducting systematic staffing reviews of training, nurses should also be trained to examine patients for indicative risk factors which may indicate higher incidence of adverse events linked to failure to rescue. For example, a study by McNicol et al (2007) of elderly patients having non-elective, non-cardiac inpatient surgery in one of three Melbourne teaching hospitals showed a 6% 30-day mortality rate and a 19% postoperative complications rate, which were linked to incidence of complications such as underlying age-related conditions, acute renal impairment, underlying systemic disease and albumin levels. (McNicol et al, 2007) Nurses should be trained to assess patients for such risk factors during their in-processing, in order to better manage and identify the onset of adverse events that may lead to failure to rescue.

As part of these systematic staffing reviews, hospital management teams should also consider the use of advanced technologies such as smart monitors equipped with machine learning capabilities. These technologies will augment the in-person interactions of nurses with their patients by detecting minor fluctuations in patient vitals, such as pulse, blood plasma and breathing rate, that can be indicative of more serious complications such as systematic inflammatory response syndrome or sepsis. (Ghaferi et al, 2011) Nurses should also be trained to use and operate these equipment as part of their daily routine.

Systematic staffing reviews, however, suffer from a number of limitations. Foremost, hospital management teams typically do not prioritise staffing reviews as they are long-term initiatives, and have insufficient financial budgets to conduct staffing reviews in an effective manner. Secondly, nurse training programs represent a significant opportunity cost in terms of time and financial investment, which make hospital management teams reluctant to invest in them. Finally, systematic staffing reviews may not resolve the underlying issues that drive higher failure to rescue rates in hospitals, such as an insufficient amount of physician resources, communication and coordination failures, safety culture, and lower nurse to patient staffing ratios. These will need to be addressed for a systematic staffing review to be effective.

Conclusion

Failure to rescue is a serious issue in the Australian acute healthcare environment, with significant detrimental impacts on the healthcare system, patients and their families. Nurses should be trained to recognise adverse events such as post-surgical complications and medication reactions, while the nursing strategies of rapid response teams and systematic staffing reviews of training can be used to prevent failure to rescue and maintain patient safety. Clearly, failure to rescue is a preventable issue which requires timely identification of adverse events and complications, escalation to specialised and trained responders, and strong teamwork and collaboration to reduce or prevent its incidence.

References

Assareh, H., Ou, L., Chen, J., Hillman, K., Flabouris, A., & Hollis, S. J. (2014). Geographic variation of failure-to-rescue in public acute hospitals in New South Wales, Australia. PloS one, 9(10).

Audet, L. A., Bourgault, P., & Rochefort, C. M. (2018). Associations between nurse education and experience and the risk of mortality and adverse events in acute care hospitals: A systematic review of observational studies. International journal of nursing studies, 80, 128-146.

Buist, M., Bernard, S., Nguyen, T. V., Moore, G., & Anderson, J. (2004). Association between clinically abnormal observations and subsequent in-hospital mortality: a prospective study. Resuscitation, 62(2), 137-141.

Chen, Q., Beal, E. W., Kimbrough, C. W., Bagante, F., Merath, K., Dillhoff, M., & Pawlik, T. M. (2018). Perioperative complications and the cost of rescue or failure to rescue in hepato-pancreato-biliary surgery. HPB, 20(9), 854-864.

Cooper, S., Buykx, P., McConnell-Henry, T., Kinsman, L., & McDermott, S. (2011). Simulation: can it eliminate failure to rescue?. Nursing times, 107(3), 18-20.

Ghaferi, A. A., Birkmeyer, J. D., & Dimick, J. B. (2009). Variation in hospital mortality associated with inpatient surgery. New England Journal of Medicine, 361(14), 1368-1375.

Johnston, M. J., Arora, S., King, D., Bouras, G., Almoudaris, A. M., Davis, R., & Darzi, A. (2015). A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery. Surgery, 157(4), 752-763.

Massarweh, N. N., Anaya, D. A., Kougias, P., Bakaeen, F. G., Awad, S. S., & Berger, D. H. (2017). Variation and impact of multiple complications on failure to rescue after inpatient surgery. Annals of surgery, 266(1), 59-65.

McNicol, L., Story, D. A., Leslie, K., Myles, P. S., Fink, M., Shelton, A. C., & Poustie, S. J. (2007). Postoperative complications and mortality in older patients having non‐cardiac surgery at three Melbourne teaching hospitals. Medical journal of Australia, 186(9), 447-452.

Miller, P. J. (2017). Case study: continuous monitoring of patient vital signs to reduce ‘failure-to-rescue’events. Biomedical instrumentation & technology, 51(1), 41-45.

Schmid, A., Hoffman, L., Happ, M. B., Wolf, G. A., & DeVita, M. (2007). Failure to rescue: a literature review. JONA: The Journal of Nursing Administration, 37(4), 188-198.

Silber, J. H., Romano, P. S., Rosen, A. K., Wang, Y., Even-Shoshan, O., & Volpp, K. G. (2007). Failure-to-rescue: comparing definitions to measure quality of care. Medical care, 918-925.

Simpson, K. R. (2016). Nurse staffing and failure to rescue. MCN: The American Journal of Maternal/Child Nursing, 41(2), 132.

Subbe, C. P., & Welch, J. R. (2013). Failure to rescue: using rapid response systems to improve care of the deteriorating patient in hospital. Clinical Risk, 19(1), 6-11.