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Helping Improve Post-Op Outcomes: Prevention of Failure to Rescue

Of the over 300 million surgical procedures being performed worldwide each year, 4.2 million people die within 30 days of their procedure, accounting for 7.7% of all deaths globally, making post-operative mortality the third leading cause of all deaths.

Nurse and old lady

Rescuing ward patients before they crash represents a major opportunity to improve patient safety.1 Central to the concept of preventing failure to rescue is the early detection of deterioration in ward patients.2 Of the over 300 million surgical procedures being performed worldwide each year, 4.2 million people die within 30 days of their procedure, accounting for 7.7% of all deaths globally, making post-operative mortality the third leading cause of all deaths. 2,3  

Failure to rescue is defined as the death of a patient after one or more potentially treatable complications and has emerged as an important surgical quality indicator.4

Increasing pressure from payers and hospitals to tie quality metrics to hospital costs has lead to post-operative outcomes coming under more scrutiny.4, 5 Many post-operative complications may not be preventable and, thus, not the best quality measures, however, failure to rescue, or the death of a patient after one or more treatable complications, may provide a more appealing target for surgical quality improvement efforts.6

With such a diverse patient population undergoing surgical procedures these days the task of risk stratifying them is daunting. In a study by Churpek et al., looking at early warning scores based on vital signs obtained on ward patients, it was discovered that while patients had similar scores at admission, those who went on to experience cardiac arrest showed divergent scores as early as 48 hours into their hospital stay.7

Multiple studies, including the Churpek investigation, have confirmed that respiratory rate monitoring is the best predictor of adverse outcomes on the wards.7-10 These findings suggest that with appropriate monitoring, there should be ample time to rescue these patients. The next step following the implementation of closer monitoring would be the development of risk prediction models that have high sensitivity while preventing the unnecessary burden of frequent false positives on the rapid response teams.7

Models already exist for utilizing patient data in an effort to catch early deterioration on the wards. In a recent study Nolan et al. found that using a computerized sepsis screening and alert system was not only feasible on the medical wards, it facilitated identification of early sepsis, which is crucial according to the Severe Sepsis Campaign guidelines.11 With over half of all in-hospital deaths occurring on the wards, this is a clear opportunity to detect deterioration early and rescue patients before it is too late.12

The evidence already exists that continuous monitoring on the wards saves lives.13 In light of these facts; hospitals need continuous monitoring solutions that improve the quality of care patients receive, not only in the operating room and intensive care units, but also on the medical and surgical wards. Such a solution must be able to follow ambulatory patients anywhere while remaining connected and consistently relaying vital data to the right people at the right time. Modern technologies like edge computing and artificial intelligence are making it possible to analyze large amounts of patient data quickly. This information provides clinicians with early warning scores that take into account patient variables over the entire admission, facilitating the early recognition of trends so that patient deterioration can be caught and failure to rescue prevented.

While continuous monitoring, particularly the continuous monitoring of respiratory rate and oxygen saturation, appears to be the best solution for preventing failure to rescue in post-operative and medical ward patients, there are many challenges. Patients are mobile by necessity as a part of enhanced recovery protocols geared toward quicker recovery, shorter hospital stays, and better clinical outcomes.14 To this end a revolution is needed. Wearable, compact, comfortable, robust, and reliable patient monitors are undergoing trials and may soon be available. This is an exciting time for patient care, the chance to provide patients and hospitals with the technology that may help lead to significant improvements in clinical outcomes, patient satisfaction, and cost-effectiveness.

References

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  2. Continuous monitoring in an inpatient medical-surgical unit: a controlled clinical trial. Am J Med 2014. https://www.amjmed.com/article/S0002-9343(13)01072-3/fulltext. Last accessed 12/04/2019.
  3. Global burden of postoperative death. Lancet, 2019. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)3313…. Last accessed 12/04/2019.
  4. Failure to rescue as a surgical quality indicator. Anesthesiology, 2019. https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2724941. Last accessed 12/04/2019.
  5. National and surgical health care expenditures, 2005-2025. Ann Surg 2010. https://insights.ovid.com/pubmed?pmid=20054269. Last accessed 12/5/2019.
  6. Agency for Healthcare Research and Quality. Patient Safety Indicators Technical Specifications Updates - Version v2018 and v2018.0.1 (ICD 10), June 2018.  https://qualityindicators.ahrq.gov/Archive/PSI_TechSpec_ICD10_v2018.aspx. Last accessed 12/05/2019.
  7. Predicting Cardiac Arrest on the Wards, A Nested Case-Control Study. Chest, 2012. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3342781/
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  9. Respiratory rate predicts cardiopulmonary arrest for internal medicine inpatients. J Gen Intern Med, 1993. https://link.springer.com/article/10.1007%2FBF02600071. Last accessed 12/05/2019.
  10. MERIT study investigators. The objective medical emergency team activation criteria: a case-control study. Resuscitation, 2007. https://www.resuscitationjournal.com/article/S0300-9572(06)00564-8/full…. Last accessed 12/05/2019.
  11. Can a Computerized Sepsis Screening and Alert System Accurately Diagnose Sepsis in Hospitalized Floor Patients and Potentially Provide Opportunities for Early Intervention? A Pilot Study. J Intensive& Crit Care, https://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2012.185…. Last accessed 12/05/2019.
  12. Incidence and outcome of in-hospital cardiac arrest in the UK National Cardiac Arrest Audit. Resuscitation, 2014. https://www.resuscitationjournal.com/article/S0300-9572(14)00469-9/full…. Last accessed 12/05/2019.
  13. Continuous monitoring in an impatient medical-surgical unit: a controlled clinical trial. Am J Med, 2014. https://www.amjmed.com/article/S0002-9343(13)01072-3/fulltext. Last accessed 12/05/2019.
  14. Enhanced recovery after surgery: current research insights and future direction. World J Gastrointest Surg, 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5329702/. Last accessed 12/05/2019.
  • Respiratory
  • Subacute care