Trauma/Critical Care A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery Maximilian J. Johnston, MB BCh, MRCS,a Sonal Arora, MRCS, PhD,a Dominic King, MB ChB, MRCS,b George Bouras, MBBS, FRCS,c Alex M. Almoudaris, MBBS, MRCS,a Rachel Davis, PhD,a and Ara Darzi, MD, FRCS, FACS,c London, UK
Background. The relationship between the ability to recognize and respond to patient deterioration (escalate care) and its role in preventing failure to rescue (FTR; mortality after a surgical complication) has not been explored. The aim of this systematic review was to determine the incidence of, and factors contributing to, FTR and delayed escalation of care for surgical patients. Methods. A search of MEDLINE, EMBASE PsycINFO, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials was conducted to identify articles exploring FTR, escalation of care, and interventions that influence outcomes. Screening of 19,887 citations led to inclusion of 42 articles. Results. The reported incidence of FTR varied between 8.0 and 16.9%. FTR was inversely related to hospital volume and nurse staffing levels. Delayed escalation occurred in 20.7–47.1% of patients and was associated with greater mortality rates in 4 studies (P < .05). Causes of delayed escalation included hierarchy and failures in communication. Of five interventional studies, two reported a significant decrease in intensive care admissions (P < .01) after introduction of escalation protocols; only 1 study reported an improvement in mortality. Conclusion. This systematic review explored factors linking FTR and escalation of care in surgery. Important factors that contribute to the avoidance of preventable harm include the recognition and communication of serious deterioration to implement definitive treatment. Targeted interventions aiming to improve these factors may contribute to enhanced patient outcome. (Surgery 2015;157:752-63.) From the Centre for Patient Safety and Service Quality, Division of Surgery, Department of Surgery and Cancer,a the Centre for Health Policy, Division of Surgery, Department of Surgery and Cancer,b and the Division of Surgery, Department of Surgery and Cancer,c Imperial College, London, UK
THE OBJECTIVE REPORTING of clinical outcomes is essential to the delivery of safe and transparent patient care.1,2 In addition, patient-reported and specialtyFunding: This review article received no direct funding. Johnston, Arora, King, Almoudaris, Davis, and Darzi are affiliated with the Imperial Patient Safety Translational Research Centre, which receives center funding from the National Institute for Health Research (UK). The grant number is 40490. Registration: This systematic review was registered with the International Prospective Register of systematic reviews (PROSPERO) ID - CRD42013004080. Accepted for publication October 31, 2014. Reprint requests: Maximilian J. Johnston, MB BCh, MRCS, Academic Surgical Unit, 10th Floor, QEQM, South Wharf Road, Imperial College, London, W2 1NY, UK. E-mail: [email protected]. 0039-6060/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2014.10.017
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specific outcomes also contribute to the drive toward high-quality care.3 The concept of failure to rescue (FTR) has emerged recently as an outcome measure that discriminates hospital performance. Defined by Silber et al,4 FTR is the number of deaths in patients who develop a postoperative complication. Hospitals with the greatest complication rates, however, do not necessarily have the greatest mortality.5 These observations suggest that high-quality postoperative care after a complication plays an important role in the avoidance of preventable harm. Several studies have defined the components of optimal patient management after a complication.2,3 Other reports have provided valuable insights into organizational factors that contribute to adverse outcomes, including lack of beds in the intensive care unit (ICU), poor access to radiology services, and unstructured emergency
Surgery Volume 157, Number 4 operating schedules.6,7 Despite this recent expansion in the evidence base, the impact interventions aiming to improve postoperative care have on FTR has not been explored previously. This topic is important because previous studies have highlighted that suboptimal care and communication failures contribute to breakdowns in information transfer along the postoperative patient pathway.8,9 Specifically, in the context of an unstable patient, early recognition of clinical deterioration may be the key to preventing FTR. Escalation of care is a process that can be defined as the recognition and communication of patient deterioration so as to implement definitive management. Rapid escalation of care can accelerate appropriate management and recovery. In contrast, if patient deterioration is not recognized or not acted on in a timely manner, delay can lead to poor outcome. Studies have demonstrated that factors that impede escalation increase cardiac arrests and death.10,11 Previous studies evaluating FTR have investigated the aftermath of complications; however, there is a paucity of literature exploring the antecedents to FTR and the role of escalation of care in this process. The aims of this review are to (1) determine the incidence of FTR events, (2) identify the factors that contribute to high FTR rates and delayed escalation of care, and (3) summarize outcomes of interventions aimed at decreasing the rates of FTR and improving escalation of care. METHODS Data sources. The databases searched included Ovid MEDLINE (1980 to week 2, November 2012), EMBASE (1980 to week 2, November 2012), PsycINFO (1987 to week 2, November 2012), the Cochrane Database of Systematic Reviews (Issue 10, 2012), and the Cochrane Central Register of Controlled Trials (Issue 10, 2012). Conference abstracts and reference lists of included articles were hand searched to identify additional relevant data. The grey literature (work lacking bibliographic control) was searched using Google. Search strategy. The search strategy employed the following terms (all searched as a keyword unless indicated): escalation of care, failure to rescue, rapid response, early warning score, critical care outreach, calling for help, patient deteriorat*, medical emergency team, postoperative care (title search), failure to escalate, postoperative complication (title search), resident supervision, clinical supervision, trainee supervision, requesting help, and requesting support. The terms ‘patient safety’/ (medical subject heading) and ‘ward’ were
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combined using ‘‘AND’’. An initial review of this combination revealed a large number of studies reporting escalation of drug dosage; therefore, to tighten the search specificity, the additional limit ‘NOT drug*’ was applied. All of these terms were then combined using the conjunction ‘‘OR’’ before limits were applied. Studies were restricted to those reporting human subjects in the English language, published from 1980 onward. The last search was conducted on November 15, 2012. All retrieved articles underwent screening of the title and subsequent abstract by 2 independent reviewers to screen for relevance. Inclusion criteria for full-text review were articles reporting hospitalbased evaluations focusing on adult patients that investigated the factors affecting escalation of care or the impact of hospital and patient characteristics on outcome measures, including FTR. Letters, commentaries, review articles, conference abstracts, and articles not fitting in with the aims of the review were excluded at this point. The 2 independent reviewers then screened the full text of the identified articles to assess eligibility for inclusion. Any disagreements during selection of articles for full-text review were resolved after discussion with a third reviewer. Data extraction. A data extraction form was designed by the research team to allow for consistent evaluation. The study setting, subjects, design, measures, and key findings were recorded for further analysis. Assessment of study quality. Quality assessment of each of the studies was evaluated independently by 2 researchers using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers.12 These criteria were chosen because the criteria included a rating scale for both qualitative and quantitative research, allowing a degree of direct comparison between articles, because there are some matching items on each rating scale. Mixed-methods studies were given quality assessment scores based on both the quantitative and qualitative quality criteria. Studies were not excluded based on their quality to ensure comprehensive capture of as many studies exploring escalation of care and FTR as possible. Had low-quality studies been excluded, some valuable qualitative and descriptive data may have been lost. RESULTS The search produced 19,887 citations with 9,414 remaining after limits were applied and duplicates removed. Of these, 8,566 articles were excluded after title review leaving 848 abstracts for further scrutiny. Abstract review led to exclusion of a further
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Figure. A PRISMA diagram demonstrating the flow of articles within this review. RRT, Rapid response team.
781 articles, leaving 67 for full-text evaluation. Thirty-eight of these articles met the inclusion criteria. A hand search of relevant article references and associated literature identified 4 additional articles that fulfilled the inclusion criteria. The inter-rater agreement for study inclusion between the 2 reviewers was high (kappa = 0.87). Study selection is presented schematically in the Figure. Study characteristics. We included 42 articles: 24 were cohort, 10 observational, 4 mixed-methods, and 4 qualitative studies. The studies were conducted in several different continents including North America (n = 17), Australasia (n = 15), Europe (n = 9), and Asia (n = 1). The primary focus of 26 articles was escalation of care. These articles were categorized into groups, namely, those reporting factors affecting the decision to escalate care, those reporting escalation delay, and those reporting interventions in the escalation process. The remaining 16 articles reported mortality, complications, and FTR rates. Analysis was performed at the hospital and patient levels. Measures of process and outcome. There was wide heterogeneity across the studies in terms of
measures used to capture the impact of patient and hospital characteristics on clinical processes and outcomes. ICU admission was a proxy measure for complications in eight articles.13-20 Other studies used delays in activation of the medical emergency team (MET) or rapid response team (RRT),13,15,17,18,21,22 rates of cardiac arrest,18,20,23,24 and documentation of vital signs16,20,25,26 as important process indicators. Additional measures evaluated included adherence to protocols and care guidelines.23,27,28 Nine studies evaluated organizational characteristics, including hospital volume,29-32 number of procedures performed,33,34 staffing level,29,32,35 teaching status,29,30,36 and staffing/bed ratios.6,30,32 A total of 22 articles reported patient outcomes, including 21 assessing mortality4,6,13,14,17,21,22,27-40 and 16 assessing morbidity (including both surgical and systemic complications).4,6,27-36,39-41 Other outcome measures used were reoperation6 and duration of stay.24 A total of 16 articles reported a metric of FTR6,27-36,39,41; however, the definitions used in each study were not uniform. There were 9 different definitions of FTR in total. The original
Study first author and reference Individual complication Arrhythmia CCF Cardiac arrest Pneumonia DVT/PE Pneumothorax Reoperation Stroke/CVA Renal failure Sepsis GI bleed/ulcer ARDS MI Coagulopathy ACS Respiratory failure POH SSI Shock Abscess Transfusion Peritonitis Pressure ulcer Line infection Malnutrition Total
Silber4 U U U U U U U U U
Bobay27
Almoudaris6
U U U U U U
Glance39
Wright31
U U
U U U
U U U U U U U
U
10
5
1
9
Ghaferi29
Ghaferi34
Ghaferi33
Moriarty41
U U U
U U
U U
U U
U U U U U
U U U U
U
U
U
U
U
U
U
U
U
U
U U U U U U
U U U
U U U
U U U
14
Haas36
U U
U U U
Yasunaga32 U U U
8
8
U U
U U U U U
U
U
U
8
Brooke28
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Table I. Individual complications used to define FTR measures
7
7
10
U U U 5
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ACS, Acute coronary syndrome; ARDS, acute respiratory distress syndrome; CCF, congestive cardiac failure; CVA, cerebrovascular accident; DVT, deep venous thrombosis; GI, gastrointestinal; MI, myocardial infarction; PE, pulmonary embolism; POH, postoperative hemorrhage; SSI, surgical site infection.
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Table II. Complications by system used to define failure to rescue measures Study first author and reference 30
Trinh Glance35 Brooke28
Complications by system Cardiac
Respiratory
Vascular
Wound
Genitourinary
Gastrointestinal
Infection
Total
U
U
U
U
U
U
U U U
7 1 2
U
FTR definition4 was used in 4 studies,4,32,38,39 a modified definition incorporating fewer complications was used in 3 articles,29,33,34 and the definition by the Agency for Health Research and Quality was used by another 3 articles.6,31,41 Other articles used unique definitions of FTR (Tables I and II). Quality assessment of included articles. Interrater agreement for the quality assessment of included studies was high: quantitative studies (kappa = 0.70), qualitative studies (kappa = 0.71), and mixed-methods papers (kappa = 0.73). Quality scores ranged from 6 to 22 (mean 19.2/22, SD 2.74) for the quantitative studies, 15-18 (mean 16.3/20, SD 1.04) for the qualitative studies, and 35-36 (mean 35.5/42, SD 0.58) for the mixedmethods studies. The breakdown of quality scores is offered as a Supplementary File. The scale of the problem: Incidence of FTR events. Overall rates of FTR ranged between 0.03%27 and 16.9%.39 The majority of studies reported an overall FTR rate between 8.0 and 16.9%. An increase in the incidence of FTR was associated with high mortality rates in 5 studies6,29,34,36,39 and low hospital volume in 2 studies.31,33 Two studies demonstrated that FTR discriminated high- and low-volume hospitals better than morbidity.6,39 Factors affecting FTR rates. The factors affecting FTR rates are presented in Table III. Hospital characteristics. Greater hospital volume was associated with lesser FTR rates in 4 studies.29-31,33 Two studies that analyzed the effect of the guidelines of the National Quality Forum revealed that FTR was less frequent in those with greater compliance.28,41 An increase in the level of nurse staffing was associated with lesser FTR rates in 2 studies,29,32 with no significant effect in another study.35 Ghaferi et al analyzed several hospital characteristics and found that the following were associated with lesser FTR rates: teaching status, hospital size >200 beds, daily census >50%, increased nurse-to-patient ratios, and use of technology.29 Patient characteristics. Lesser FTR rates were associated with patient age .05) Location, setting Design Intervention
Ludikhuize42 Adelstein18
Table VI. Effect of interventions on the escalation of care process
Robb24
Kansal24
Mitchell16
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care.60 This is of importance, because these interventions require both individual and team skills to recognize, communicate, and respond to a deteriorating postoperative patient. Regarding limitations of this review, the heterogeneity of definitions and metrics in the reviewed articles meant that a meta-analysis was not possible. There was also a lack of control groups and poor reporting of analytical techniques of data management. Studies evaluating interventions were few. Further interventional studies with randomization are necessary to build on the evidence base and to determine what factors impact on outcomes. Our quality assessment may facilitate much needed future research in this area. The implications of this review stem from the fact that the reviewed articles suggest that escalation of care influences FTR, with several studies linking delayed escalation to poor survival. Patient safety may, therefore, be improved by addressing the factors that influence escalation and FTR. Although structural issues can be optimized, efforts to improve human factors may be an undervalued approach to decreasing FTR. The importance of teamwork and leadership in this setting cannot be underestimated. Specifically, individual surgeons should play a key role in the education of junior team members in timely recognition of complications, which improve patient outcomes.61 Training by a skilled nurse practitioner could also facilitate such learning and contribute to healthy interprofessional relationships. Much of the research featured in this review involves retrospective methodology with a focus on database analysis in the FTR literature. This baseline work has provided valuable information to clinicians and health care providers, but has not addressed adequately the safety concerns that have been identified. To achieve an improvement in outcomes, researchers need to start looking beyond the numbers, using both qualitative techniques and front-line research methods, such as direct observation to develop targeted interventions aimed at improving the quality of surgical patient care. In conclusion, this is the first systematic review to explore factors linking escalation of care and FTR in surgery. Despite widespread heterogeneity in the literature, a link has been established between these important areas of patient care. Factors that contribute to the avoidance of preventable harm include the recognition and communication of deterioration to implement
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definitive treatment. Further research utilizing targeted observational and interventional techniques is required to bring about improvements in patient outcomes. SUPPLEMENTAL DATA Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.surg.2014. 10.017. REFERENCES 1. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991;324:377-84. 2. Hirose M, Regenbogen SE, Lipsitz S, Imanaka Y, Ishizaki T, Sekimoto M, et al. Lag time in an incident reporting system at a university hospital in Japan. Qual Saf Health Care 2007;16:101-4. 3. Haywood KL, Garratt AM, Fitzpatrick R. Quality of life in older people: a structured review of generic self-assessed health instruments. Qual Life Res 2005;14:1651-68. 4. Silber JH, Williams SV, Krakauer H, Schwartz JS. Hospital and patient characteristics associated with death after surgery. A study of adverse occurrence and failure to rescue. Med Care 1992;30:615-29. 5. Sheetz KH, Waits SA, Krell RW, Campbell DA Jr, Englesbe MJ, Ghaferi AA. Improving mortality following emergent surgery in older patients requires focus on complication rescue. Ann Surg 2013;258:614-7. 6. Almoudaris AM, Burns EM, Mamidanna R, Bottle A, Aylin P, Vincent C, et al. Value of failure to rescue as a marker of the standard of care following reoperation for complications after colorectal resection. Br J Surg 2011;98:1775-83. 7. Symons NR, Moorthy K, Almoudaris AM, Bottle A, Aylin P, Vincent CA, et al. Mortality in high-risk emergency general surgical admissions. Br J Surg 2013;100:1318-25. 8. Mackintosh N, Sandall J. Overcoming gendered and professional hierarchies in order to facilitate escalation of care in emergency situations: the role of standardised communication protocols. Soc Sci Med 2010;71:1683-6. 9. Johnston M, Arora S, King D, Stroman L, Darzi A. Escalation of care and failure to rescue: a multi-centre, multi-professional qualitative study. Surgery 2014;155:989-94. 10. Chen J, Bellomo R, Flabouris A, Hillman K, Finfer S. The relationship between early emergency team calls and serious adverse events. Crit Care Med 2009;37:148-53. 11. Hodgetts TJ, Kenward G, Vlachonikolis IG, Payne S, Castle N. The identification of risk factors for cardiac arrest and formulation of activation criteria to alert a medical emergency team. Resuscitation 2002;54:125-31. 12. Kmet LM, Lee RC, Cook LS. Standard quality assessment criteria for evaluating primary research papers from a variety of fields. Edmonton, Alberta, Canada: Alberta Heritage Foundation for Medical Research; 2004. 13. Quach JL, Downey AW, Haase M, Haase-Fielitz A, Jones D, Bellomo R. Characteristics and outcomes of patients receiving a medical emergency team review for respiratory distress or hypotension. J Crit Care 2008;23:325-31. 14. Cabrini L, Monti G, Plumari VP, Landoni G, Turi S, Laura P, et al. Observed versus predicted hospital mortality in general wards patients assisted by a medical emergency team. Signa Vitae 2012;7:38-42.
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15. Shearer B, Marshall S, Buist MD, Finnigan M, Kitto S, Hore T, et al. What stops hospital clinical staff from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response system in a multi-campus Australian metropolitan healthcare service. BMJ Qual Saf 2012;21: 569-75. 16. Mitchell IA, McKay H, Van Leuvan C, Berry R, McCutcheon C, Avard B, et al. A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients. Resuscitation 2010;81:658-66. 17. Pattison N, Eastham E. Critical care outreach referrals: a mixed-method investigative study of outcomes and experiences. Nurs Crit Care 2012;17:71-82. 18. Adelstein BA, Piza MA, Nayyar V, Mudaliar Y, Klineberg PL, Rubin G. Rapid response systems: a prospective study of response times. J Crit Care 2011;26:635.e11-8. 19. Kaplan LJ, Maerz LL, Schuster K, Lui F, Johnson D, Roesler D, et al. Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire. J Trauma 2009;67:173-8. 20. Robb G, Seddon M. A multi-faceted approach to the physiologically unstable patient. Qual Saf Health Care 2010;19: e47. 21. Bapoje SR, Gaudiani JL, Narayanan V, Albert RK. Unplanned transfers to a medical intensive care unit: causes and relationship to preventable errors in care. J Hosp Med 2011;6:68-72. 22. Downey AW, Quach JL, Haase M, Haase-Fielitz A, Jones D, Bellomo R. Characteristics and outcomes of patients receiving a medical emergency team review for acute change in conscious state or arrhythmias. Crit Care Med 2008;36:477-81. 23. Mackintosh N, Rainey H, Sandall J. Understanding how rapid response systems may improve safety for the acutely ill patient: learning from the frontline. BMJ Qual Saf 2012;21:135-44. 24. Kansal A, Havill K. The effects of introduction of new observation charts and calling criteria on call characteristics and outcome of hospitalised patients. Crit Care Resusc 2012;14: 38-43. 25. Endacott R, Kidd T, Chaboyer W, Edington J. Recognition and communication of patient deterioration in a regional hospital: a multi-methods study. Aust Crit Care 2007;20: 100-5. 26. Wong K, Levy RD. Do surgeons need to look after unwell patients? The role of medical emergency teams. ANZ J Surg 2005;75:848-51. 27. Bobay KL, Fiorelli KL, Anderson AJ. Failure to rescue: a preliminary study of patient-level factors. J Nurs Care Qual 2008;23:211-5. 28. Brooke BS, Dominici F, Pronovost PJ, Makary MA, Schneider E, Pawlik TM. Variations in surgical outcomes associated with hospital compliance with safety practices. Surgery 2012;151:651-9. 29. Ghaferi AA, Osborne NH, Birkmeyer JD, Dimick JB. Hospital characteristics associated with failure to rescue from complications after pancreatectomy. J Am Coll Surg 2010; 211:325-30. 30. Trinh QD, Bianchi M, Hansen J, Tian Z, Abdollah F, Shariat SF, et al. In-hospital mortality and failure to rescue after cytoreductive nephrectomy. Eur Urol 2013;63:1107-14. 31. Wright JD, Herzog TJ, Siddiq Z, Arend R, Neugut AI, Burke WM, et al. Failure to rescue as a source of variation in
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hospital mortality for ovarian cancer. J Clin Oncol 2012;30: 3976-82. Yasunaga H, Hashimoto H, Horiguchi H, Miyata H, Matsuda S. Variation in cancer surgical outcomes associated with physician and nurse staffing: a retrospective observational study using the Japanese Diagnosis Procedure Combination Database. BMC Health Serv Res 2012;12:129. Ghaferi AA, Birkmeyer JD, Dimick JB. Hospital volume and failure to rescue with high-risk surgery. Med Care 2011;49: 1076-81. Ghaferi AA, Birkmeyer JD, Dimick JB. Complications, failure to rescue, and mortality with major inpatient surgery in Medicare patients. Ann Surg 2009;250:1029-34. Glance LG, Dick AW, Osler TM, Mukamel DB, Li Y, Stone PW. The association between nurse staffing and hospital outcomes in injured patients. BMC Health Serv Res 2012; 12:247. Haas B, Gomez D, Hemmila MR, Nathens AB. Prevention of complications and successful rescue of patients with serious complications: characteristics of high-performing trauma centers. J Trauma 2011;70:575-82. Calzavacca P, Licari E, Tee A, Egi M, Haase M, Haase-Fielitz A, et al. A prospective study of factors influencing the outcome of patients after a Medical Emergency Team review. Intensive Care Med 2008;34:2112-6. Friese CR, Earle CC, Silber JH, Aiken LH. Hospital characteristics, clinical severity, and outcomes for surgical oncology patients. Surgery 2010;147:602-9. Glance LG, Dick AW, Meredith JW, Mukamel DB. Variation in hospital complication rates and failure-to-rescue for trauma patients. Ann Surg 2011;253:811-6. Kendall-Gallagher D, Aiken LH, Sloane DM, Cimiotti JP. Nurse specialty certification, inpatient mortality, and failure to rescue. J Nurs Scholarsh 2011;43:188-94. Moriarty JP, Finnie DM, Johnson MG, Huddleston JM, Naessens JM. Do pre-existing complications affect the failure to rescue quality measures? Qual Saf Health Care 2010;19:65-8. Ludikhuize J, de Jonge E, Goossens A. Measuring adherence among nurses one year after training in applying the Modified Early Warning Score and Situation-BackgroundAssessment-Recommendation instruments. Resuscitation 2011;82:1428-33. Peebles E, Subbe CP, Hughes P, Gemmell L. Timing and teamwork–an observational pilot study of patients referred to a Rapid Response Team with the aim of identifying factors amenable to re-design of a Rapid Response System. Resuscitation 2012;83:782-7. Donohue LA, Endacott R. Track, trigger and teamwork: communication of deterioration in acute medical and surgical wards. Intensive Crit Care Nurs 2010;26:10-7. Cooper S, Kinsman L, Buykx P, McConnell-Henry T, Endacott R, Scholes J. Managing the deteriorating patient in a simulated environment: nursing students’ knowledge, skill and situation awareness. J Clin Nurs 2010;19:2309-18.
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46. Rattray JE, Lauder W, Ludwick R, Johnstone C, Zeller R, Winchell J, et al. Indicators of acute deterioration in adult patients nursed in acute wards: a factorial survey. J Clin Nurs 2011;20:723-32. 47. Jones D, Baldwin I, McIntyre T, Story D, Mercer I, Miglic A, et al. Nurses’ attitudes to a medical emergency team service in a teaching hospital. Qual Saf Health Care 2006;15: 427-32. 48. Wynn JD, Engelke MK, Swanson M. The front line of patient safety: staff nurses and rapid response team calls. Qual Manag Health Care 2009;18:40-7. 49. Cioffi J, Salter C, Wilkes L, Vonu-Boriceanu O, Scott J. Clinicians’ responses to abnormal vital signs in an emergency department. Aust Crit Care 2006;19:66-72. 50. Andrews T, Waterman H. Packaging: a grounded theory of how to report physiological deterioration effectively. J Adv Nurs 2005;52:473-81. 51. Chen J, Bellomo R, Hillman K, Flabouris A, Finfer S. Triggers for emergency team activation: a multicenter assessment. J Crit Care 2010;25:359.e1-7. 52. Jones D, Drennan K, Hart GK, Bellomo R, Web SA. Rapid Response Team composition, resourcing and calling criteria in Australia. Resuscitation 2012;83:563-7. 53. Kennedy TJ, Regehr G, Baker GR, Lingard L. Preserving professional credibility: grounded theory study of medical trainees’ requests for clinical support. BMJ 2009; 338:b128. 54. Singer S, Lin S, Falwell A, Gaba D, Baker L. Relationship of safety climate and safety performance in hospitals. Health Serv Res 2009;44:399-421. 55. Paine LA, Rosenstein BJ, Sexton JB, Kent P, Holzmueller CG, Pronovost PJ. Republished paper: assessing and improving safety culture throughout an academic medical centre: a prospective cohort study. Postgrad Med J 2011; 87:428-35. 56. van Beuzekom M, Boer F, Akerboom S, Hudson P. Patient safety: latent risk factors. Br J Anaesth 2010;105:52-9. 57. Manser T, Foster S, Flin R, Patey R. Team communication during patient handover from the operating room: more than facts and figures. Hum Factors 2013;55:138-56. 58. Sevdalis N, Wong HW, Arora S, Nagpal K, Healey A, Hanna GB, et al. Quantitative analysis of intraoperative communication in open and laparoscopic surgery. Surg Endosc 2012;26:2931-8. 59. Anderson O, Brodie A, Vincent CA, Hanna GB. A systematic proactive risk assessment of hazards in surgical wards: a quantitative study. Ann Surg 2012;255:1086-92. 60. Waldron N, Dey I, Nagree Y, Xiao J, Flicker L. A multifaceted intervention to implement guideline care and improve quality of care for older people who present to the emergency department with falls. BMC Geriatr 2011; 11:6. 61. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med 2009;361:1368-75.
Background. The relationship between the ability to recognize and respond to patient deterioration (escalate care) and its role in preventing failure to rescue (FTR; mortality after a surgical complication) has not been explored. The aim of this systematic review was to determine the incidence of, and factors contributing to, FTR and delayed escalation of care for surgical patients. Methods. A search of MEDLINE, EMBASE PsycINFO, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials was conducted to identify articles exploring FTR, escalation of care, and interventions that influence outcomes. Screening of 19,887 citations led to inclusion of 42 articles. Results. The reported incidence of FTR varied between 8.0 and 16.9%. FTR was inversely related to hospital volume and nurse staffing levels. Delayed escalation occurred in 20.7–47.1% of patients and was associated with greater mortality rates in 4 studies (P < .05). Causes of delayed escalation included hierarchy and failures in communication. Of five interventional studies, two reported a significant decrease in intensive care admissions (P < .01) after introduction of escalation protocols; only 1 study reported an improvement in mortality. Conclusion. This systematic review explored factors linking FTR and escalation of care in surgery. Important factors that contribute to the avoidance of preventable harm include the recognition and communication of serious deterioration to implement definitive treatment. Targeted interventions aiming to improve these factors may contribute to enhanced patient outcome. (Surgery 2015;157:752-63.) From the Centre for Patient Safety and Service Quality, Division of Surgery, Department of Surgery and Cancer,a the Centre for Health Policy, Division of Surgery, Department of Surgery and Cancer,b and the Division of Surgery, Department of Surgery and Cancer,c Imperial College, London, UK
THE OBJECTIVE REPORTING of clinical outcomes is essential to the delivery of safe and transparent patient care.1,2 In addition, patient-reported and specialtyFunding: This review article received no direct funding. Johnston, Arora, King, Almoudaris, Davis, and Darzi are affiliated with the Imperial Patient Safety Translational Research Centre, which receives center funding from the National Institute for Health Research (UK). The grant number is 40490. Registration: This systematic review was registered with the International Prospective Register of systematic reviews (PROSPERO) ID - CRD42013004080. Accepted for publication October 31, 2014. Reprint requests: Maximilian J. Johnston, MB BCh, MRCS, Academic Surgical Unit, 10th Floor, QEQM, South Wharf Road, Imperial College, London, W2 1NY, UK. E-mail: [email protected]. 0039-6060/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2014.10.017
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specific outcomes also contribute to the drive toward high-quality care.3 The concept of failure to rescue (FTR) has emerged recently as an outcome measure that discriminates hospital performance. Defined by Silber et al,4 FTR is the number of deaths in patients who develop a postoperative complication. Hospitals with the greatest complication rates, however, do not necessarily have the greatest mortality.5 These observations suggest that high-quality postoperative care after a complication plays an important role in the avoidance of preventable harm. Several studies have defined the components of optimal patient management after a complication.2,3 Other reports have provided valuable insights into organizational factors that contribute to adverse outcomes, including lack of beds in the intensive care unit (ICU), poor access to radiology services, and unstructured emergency
Surgery Volume 157, Number 4 operating schedules.6,7 Despite this recent expansion in the evidence base, the impact interventions aiming to improve postoperative care have on FTR has not been explored previously. This topic is important because previous studies have highlighted that suboptimal care and communication failures contribute to breakdowns in information transfer along the postoperative patient pathway.8,9 Specifically, in the context of an unstable patient, early recognition of clinical deterioration may be the key to preventing FTR. Escalation of care is a process that can be defined as the recognition and communication of patient deterioration so as to implement definitive management. Rapid escalation of care can accelerate appropriate management and recovery. In contrast, if patient deterioration is not recognized or not acted on in a timely manner, delay can lead to poor outcome. Studies have demonstrated that factors that impede escalation increase cardiac arrests and death.10,11 Previous studies evaluating FTR have investigated the aftermath of complications; however, there is a paucity of literature exploring the antecedents to FTR and the role of escalation of care in this process. The aims of this review are to (1) determine the incidence of FTR events, (2) identify the factors that contribute to high FTR rates and delayed escalation of care, and (3) summarize outcomes of interventions aimed at decreasing the rates of FTR and improving escalation of care. METHODS Data sources. The databases searched included Ovid MEDLINE (1980 to week 2, November 2012), EMBASE (1980 to week 2, November 2012), PsycINFO (1987 to week 2, November 2012), the Cochrane Database of Systematic Reviews (Issue 10, 2012), and the Cochrane Central Register of Controlled Trials (Issue 10, 2012). Conference abstracts and reference lists of included articles were hand searched to identify additional relevant data. The grey literature (work lacking bibliographic control) was searched using Google. Search strategy. The search strategy employed the following terms (all searched as a keyword unless indicated): escalation of care, failure to rescue, rapid response, early warning score, critical care outreach, calling for help, patient deteriorat*, medical emergency team, postoperative care (title search), failure to escalate, postoperative complication (title search), resident supervision, clinical supervision, trainee supervision, requesting help, and requesting support. The terms ‘patient safety’/ (medical subject heading) and ‘ward’ were
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combined using ‘‘AND’’. An initial review of this combination revealed a large number of studies reporting escalation of drug dosage; therefore, to tighten the search specificity, the additional limit ‘NOT drug*’ was applied. All of these terms were then combined using the conjunction ‘‘OR’’ before limits were applied. Studies were restricted to those reporting human subjects in the English language, published from 1980 onward. The last search was conducted on November 15, 2012. All retrieved articles underwent screening of the title and subsequent abstract by 2 independent reviewers to screen for relevance. Inclusion criteria for full-text review were articles reporting hospitalbased evaluations focusing on adult patients that investigated the factors affecting escalation of care or the impact of hospital and patient characteristics on outcome measures, including FTR. Letters, commentaries, review articles, conference abstracts, and articles not fitting in with the aims of the review were excluded at this point. The 2 independent reviewers then screened the full text of the identified articles to assess eligibility for inclusion. Any disagreements during selection of articles for full-text review were resolved after discussion with a third reviewer. Data extraction. A data extraction form was designed by the research team to allow for consistent evaluation. The study setting, subjects, design, measures, and key findings were recorded for further analysis. Assessment of study quality. Quality assessment of each of the studies was evaluated independently by 2 researchers using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers.12 These criteria were chosen because the criteria included a rating scale for both qualitative and quantitative research, allowing a degree of direct comparison between articles, because there are some matching items on each rating scale. Mixed-methods studies were given quality assessment scores based on both the quantitative and qualitative quality criteria. Studies were not excluded based on their quality to ensure comprehensive capture of as many studies exploring escalation of care and FTR as possible. Had low-quality studies been excluded, some valuable qualitative and descriptive data may have been lost. RESULTS The search produced 19,887 citations with 9,414 remaining after limits were applied and duplicates removed. Of these, 8,566 articles were excluded after title review leaving 848 abstracts for further scrutiny. Abstract review led to exclusion of a further
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Figure. A PRISMA diagram demonstrating the flow of articles within this review. RRT, Rapid response team.
781 articles, leaving 67 for full-text evaluation. Thirty-eight of these articles met the inclusion criteria. A hand search of relevant article references and associated literature identified 4 additional articles that fulfilled the inclusion criteria. The inter-rater agreement for study inclusion between the 2 reviewers was high (kappa = 0.87). Study selection is presented schematically in the Figure. Study characteristics. We included 42 articles: 24 were cohort, 10 observational, 4 mixed-methods, and 4 qualitative studies. The studies were conducted in several different continents including North America (n = 17), Australasia (n = 15), Europe (n = 9), and Asia (n = 1). The primary focus of 26 articles was escalation of care. These articles were categorized into groups, namely, those reporting factors affecting the decision to escalate care, those reporting escalation delay, and those reporting interventions in the escalation process. The remaining 16 articles reported mortality, complications, and FTR rates. Analysis was performed at the hospital and patient levels. Measures of process and outcome. There was wide heterogeneity across the studies in terms of
measures used to capture the impact of patient and hospital characteristics on clinical processes and outcomes. ICU admission was a proxy measure for complications in eight articles.13-20 Other studies used delays in activation of the medical emergency team (MET) or rapid response team (RRT),13,15,17,18,21,22 rates of cardiac arrest,18,20,23,24 and documentation of vital signs16,20,25,26 as important process indicators. Additional measures evaluated included adherence to protocols and care guidelines.23,27,28 Nine studies evaluated organizational characteristics, including hospital volume,29-32 number of procedures performed,33,34 staffing level,29,32,35 teaching status,29,30,36 and staffing/bed ratios.6,30,32 A total of 22 articles reported patient outcomes, including 21 assessing mortality4,6,13,14,17,21,22,27-40 and 16 assessing morbidity (including both surgical and systemic complications).4,6,27-36,39-41 Other outcome measures used were reoperation6 and duration of stay.24 A total of 16 articles reported a metric of FTR6,27-36,39,41; however, the definitions used in each study were not uniform. There were 9 different definitions of FTR in total. The original
Study first author and reference Individual complication Arrhythmia CCF Cardiac arrest Pneumonia DVT/PE Pneumothorax Reoperation Stroke/CVA Renal failure Sepsis GI bleed/ulcer ARDS MI Coagulopathy ACS Respiratory failure POH SSI Shock Abscess Transfusion Peritonitis Pressure ulcer Line infection Malnutrition Total
Silber4 U U U U U U U U U
Bobay27
Almoudaris6
U U U U U U
Glance39
Wright31
U U
U U U
U U U U U U U
U
10
5
1
9
Ghaferi29
Ghaferi34
Ghaferi33
Moriarty41
U U U
U U
U U
U U
U U U U U
U U U U
U
U
U
U
U
U
U
U
U
U
U U U U U U
U U U
U U U
U U U
14
Haas36
U U
U U U
Yasunaga32 U U U
8
8
U U
U U U U U
U
U
U
8
Brooke28
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Table I. Individual complications used to define FTR measures
7
7
10
U U U 5
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ACS, Acute coronary syndrome; ARDS, acute respiratory distress syndrome; CCF, congestive cardiac failure; CVA, cerebrovascular accident; DVT, deep venous thrombosis; GI, gastrointestinal; MI, myocardial infarction; PE, pulmonary embolism; POH, postoperative hemorrhage; SSI, surgical site infection.
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Table II. Complications by system used to define failure to rescue measures Study first author and reference 30
Trinh Glance35 Brooke28
Complications by system Cardiac
Respiratory
Vascular
Wound
Genitourinary
Gastrointestinal
Infection
Total
U
U
U
U
U
U
U U U
7 1 2
U
FTR definition4 was used in 4 studies,4,32,38,39 a modified definition incorporating fewer complications was used in 3 articles,29,33,34 and the definition by the Agency for Health Research and Quality was used by another 3 articles.6,31,41 Other articles used unique definitions of FTR (Tables I and II). Quality assessment of included articles. Interrater agreement for the quality assessment of included studies was high: quantitative studies (kappa = 0.70), qualitative studies (kappa = 0.71), and mixed-methods papers (kappa = 0.73). Quality scores ranged from 6 to 22 (mean 19.2/22, SD 2.74) for the quantitative studies, 15-18 (mean 16.3/20, SD 1.04) for the qualitative studies, and 35-36 (mean 35.5/42, SD 0.58) for the mixedmethods studies. The breakdown of quality scores is offered as a Supplementary File. The scale of the problem: Incidence of FTR events. Overall rates of FTR ranged between 0.03%27 and 16.9%.39 The majority of studies reported an overall FTR rate between 8.0 and 16.9%. An increase in the incidence of FTR was associated with high mortality rates in 5 studies6,29,34,36,39 and low hospital volume in 2 studies.31,33 Two studies demonstrated that FTR discriminated high- and low-volume hospitals better than morbidity.6,39 Factors affecting FTR rates. The factors affecting FTR rates are presented in Table III. Hospital characteristics. Greater hospital volume was associated with lesser FTR rates in 4 studies.29-31,33 Two studies that analyzed the effect of the guidelines of the National Quality Forum revealed that FTR was less frequent in those with greater compliance.28,41 An increase in the level of nurse staffing was associated with lesser FTR rates in 2 studies,29,32 with no significant effect in another study.35 Ghaferi et al analyzed several hospital characteristics and found that the following were associated with lesser FTR rates: teaching status, hospital size >200 beds, daily census >50%, increased nurse-to-patient ratios, and use of technology.29 Patient characteristics. Lesser FTR rates were associated with patient age .05) Location, setting Design Intervention
Ludikhuize42 Adelstein18
Table VI. Effect of interventions on the escalation of care process
Robb24
Kansal24
Mitchell16
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care.60 This is of importance, because these interventions require both individual and team skills to recognize, communicate, and respond to a deteriorating postoperative patient. Regarding limitations of this review, the heterogeneity of definitions and metrics in the reviewed articles meant that a meta-analysis was not possible. There was also a lack of control groups and poor reporting of analytical techniques of data management. Studies evaluating interventions were few. Further interventional studies with randomization are necessary to build on the evidence base and to determine what factors impact on outcomes. Our quality assessment may facilitate much needed future research in this area. The implications of this review stem from the fact that the reviewed articles suggest that escalation of care influences FTR, with several studies linking delayed escalation to poor survival. Patient safety may, therefore, be improved by addressing the factors that influence escalation and FTR. Although structural issues can be optimized, efforts to improve human factors may be an undervalued approach to decreasing FTR. The importance of teamwork and leadership in this setting cannot be underestimated. Specifically, individual surgeons should play a key role in the education of junior team members in timely recognition of complications, which improve patient outcomes.61 Training by a skilled nurse practitioner could also facilitate such learning and contribute to healthy interprofessional relationships. Much of the research featured in this review involves retrospective methodology with a focus on database analysis in the FTR literature. This baseline work has provided valuable information to clinicians and health care providers, but has not addressed adequately the safety concerns that have been identified. To achieve an improvement in outcomes, researchers need to start looking beyond the numbers, using both qualitative techniques and front-line research methods, such as direct observation to develop targeted interventions aimed at improving the quality of surgical patient care. In conclusion, this is the first systematic review to explore factors linking escalation of care and FTR in surgery. Despite widespread heterogeneity in the literature, a link has been established between these important areas of patient care. Factors that contribute to the avoidance of preventable harm include the recognition and communication of deterioration to implement
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definitive treatment. Further research utilizing targeted observational and interventional techniques is required to bring about improvements in patient outcomes. SUPPLEMENTAL DATA Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.surg.2014. 10.017. REFERENCES 1. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991;324:377-84. 2. Hirose M, Regenbogen SE, Lipsitz S, Imanaka Y, Ishizaki T, Sekimoto M, et al. Lag time in an incident reporting system at a university hospital in Japan. Qual Saf Health Care 2007;16:101-4. 3. Haywood KL, Garratt AM, Fitzpatrick R. Quality of life in older people: a structured review of generic self-assessed health instruments. Qual Life Res 2005;14:1651-68. 4. Silber JH, Williams SV, Krakauer H, Schwartz JS. Hospital and patient characteristics associated with death after surgery. A study of adverse occurrence and failure to rescue. Med Care 1992;30:615-29. 5. Sheetz KH, Waits SA, Krell RW, Campbell DA Jr, Englesbe MJ, Ghaferi AA. Improving mortality following emergent surgery in older patients requires focus on complication rescue. Ann Surg 2013;258:614-7. 6. Almoudaris AM, Burns EM, Mamidanna R, Bottle A, Aylin P, Vincent C, et al. Value of failure to rescue as a marker of the standard of care following reoperation for complications after colorectal resection. Br J Surg 2011;98:1775-83. 7. Symons NR, Moorthy K, Almoudaris AM, Bottle A, Aylin P, Vincent CA, et al. Mortality in high-risk emergency general surgical admissions. Br J Surg 2013;100:1318-25. 8. Mackintosh N, Sandall J. Overcoming gendered and professional hierarchies in order to facilitate escalation of care in emergency situations: the role of standardised communication protocols. Soc Sci Med 2010;71:1683-6. 9. Johnston M, Arora S, King D, Stroman L, Darzi A. Escalation of care and failure to rescue: a multi-centre, multi-professional qualitative study. Surgery 2014;155:989-94. 10. Chen J, Bellomo R, Flabouris A, Hillman K, Finfer S. The relationship between early emergency team calls and serious adverse events. Crit Care Med 2009;37:148-53. 11. Hodgetts TJ, Kenward G, Vlachonikolis IG, Payne S, Castle N. The identification of risk factors for cardiac arrest and formulation of activation criteria to alert a medical emergency team. Resuscitation 2002;54:125-31. 12. Kmet LM, Lee RC, Cook LS. Standard quality assessment criteria for evaluating primary research papers from a variety of fields. Edmonton, Alberta, Canada: Alberta Heritage Foundation for Medical Research; 2004. 13. Quach JL, Downey AW, Haase M, Haase-Fielitz A, Jones D, Bellomo R. Characteristics and outcomes of patients receiving a medical emergency team review for respiratory distress or hypotension. J Crit Care 2008;23:325-31. 14. Cabrini L, Monti G, Plumari VP, Landoni G, Turi S, Laura P, et al. Observed versus predicted hospital mortality in general wards patients assisted by a medical emergency team. Signa Vitae 2012;7:38-42.
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