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Calling for backup before it’s needed

Hospitals tackle “failure to rescue” errors

By Karen Lusky

From the November ACP Hospitalist, copyright © 2008 by the American College of Physicians

Preventable errors are at the forefront of many hospital administrators’ minds these days. Thanks to the growth of public reporting, Medicare’s do-not-pay list, and general concern about patient outcomes, every hospital is looking for the key to reducing errors.

Calling for backup before it’s neededBut one of the most common preventable errors is also one of the most amorphous and difficult to tackle. “Failure to rescue” was one of the top three preventable errors found in hospitals in 2004-2006, accounting for 17% of total errors, according to a report from HealthGrades, a ratings organization for health care facilities and providers. “Failure to rescue,” said Michael A. DeVita, FACP, professor of critical care medicine at the University of Pittsburgh, “is the failure to identify patients with critical abnormalities and provide the resources necessary to prevent harm.” Although bed sores and post-operative clots accounted for more errors, failure to rescue caused the most deaths, since such errors are, by definition, fatal.

Obviously, no one means to be ignoring these critically ill patients. But what’s the best way to identify the inpatients in danger and get the necessary resources to them? Experts at hospitals around the country offered their varying solutions to the failure to rescue problem.

Set your triggers

The first step to preventing these errors is deciding, and making it clear to all staff, what signs and symptoms indicate that a patient may be at risk, experts said. New York Methodist Hospital has established triggers for vital signs and empowered all of their employees to take action on them. “Anyone, including a nurse’s aide, who feels that a patient’s condition has deteriorated, can use the triggers to call the response team,” said Suhail Raoof, FACP, chief of pulmonary and critical care medicine there.

DeKalb Medical Center in Decatur, Ga., uses triggers reflecting guidelines based on current literature, according to Nancy Curdy, RN, a clinical nurse specialist with the hospital’s quality institute. For example, a call could be triggered by a heart rate greater than 130 beats per minute or less than 40, systolic blood pressure less than 90 mm Hg, chest pain, or decreased level of consciousness. “But we also have a catchall criteria of ‘something concerns you about the patient’—which is the old ‘they just don’t look right,’” she said. Click here[PDF] to view a form DeKalb Medical Center uses to track calls to their rapid response team.

Some hospitals use lab tests as part of their rapid response triggers. Close attention to certain lab results can have a clear impact on outcomes, according to Dr. DeVita. For example, hospitals that don’t respond quickly to a low or high potassium value have more cardiac arrests, he said.

Mitchell M. Levy, MD, professor of medicine at Brown University School of Medicine, suggested there’s a role for using lactate to help identify patients at high risk for sepsis, a condition where a patient can appear relatively stable one minute and in need of life support the next.

“Even in the absence of low blood pressure, a lactate greater than 4 mmol/L identifies a group of patients at high risk,” said Dr. Levy.

Part of using a trigger system effectively involves knowing who’s at high risk for deterioration so that staff can monitor those patients more closely on general wards.

Flagging patients at high risk for sepsis involves identifying those with infection at risk for getting worse, for example, patients with community-acquired pneumonia or comorbidities such as lung disease, diabetes or cancer, Dr. Levy said. The first 24 hours after admission are also critical. “Say the person’s blood pressure where it was normally 130 and now it’s 110. If that doesn’t get better in 24 hours, that patient is at high risk.”

Nurses are key

As the ones who take vital signs, nurses are often the first to notice a potential problem. But they can also use better communication, especially in handoffs, to help rein in failure to rescue rates, according to Samantha L. Collier, ACP Member, chief medical officer for HealthGrades.

“Nursing shift reports should identify anyone at risk for delirium, as one example,” she said. Elderly, post-op, severely ill and demented patients are at highest risk for delirium and resulting negative outcomes.

Some studies show hospital nurse staffing shortages are involved in failure to rescue, Dr. Collier added, noting, however, that more often the problem lies with nurses’ training. “Studies have found that more registered nurses per patient correlate to lower failure-to-rescue patient mortality rates.” She thinks training programs to help nurses recognize subtle signs of deterioration and how to best communicate with doctors can help.

As part of its quality improvement, DeKalb Medical Center has taught its medical-surgical nurses to trend their patients’ data. The nurses are taught not to take a “one-shot look at vital signs or oxygen saturations,” said Ms. Curdy, noting that the hospital has found that some patients show subtle changes in oxygen saturation before a cardiac arrest.

For example, the significance of an oxygen saturation of 93% or 94% depends greatly on what the levels were before. “That may not seem like a big deal if the patient wasn’t exhibiting overt signs of distress,” said Ms. Curdy. But if an attuned nurse noticed that the patient’s saturation had consistently registered at 99% previously, it could be time to take action.

DeKalb has also given patient technicians objective guidelines to notify the nurse if a patient’s vital signs or oxygen saturation is less than the previously recorded value.

Rapid response teams

Of course, once the endangered patients have been identified, it’s crucial to get rescuers—who are often hospitalists—to them fast. Many hospitals have found rapid response teams to be an important facet of their failure to rescue reduction efforts. The benefits can be cost- as well as life-saving.

Allegheny General Hospital in Pittsburgh, for example, has had a sustained 50% reduction in codes since launching its rapid response program a few years ago. Michael Cratty, MD, who has participated in many rapid response calls there, finds that about a quarter of patients treated by the rapid response team don’t end up having to move to a higher level of care, such as the ICU.

Other patients receive quick life-saving action, like one patient with shortness of breath and acute hypoxia whom the team diagnosed quickly as having a pulmonary embolism. The patient received thrombolytic therapy and did well, said Dr. Cratty, head of the hospital medicine section at Allegheny General Hospital.

DeKalb Medical Center has also found that a rapid response often allows patients to stay on the regular floor and not go to intensive care, “a nice offshoot in terms of staffing and bed utilization,” said Ms. Curdy.

Thanks to its rapid response system, the University of Pittsburgh Medical Center’s Presbyterian Shady Side Hospital now gets inpatients who develop chest pain to coronary intervention as quickly as it does emergency department patients, according to Dr. DeVita.

At Allegheny, hospitalists lead the rapid response team, known there as the medical emergency team (MET). In addition to a hospitalist, the MET includes two ICU nurses, a bedside nurse, an internal medicine resident and a respiratory therapist. An EKG technician, an IV-team nurse and hospital administrator also respond.

Continuous assessment

The team members and the trigger settings may differ at hospitals around the U.S., but the commonality among the programs is that they are successful at preventing failure to rescue errors. And there’s only one way to make sure that your hospital’s system is working for you—data collection.

“Gather data monthly and don’t get behind. It’s fast and furious. Get ongoing feedback from staff on what is and is not working,” advised Ms. Curdy.

Dekalb Medical Center investigates all of its Blue Alerts to find out what was going on with the patient for 12 to 18 hours before the code. The goal is to see if anything could have been done to potentially avoid the alert; everyone benefits from reflecting on and learning from an event, Ms. Curdy said.

Allegheny General Hospital has assessed its rapid responses by unit, time of day and type of response, said Sharon C. Kiely, MD, medical director of quality and patient safety who headed up the hospitalist service there during deployment of its rapid response system.

The analysis has revealed that some units consistently trigger the rapid response more frequently—and that those units have fewer codes. The hospital is in the process of analyzing a survey of nurses who have called or participated in rapid response, and stratifying them based on training, the number of years they’ve worked at the hospital, and their years of clinical experience.

Once the results are analyzed completely, the hospital anticipates using the information to educate nurses and physicians, reported Dr. Kiely.

It’s not always easy to pinpoint the exact root cause of an instance of failure to rescue, cautioned Dr. Collier. It may have “involved a series of missed opportunities—the daughter who said her father didn’t seem right, or the nurse who didn’t pass along information at shift change, and so on,” she said. “It’s easy to Monday morning quarterback it and see five or six processes that failed the patient.”

On the bright side, it only takes one person to notice the mistakes and take action, a reason that everyone in the hospital should be aware of the failure to rescue problem and their power to fix it. “Calling for the rapid response team is an act of heroism— not failure,” said Dr. DeVita.

Karen Lusky is a registered nurse and a freelance writer in Brentwood, Tenn.

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The problem may also be part of the solution

When a patient is discovered in need of rescue, there’s a common, and commonly overlooked, cause—medication.

“The rapid response team should have processes to look at a medication error or adverse medication response as the cause of the person’s decline,” said Russell H. Jenkins, MD, an internist and medical director for the Institute for Safe Medication Practices in Huntington, Pa.

“Unfortunately, as physicians we have not in the past been trained to think of a med error as the cause of a patient going bad.”

Dr. Jenkins advised paying special attention to high-alert medications, such as heparin, potassium, insulin, chemotherapy and certain heart medications, all of which can have a disastrous effect when involved in a medication error.

For example, always consider an insulin administration error for patients on tight glycemic control protocols who show a change in mental status, he emphasized.

Also be on the lookout for medications known to cause delirium, especially in the older patient. Dr. Jenkins cautioned that some physicians aren’t aware of the Beers criteria, a list of medications that even in low doses should be avoided in elderly people at all costs (available online.)

Patients on opioid medications who have a change in mental status can receive a small dose of Narcan to see if that helps, said Dr. Jenkins, although you have to be careful to avoid putting someone on opioids in withdrawal.

One way to get on top of a patient’s medications is to have a clinical pharmacist on the rapid response team, said Dr. Jenkins.

Allegheny General Hospital in Pittsburgh doesn’t have a pharmacist on its rapid response team, said Michael Cratty, MD, head of hospital medicine there. But the rapid response system does work closely and meet with the pharmacist as part of an interdisciplinary approach, he added.

“For example, the pharmacist helps the team determine the necessary medications for the team to have on its cart for rapid response calls.”

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