Deaths After Readmissions are Mostly Attributable to Failure-to-Rescue in EGS Patients

INTRODUCTION

We have recently shown that readmission after EGS procedures carries a 4-fold higher mortality rate when compared to those not readmitted. Understanding factors associated with death after readmission is paramount to improving outcomes for EGS patients. We aimed to identify risk factors contributing to failure-to-rescue (FTR) during readmission after EGS. We hypothesized that most post-readmission deaths in EGS are attributable to FTR.

METHODS

A retrospective cohort study using the NSQIP database 2013-2019 was performed. Patients who underwent 1 of 9 urgent/emergent surgical procedures representing 80% of EGS burden of disease, who were readmitted within 30 days post-procedure were identified. The procedures were classified as low- and high-risk. Patient characteristics analyzed included age, sex, BMI, ASA score comorbidities, postoperative complications, frailty, and FTR. The population was assessed for risk factors associated with mortality and FTR by uni- and multivariate logistic regression.

RESULTS

Of 312,862 EGS cases, 16,306 required readmission. Of those, 10,748 (3.4%) developed a postoperative complication. Overall mortality after readmission was 2.4%, with 90.6% of deaths attributable to FTR. Frailty, high-risk procedures, pulmonary complications, AKI, sepsis, and the need for reoperation increased the risk of FTR.

DISCUSSION

Death after a complication is common in EGS readmissions. The impact of FTR could be minimized with the implementation of measures to allow early identification and intervention or prevention of infectious, respiratory, and renal complications.

Interhospital variability in failure to rescue rates following aortic valve surgery

Objective

This study evaluated interhospital variability and determinants of failure-to-rescue for patients undergoing surgical aortic valve replacement.

Methods

An observational study was conducted among 28,842 patients undergoing aortic valve replacement with or without coronary artery bypass grafting between July 2011 and June 2017 across 90 hospitals participating in the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Postoperative complications were defined as major (stroke, renal failure, reoperation, prolonged ventilation, sternal infection) and overall (major plus 14 other morbidities). Hospital terciles of observed to expected (O/E) mortality were compared on crude rates of major and overall complications, operative mortality, and failure to rescue (among major and overall complications). The correlation between hospital observed and expected failure-to-rescue rates was assessed.

Results

Median Society of Thoracic Surgeons Adult Cardiac Surgery Database predicted mortality risk was similar across hospital O:E mortality terciles (P = .10). As expected, mortality rates significantly increased across terciles (low O/E tercile: 1.6%, high O/E tercile: 4.7%; P < .001). Failure-to-rescue rates increased substantially across hospital mortality terciles among patients with major (low tercile, 8.8% and high tercile, 20.8%) and overall (low tercile, 3.0% and high tercile, 8.9%) complications. Hospital-level expected failure to rescue had a higher correlation with observed complications for overall complications (R2 = 0.71) compared with Society of Thoracic Surgeons major complications (R2 = 0.24).

Conclusions

Considerable interhospital variation exists in failure-to-rescue rates following aortic valve replacement. Hospitals in the low O/E mortality tercile experience failure to rescue nearly one-third less than those in the high O/E mortality tercile. Efforts to advance quality will benefit from identifying and disseminating optimal rescue strategies in this patient population.

Initiatives to detect and prevent death from perioperative deterioration

PURPOSE OF REVIEW

This study indicates that there are differences between hospitals in detection, as well as in adequate management of postsurgical complications, a phenomenon that is described as 'failure-to-rescue'.In this review, recent initiatives to reduce failure-to-rescue in the perioperative period are described.

RECENT FINDINGS

Use of cognitive aids, emergency manuals, family participation as well as remote monitoring systems are measures to reduce failure-to-rescue situations. Postoperative visit of an anaesthesiologist on the ward was not shown to improve outcome, but there is still room for improvement of postoperative care.

SUMMARY

Improving the complete emergency chain, including monitoring, recognition and response in the afferent limb, as well as diagnostic and treatment in the efferent limb, should lead to reduced failure-to-rescue situations in the perioperative period.

Complications and failure-to-rescue after pancreatectomy and hospital participation in the targeted American College of Surgeons National Surgical Quality Improvement Program registry

BACKGROUND

More than 700 hospitals participate in the American College of Surgeons National Surgical Quality Improvement Program, but most pancreatectomies are performed in 165 centers participating in the pancreas procedure-targeted registry. We hypothesized that these hospitals ("targeted hospitals") might provide more specialized care than those not participating ("standard hospitals").

METHODS

The 2014 to 2019 pancreas-targeted and standard American College of Surgeons National Surgical Quality Improvement Program registry were reviewed regarding patient demographics, comorbidities, and perioperative outcomes using standard univariate and multivariable logistic regression analyses. Primary outcomes included 30-day mortality and serious morbidity.

RESULTS

The registry included 30,357 pancreatoduodenectomies (80% in targeted hospitals) and 14,800 distal pancreatectomies (76% in targeted hospitals). Preoperative and intraoperative characteristics of patients treated at targeted versus standard hospitals were comparable. On multivariable analysis, pancreatoduodenectomies performed at targeted hospitals were associated with a 39% decrease in 30-day mortality (odds ratio, 0.61; 95% confidence interval, 0.50-0.75), 17% decrease in serious morbidity (odds ratio, 0.83; 95% confidence interval, 0.77-0.89), and 41% decrease in failure-to-rescue (odds ratio, 0.59; 95% confidence interval, 0.47-0.74). These differences did not apply to distal pancreatectomies. Participation in the targeted registry was associated with higher rates of optimal surgery for both pancreatoduodenectomy (odds ratio, 1.33; 95% confidence interval, 1.25-1.41) and distal pancreatectomy (odds ratio, 1.17; 95% confidence interval, 1.06-1.30).

CONCLUSION

Mortality and failure-to-rescue rates after pancreatoduodenectomy in targeted hospitals were nearly half of rates in standard American College of Surgeons National Surgical Quality Improvement Program hospitals. Further research should delineate factors underlying this effect and highlight opportunities for improvement.

Enhanced peri-operative care to improve outcomes for high-risk surgical patients in Brazil: a single-centre before-and-after cohort study

Mortality and morbidity for high-risk surgical patients are often high, especially in low-resource settings. Enhanced peri-operative care has the potential to reduce preventable deaths but must be designed to meet local needs. This before-and-after cohort study aimed to assess the effectiveness of a postoperative 48-hour enhanced care pathway for high-risk surgical patients ('high-risk surgical bundle') who did not meet the criteria for elective admission to intensive care. The pathway comprised of six elements: risk identification and communication; adoption of a high-risk post-anaesthesia care unit discharge checklist; prompt nursing admission to ward; intensification of vital signs monitoring; troponin measurement; and prompt access to medical support if required. The primary outcome was in-hospital mortality. Data describing 1189 patients from two groups, before and after implementation of the pathway, were compared. The usual care group comprised a retrospective cohort of high-risk surgical patients between September 2015 and December 2016. The intervention group prospectively included high-risk surgical patients from February 2019 to March 2020. Unadjusted mortality rate was 10.5% (78/746) for the usual care and 6.3% (28/443) for the intervention group. After adjustment, the intervention effect remained significant (RR 0.46 (95%CI 0.30-0.72). The high-risk surgical bundle group received more rapid response team calls (24% vs. 12.6%; RR 0.63 [95%CI 0.49-0.80]) and surgical re-interventions (18.9 vs. 7.5%; RR 0.41 [95%CI 0.30-0.59]). These data suggest that a clinical pathway based on enhanced surveillance for high-risk surgical patients in a resource-constrained setting could reduce in-hospital mortality.

Understanding Preventable Deaths in the Geriatric Trauma Population: Analysis of 3,452,339 Patients From the Center of Medicare and Medicaid Services Database

BACKGROUND

Patient safety indicators (PSIs) are avoidable complications that can impact outcomes. Geriatric patients have a higher mortality than younger patients with similar injuries, and understanding the etiology may help reduce mortality. We aim to estimate preventable geriatric trauma mortality in the United States and identify PSIs associated with increased preventable mortality.

METHODS

A retrospective cohort study of patients aged ≥65 years, in the CMS database, 2017-second quarter of 2020. Risk-adjusted multivariable regression was performed to calculate observed-to-expected (O/E) mortality ratios for failure-to-prevent and failure-to-rescue PSIs with significance defined as P < .05.

RESULTS

3,452,339 geriatric patients were analyzed. Patients aged 75-84 years had 33% higher odds of preventable mortality (adjusted odds ratio [aOR] = 1.33 and 95% confidence interval [CI] = 1.31, 1.36), whereas patients aged ≥85 years had 91% higher odds of preventable mortality (aOR = 1.91 and 95% CI = 1.87, 1.94) compared to patients aged 65-74 years. Failure-to-prevent O/E were >1 for all PSIs evaluated with central line-related blood stream infection having a high O/E (747.93). Failure-to-rescue O/E were >1 for 10/11 (91%) PSIs with physiologic and metabolic derangements having the highest O/E (5.98). United States' states with higher quantities of geriatric trauma patients experienced reduced preventable mortality.

CONCLUSION

Odds of preventable mortality increases with age. Perioperative venous thrombotic events, hemorrhage or hematoma, and postoperative physiologic/metabolic derangements produce significant preventable mortalities. United States' states differ in their failure-to-prevent and failure-to-rescue PSIs. Utilization of national guidelines, minimization of central venous catheter use, addressing polypharmacy especially anticoagulation, ensuring operative and procedure-based competencies, and greater incorporation of inpatient geriatricians may serve to reduce preventable mortality in elderly trauma patients.

The Association of Nurse-Physician Teamwork and Mortality in Surgical Patients

In this study we describe nurse-physician teamwork, estimate its association with surgical patient outcomes (30-day mortality and failure-to-rescue), and determine whether these relationships depend upon other modifiable hospital nursing characteristics (nurse staffing and education levels) known to be associated with patient outcomes. This cross-sectional analysis included linked data from 29,391 nurses representing 665 acute care hospitals and 1,321,904 adult patients who underwent a general surgical, vascular, or orthopedic procedure. Surgical patients cared for in hospitals with better nurse-physician teamwork had significantly lower odds of 30-day mortality (odds ratio [OR] = 0.95) and failure-to-rescue (OR = 0.95). In addition, the odds of death and failure-to-rescue were lower for patients in hospitals with both higher nurse-physician teamwork and more favorable patient-to-nurse staffing ratios. Similar trends were observed related to nursing education levels. Improving interprofessional teamwork is one strategy to improve patient outcomes with the added importance of also considering additional features of their nursing workforce.

A patient safety focused registered nurse transition to practice program

Abstract New graduate registered nurses (NGRN's) have an expectation of clinical support as they make the transition from novice to advanced beginner. In this 2008-2009 study of three rural transition to practice programs we found that clinical support did not eventuate. Consequently, NGRN's reported feeling underprepared for practice, overwhelmed by responsibility and often abandoned. Against this background, many were concerned that their inexperience had implications for safe patient care. Graduate nurse transition programs need to have the physical and human resources necessary to deliver the clinical support as promised in their prospectus, to ensure patient safety. This grounded theory study identified three essential core elements - leadership support, clinical supervision, and effective interprofessional relationships. Recommendation is made to address these deficits by mandating their inclusion in all transition to professional practice programs.

Nursing assessment of continuous vital sign surveillance to improve patient safety on the medical/surgical unit

AIMS AND OBJECTIVES

Evaluate continuous vital sign surveillance as a tool to improve patient safety in the medical/surgical unit.

BACKGROUND

Failure-to-rescue is an important measure of hospital quality. Patient deterioration is often preceded by changes in vital signs. However, continuous multi-parameter vital sign monitoring may decrease patient safety with an abundance of unnecessary alarms.

DESIGN

Prospective observational study at two geographically disperse hospitals in a single hospital system.

METHODS

A multi-parameter vital sign monitoring system was installed in a medical/surgical unit in Utah and one in Alabama providing continuous display of SpO2, heart rate, blood pressure and respiration rate on a central station. Alarm thresholds and time to alert annunciations were set based on prior analysis of the distribution of each vital sign. At the end of 4 weeks, nurses completed a survey on their experience. An average alert per patient, per day was determined retrospectively from the saved vital signs data and knowledge of the alarm settings.

RESULTS

Ninety-two per cent of the nurses agreed that the number of alarms and alerts were appropriate; 54% strongly agreed. On average, both units experienced 10·8 alarms per patient, per day. One hundred per cent agreed the monitor provided valuable patient data that increased patient safety; 79% strongly agreed.

CONCLUSIONS

Continuous, multi-parameter patient monitoring could be performed on medical/surgical units with a small and appropriate level of alarms. Continuous vital sign assessment may have initiated nursing interventions that prevented failure-to-rescue events. Nurses surveyed unanimously agreed that continuous vital sign surveillance will help enhance patient safety.

RELEVANCE TO CLINICAL PRACTICE

Nursing response to abnormal vital signs is one of the most important levers in patient safety, by providing timely recognition of early clinical deterioration. This occurs through diligent nursing surveillance, involving assessment, interpretation of data, recognition of a problem and meaningful response.

A patient safety focused registered nurse transition to practice program

New graduate registered nurses (NGRN's) have an expectation of clinical support as they make the transition from novice to advanced beginner. In this 2008-2009 study of three rural transition to practice programs we found that clinical support did not eventuate. Consequently, NGRN's reported feeling underprepared for practice, overwhelmed by responsibility and often abandoned. Against this background, many were concerned that their inexperience had implications for safe patient care. Graduate nurse transition programs need to have the physical and human resources necessary to deliver the clinical support as promised in their prospectus, to ensure patient safety. This grounded theory study identified three essential core elements - leadership support, clinical supervision, and effective interprofessional relationships. Recommendation is made to address these deficits by mandating their inclusion in all transition to professional practice programs.