FAILURE TO RESCUE: ONE HOSPITAL’S JOURNEY

Spalding Regional Hospital

Who we are…..Who we are….. Spalding Regional Hospital Founded in 1903 Sole community provider 160 bed facility 900+ employees 196+ affiliated physicians Owned and operated by Tenet Healthcare Corporation Major specialties include cardiology, general medicine, OBGYN, pulmonary

To Err Is Human

Failure to Rescue is inevitable when relying solely on human cognition (Acquaviva, Haskell, Johnson, 2013)

Failure to Rescue –Identification of Issue Driven by opportunities identified by CNO and

education department to make a difference in safety measures and patient outcomes

Evidence of variability in nursing responses to crisis across hospital

Used rapid cycle PDCA –of all opportunities identified, the educational component was most needed

LEAPT initiative

Educational Plan With Teeth Mandatory in-services Around the clock in-services including weekend 100% compliance required-if did not attend, could not

work—supported by CNO In-services completed at sister hospital and if staff

missed in-service at Spalding, attended at sister facility prior to working

Interactive learning approach used including e-learning and case studies

Follow-up Processes Chain of command taught and emphasized in policy & procedure ( staff

cannot be threatened or bullied into not calling MET(Medical Emergency Team) call if needed)

Every nurse in building taught, every person in building assigned e-learning in how and when to call MET call

MET team education incorporated into orientation and yearly required skills in-services.

MET call Video “Who You Gonna Call—MET team” with employee and shown on holidays, special occasions.

Feedback received from other facilities regarding the nurses who worked at Spalding, complimenting the nurses clinical knowledge and abilities in crisis situations

Data review Reviewed trends and saw opportunity in PSI 4 in 2011 & 2012:

Death Rate among Surgical Inpatients with Serious Treatable Conditions

Renewed interest – LEAPT project Hospital’s focus on failure to rescue had renewed interest in

2013

Focused specifically on surgical patients to determine if there were triggers that one could recognize prior to MET call

Monitored MET calls to determine if MET calls made a difference in number of Code blues outside of ICU---to determine if there were triggers in MET call patients that were not present in those with same diagnosis without a MET call

Project Overview -Methodology Examined records of MET call patients

All patients who experienced a Medical Emergency Team (MET) call between July 1, 2013 and December 31, 2013 on the 3W Medical/Surgical Unit

Interviewed MET call initiators, responders, physicians Determined the frequency distribution of specific Diagnosis Related

Groups (DRGs) of patients receiving a MET call Compared and contrasted the length of stay of patients with a similar

DRG with those who did not experience a MET call Proposed a plan to help address earlier recognition of patient

decompensation and/or the development of complications Literature review

Postoperative patients

41% of post-op MET calls occurred within 48hrs following surgery

17

10

7

All OthersPOST Op Within 48hrs

Notable MET call trends Albumin less than 3.4 g/dl – 44% Obesity (BMI>30) – 41% At least one co-morbidity (HTN, DM,

CAD, Hyperlipidemia, CHF, COPD) – 76% Two or more co-morbidities – 71%

Comparison of LOS for DRG’s with and without MET call

DRG

DAYS

Study group compared to patients with the same DRG during the same period

0

5

10

15

20

25

30

35

LOS with MET CallAVG LOS

299207

335

392

460

682

34 study patients27 different DRGs

Overview of Focus Group Perceptions Those interviewed did not perceive any trends in diagnosis

or precipitating factors Some responders felt MET calls were most often called

following routine assessments and shift changes The MET call process was not perceived to be over utilized The process was felt to be effective Med/Surg nurses feel direct admissions are at risk MET team responders would like the Med/Surg nurses to be

more involved in the process

Conclusions No consistent MET call risk by DRG/Diagnosis Most patients experiencing a MET call have a longer LOS Staff may rely on MET team for assessment rather than validation MET calls occurred most often within 48hrs of admission Risk factors appear to be patients with chronic illness reflected by one or

more significant comorbidities; 1. morbid obesity 2. low albumin3. HTN4. DM5. CAD w/wo CHF6. COPD

Recommendations Leadership commitment at highest level Need an accurate and visible method of determining acuity -

Rothman Index is one example, another may be 12 hour lab or vital sign trend

Continued Physical Assessment Education for Med/Surg Nurses Train MET responders to coach/educate MET call/Code Blue Grand Rounds-continuous education Review direct admit diagnosis to insure protocols in place for

high risk diagnoses

Proposed Bundle Leadership buyin, Champion to assist with spread of concept throughout

organization Multidiciplinary team to implement MET protocols/ policies/procedures Education of entire hospital staff-when to call and who can call a MET call

(anyone and everyone) Medical Emergency/Rapid Response team development-staff with skill set to

handle emergency care-role definitions Implementation of general preventive measures:

purposeful hourly rounding Early detection-vs/lab trend review Bedside reports with patient/family participation

Analyze data and provide feedback to entire hospital –Report card Follow-up education

ReferencesAcquaviva, K., Haskell, H., & Johnson, J. (2013). Human Cognition and the Dynamics of Failure to Rescue: The Lewis Blackman

Case. Journal Of Professional Nursing, 29(2), 95-101. doi:10.1016/j.profnurs.2013.03.009Finlay, G. D., Rothman, M. J., & Smith, R. A. (2013). Measuring the modified early warning score and the Rothman Index: Advantages

of utilizing the electronic medical record in an early warning system. Journal of Hospital Medicine.

Georgia Hospital Association (2014). LEAPT/GAPP. Retrieved from: https://quality.gha.org /Home/ Hospital EngagementNetwork /LEAPTGAPP.aspx

Perahealth (2014). The Rothman Index: The New Universal Patient Score. Retrieved from: http://www.perahealth.com/solutions/rothman-index/

Rothman, M. J., Solinger, A. B., Rothman, S. I., & Finlay, G. D. (2012). Clinical implications and validity of nursing assessments: a longitudinal measure of patient condition from analysis of the Electronic Medical Record. BMJ open, 2(4).

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

Taenzer, A. H., Pyke, J. B., & McGrath, S. P. (2011). A review of current and emerging approaches to address failure-to-rescue. Anesthesiology, 115(2), 421-431