Addressing “failure to rescue” with IT solutions

A rare find! Information technology being used enthusiastically by clinicians …. an innovation that both benefits patients and clinicians

There have been a couple of very influential reports that have raised the visibility of the serious issue of patient safety within the healthcare system. The US Institute of Medicine’s report “To Err is Human” in 1999 concluded that tens of thousands of Amercians die each year as a result of preventable mistakes in their care. In the UK, the Department of Health’s report “An organisation with a memory” estimated that adverse incidents occurred in about 1% of hospital admissions and cost over £2bn a year. These adverse events lead to unexpected deaths at worse or, for survivors, a spell in ICU and maybe a resulting long term illness.The great majority of these “adverse incidents” within hospitals (defined as ‘an unintended injury caused by medical management rather than by the disease process’) are preventable or could be mitigated by an early medical response.

The category of adverse events in which the patient’s clinicians fail to respond to the early signs of a patient’s deteriorating condition are called “failure to rescue”. There has been considerable research in the US, Canada, Australia and the UK on the use of early warning scoring (EWS) systems, emergency medical teams and other interventions to try and reduce the mortality and morbidity that results from “failure to rescue” in acute hospitals. Like all causes of clinical risk it is a “whole system” problem that requires a whole system solution – and effective management of clinical information is a key element of the solution.

A number of small studies have suggested that these interventions reduce cardiac arrests, ICU admissions and unexpected deaths. The logic is compelling in that if you can detect that a patient’s condition is deteriorating and then take early effective action then the follow on consequences of the physiological deterioration such as cardiac arrest, stroke, acute renal failure etc. should be avoided. One of the largest and most robust studies is the Merit study carried out in Australia and published in the Lancet in 2005. It looked at the effectiveness of introducing medical emergency teams to address the “failure to rescue” clinical risk. This larger study did not demonstrate any statistically significant reduction in the incidence of cardiac arrrest, ICU admissions and unexpected death contradicting some earlier studies.  But what it did demonstrate was the poor recording of basic clinical observations (heart rate, BP, respiratory rate) and reluctance in calling for help even when the clinical signs should have triggered a call in both study and control hospitals. This observation has also been made in UK studies looking at the implementation of early warning scoring systems.

The obvious lesson from the Merit study is the need for a method to consistently and reliably record a patient’s clinical observations, identify those patients who are deteriorating and trigger an alert to medical staff that they need to take action.

There are a small number of applications on the market that enable bedside capture of nursing observations using PDAs /WiFi, automatic calculation of EWS, real time display on ward-based tablet PCs or any network connected PC and automatic escalation via the bleep paging system. These systems are called “track and trigger” applications because they track the patient’s chart observations and trigger alerts according to pre-defined rules.

These systems are well-liked by nursing staff because it is as quick to use a PDA to record observations as it is to fill in a paper chart, they don’t get moved unlike end-of-bed charts, and the system prompts the user to take each patient’s observations at the instructed interval. Doctors love the system because they can see the up to date patient chart from any PC and the completeness of the chart record jumps from a typical 40% to close to 100% (recording of paper chart observations is particularly poor at night and weekends). Ward managers can audit the performance of the ward in completing observations.

It is not sufficient to introduce this technology if you are trying to reduce “failure to rescue” adverse events but the evidence is very strong that it is a necessary element of the solution. The hospital also needs to ensure that wards are staffed and managed to achieve good observations compliance and that the appropriate medical staff respond quickly to patient alerts.

The benefits from reducing adverse events are not limited to improved patient safety as there are also, as one might expect, reported reductions in length of stay and ICU admissions.

The use of small PDAs by nursing staff to record clinical observations, replacing the end-of-bed chart, and tablet PCs on the ward to display the real time clinical observations seems to “tick the boxes” where the vast majority of traditional clinical applications fail.

  • as fast as using paper charts so doesn’t have a time penalty
  • delivers clinically useful information to doctors while it is relevant and actionable
  • adds value by allowing remote access to the clinical information

In these respects it is very similar to those other clinically popular systems that provide electronic pathology results and images (PACS) where adoption and hospital-wide rollout is enthusiastically supported by cliniicans.

This is an innovation that has a strong patient safety benefit, has strong medical and nursing support in the hospitals in which it is being used, and has a good financial business case for the hospital. If you would like to discuss the business case for, and the practical implementation of, “track and trigger” systems and other mobile technologies in hospitals then please conact us.

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