Failure to Rescue Patient Safety Learning Lab (FTR PSLL)

Principal Investigator: George Blike, M.D., Dartmouth-Hitchcock, Lebanon, NH
AHRQ Grant No.: HS024403
Project Period: 09/30/15-03/31/20
Description: The overall goal of this project was to create the ideal hospital rescue system. Minimizing failure to rescue (FTR)—death following a major complication—is critical to reducing mortality in hospitalized patients. Successful rescue hinges on early recognition and timely management of serious complications once they occur.
The project aims were to:

• Target gaps in understanding the technology and human factors behind ideal risk assessment and risk surveillance.
• Support early detection of nonpreventable complications and all of the factors (individual, team, and technology) that define an ideal rescue system that effectively responds to and manages these complications.

The FTR PSLL comprehensively assessed the whole rescue system as opposed to fixing subsystems.^[1] Used for the first time, high-level simulation allowed researchers to identify four drivers of most FTR events: loss of information, delays, lack of shared mental models, and noise.^[1] The lab used these drivers to identify system leverage points and applied them as evaluation criteria for interventions in a high-reliability rescue system design.

This work led to the development of an FTR Event Mitigation System (i.e., policies and procedures, reporting mechanisms, tools, technologies, and other elements) that provides a roadmap for Dartmouth-Hitchcock.^{[2, 3]}  This roadmap and its interventions can also be used by other healthcare organizations to develop their own mitigation system. Further, each intervention is accompanied by a concept model that shows stages of implementation for each organization's capability level.

The FTR PSLL also designed and evaluated an enhanced surveillance monitoring system comprising wireless patient sensors and pulse oximetry-based monitors with advanced display and information system capabilities.^[4] To detect early patient deterioration, the lab conducted a before and after study on two units with 71 beds. Results showed the system significantly improved key clinical elements related to early recognition of changes in patient state and increased overall patient monitoring time (rate ratio 1.22) while reducing staff's data collection time by 28 percent. This system received high satisfaction marks by staff.

With a better understanding of how the rescue system works, researchers also used new evaluation methods to review past interventions in a new way. The FTR PSLL reviewed a physiologic monitoring strategy used to detect and treat opioid-induced respiratory arrest; a retrospective analysis found continuous pulse oximetry monitoring was associated with a 19-fold reduction in patient mortality for that group of patients at risk.

To date, this PSLL's work has resulted in at least 38 peer-reviewed journal publications, with nearly 600 citations in other publications; and presentations at institutions and conferences.

Publications

2020

• Chhabra KR, et al. Relationship between health care spending and clinical outcomes in bariatric surgery: implications for Medicare bundled payments. Ann Surg 2020 Jun 12. Online ahead of print.
• deMeireles A, et al. Association between surgeon practice knowledge and venous thromboembolism. Obes Surg 2020;30(6):2274-9.
• deMeireles AJ, et al. A longitudinal analysis of variation in psychological well-being and body image in patients before and after bariatric surgery. Ann Surg. 2020;271(5):885-90. https://journals.lww.com/annalsofsurgery/Citation/2020/05000/A_Longitudinal_Analysis_of_Variation_in.16.aspx?context=LatestArticles.
• Ghaferi AA, Dimick JB. Considering surgeon skill in randomized clinical trials. JAMA Surg. 2020;155(7):599. https://jamanetwork.com/journals/jamasurgery/article-abstract/2765477.
• Massarweh NN, et al. Achieving critical mass in surgical outcomes research: the changing role of the surgical outcomes club. JAMA Surgery. 2020;155(10):911-12. https://jamanetwork.com/journals/jamasurgery/article-abstract/2768497.
• McGovern KM, et al. Understanding interpersonal and organizational dynamics among providers responding to crisis. Qual Health Res. 2020;30(3):331-40.
• McGrath SP, et al. Inpatient respiratory arrest associated with sedative and analgesic medications: impact of continuous monitoring on patient mortality and severe morbidity. J Patient Saf. 2020 Mar 14.
• McGrath SP, et al. Patterns in continuous pulse oximetry data prior to pulseless electrical activity arrest in the general care setting. J Clin Monit Comput. 2020 Apr 8.
• Nasser H, et al. Comparison of early outcomes between Roux-en-Y gastric bypass and sleeve gastrectomy among patients with body mass index ≥ 60 kg/m². Surg Endosc. 2020 Jun 22. Online ahead of print.

2019

• deMeireles A, et al. Leveraging mobile technologies to improve longitudinal quality and outcomes following bariatric surgery. Mhealth. 2019 Feb 25;5:6.
• Ibrahim N, et al. New onset alcohol use disorder following bariatric surgery. Surg Endosc 2019;33(8):2521-30.
• McGrath SP, et al. A systems approach to design and implementation of patient assessment tools in the inpatient setting. Adv Health Care Manag. 2019 Oct 24;18.
• McGrath SP, et al. Improving patient safety and clinician workflow in the general care setting with enhanced surveillance monitoring. IEEE J Biomed Health Inform. 2019;23(2):857-66.
• McGrath SP. Failure to rescue event mitigation system assessment: a mixed-methods approach to analysis of complex adaptive systems. In: Wells E, ed. Structural Approaches to Address Issues in Patient Safety. Bingley, UK: Emerald Publishing Limited; 2019. p. 119-157.
• Smith ME, et al. Effect of new persistent opioid use on physiologic and psychologic outcomes following bariatric surgery. Surg Endosc. 2019;33(8):2649-56.
• Umberfield E, et al. Using incident reports to assess communication failures and patient outcomes. Jt Comm J Qual Patient Saf. 2019;45(6):406-13.
• Ward ST, et al. Association between hospital staffing models and failure to rescue. Ann Surg. 2019;270(1):91-94.

2018

• Abdel Khalik H et al. Site-specific approach to reducing emergency department visits following surgery. Ann Surg. 2018;267(4):721-6.
• Ghaferi AA, Dimick JB. Practical guide to surgical data sets: Medicare claims data. JAMA Surg. 2018;153(7):677-8. https://jamanetwork.com/journals/jamasurgery/article-abstract/2677720.
• Ghaferi AA, Varban OA. Setting appropriate expectations after bariatric surgery: evaluating weight regain and clinical outcomes. JAMA. 2018;320(15):1543-4. https://jamanetwork.com/journals/jama/article-abstract/2707439.
• Inadomi M, et al. Effect of patient-reported smoking status on short-term bariatric surgery outcomes. Surg Endosc 2018;32(2):720-6.
• Kelsall AC, et al. Variation in bariatric surgery episode costs in the commercially insured: implications for bundled payments in the private sector. Ann Surg. 2018;268(6):1014-8.
• Kochkodan J, et al. Physiologic and psychological gender differences in bariatric surgery. Surg Endosc. 2018;32(3):1382-8.
• Myers CG, et al. Social media as a platform for surgical learning: use and engagement patterns among robotic surgeons. Ann Surg. 2018;267(2):233-5.
• Perreard IM, et al. Feasibility and utility of continuous noninvasive hemoglobin monitoring in the general care setting. In Society for Technology in Anesthesia (STA) Annual Meeting. 2018.
• Smith ME, Ghaferi AA. Understanding the benefits of bariatric surgery: how much evidence is enough? JAMA Surg. 2018;153(11):e183332. https://jamanetwork.com/journals/jamasurgery/article-abstract/2698679.
• Smith ME, Ghaferi AA. Understanding the long-term effects of bariatric surgery: from weight loss to bone health. JAMA Surg. 2019;154(8):754-4.
• Smith ME, et al. Interpersonal and organizational dynamics are key drivers of failure to rescue. Health Aff (Millwood). 2018;37(11):1870-6.
• Srivatsan S, et al. Clinical versus patient-reported measures of depression in bariatric surgery. Surg Endosc. 2018;32(8):3683-90.
• Stevens H, et al. Effect of surgeon age on bariatric surgery outcomes. Ann Surg. 2018;267(5):905-9.
• Stevens H, et al. Patient perspectives on emergency department self-referral after bariatric surgery. Surg Obes Relat Dis. 2018;14(5):674-81.
• Taenzer AH, et al. Characteristics of desaturation and respiratory rate in postoperative patients breathing room air versus supplemental oxygen: are they different? Anesth Analg. 2018;126(3):826-32.

2017

• Ibrahim AM, et al. Hospital Quality and Medicare Expenditures for Bariatric Surgery in the United States. Ann Surg 2017;266(1):105-110.
• Ibrahim AM, et al. Variation in Outcomes at Bariatric Surgery Centers of Excellence. JAMA Surg 2017;152(7):629-636.
• Jacobs BL, et al. Variation in readmission expenditures after high-risk surgery. J Surg Res 2017;213:60-68.
• McGrath SP, et al. Assessment of continuous acoustic respiratory rate monitoring as an addition to a pulse oximetry-based patient surveillance system. J Clin Monit Comput. 2017;31(3):561-9.

2016

• Ghaferi AA, Dimick JB. Importance of teamwork, communication and culture on failure-to-rescue in the elderly. Br J Surg. 2016;103(2):e47-51.
• Ghaferi AA, Friese CR. Revisiting nursing's effect on surgical quality and cost. JAMA Surg. 2016;151(6):536-7. https://jamanetwork.com/journals/jamasurgery/article-abstract/2482666.
• McGrath SP, et al. Surveillance monitoring management for general care units: strategy, design, and implementation. Jt Comm J Qual Patient Saf. 2016;42(7):293-302.
• Nagendran M, et al. Mortality among older adults before versus after hospital transition to intensivist staffing. Med Care. 2016;54(1):67-73.

References

1. AFYA. PSLL CONNECT Newsletter: Issue 7. 2019. [Internal Communication] AHRQ. p. 1-15.
2. AFYA. PSLL Learning Network Webinar #11 Report. 2020. [Internal Communication] AHRQ. p. 1-10.
3. AFYA. Patient Safety Learning Laboratories In-Person Meeting Report: Design, Evaluate, Transform. 2019. [Internal Communication] AHRQ. p. 1-52.
4. McGrath SP, et al. Improving patient safety and clinician workflow in the general care setting with enhanced surveillance monitoring. IEEE J Biomed Health Inform. 2019;23(2):857-66.