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Background: Failure to rescue (FTR), defined as a postoperative complication leading to death, is a recently described outcome metric used to evaluate treatment quality. However, the predictive factors for FTR, particularly following highly advanced hepatobiliary-pancreatic surgery (HBPS), have not been adequately investigated. This study aimed to identify perioperative predictive factors for FTR following highly advanced HBPS. Methods: This single-institution retrospective study involved 177 patients at Gifu University Hospital, Japan, who developed severe postoperative complications (Clavien–Dindo classification grades ≥ III) between 2010 and 2022 following highly advanced HBPS. Univariate analysis was used to identify pre-, intra-, and postoperative risks of FTR. Results: Nine postoperative mortalities occurred during the study period (overall mortality rate, 1.3% [9/686]; FTR rate, 5.1% [9/177]). Univariate analysis indicated that comorbid liver disease, intraoperative blood loss, intraoperative blood transfusion, postoperative liver failure, postoperative respiratory failure, and postoperative bleeding significantly correlated with FTR. Conclusions: FTR was found to be associated with perioperative factors. Well-coordinated surgical procedures to avoid intra- and postoperative bleeding and unnecessary blood transfusions, as well as postoperative team management with attention to the occurrence of organ failure, may decrease FTR rates. [ABSTRACT FROM AUTHOR]

Objective: To report one-year morbidity of robotic-assisted laparoscopic surgery (RALS) in a dedicated, multidisciplinary, pediatric robotic surgery program. Summary Background Data. RALS in pediatric surgery is expanding, but data on morbidity in children is limited. Methods: All children who underwent RALS (Da Vinci Xi, Intuitive Surgical, USA) were prospectively included (October 2016 to May 2020; follow-up ≥1 year). Analyzed data: patient characteristics, surgical indication/procedure, intraoperative adverse events (ClassIntra classi- fication), blood transfusion, hospital stay, postoperative complications (Clavien-Dindo). Results: Three hundred consecutive surgeries were included: urology/ gynecology (n=105), digestive surgery (n=83), oncology (n=66), ENT surgery (n=28), thoracic surgery (n=18). Median age and weight at surgery were 9.5 [interquartile range (IQR)=8.8] years and 31 [IQR=29.3] kg, respectively. Over one year, 65 (22%) children presented with ≥1 complication, with Clavien-Dindo ≥III in 14/300 (5%) children at ≤30 days, 7/300 (2%) at 30-90 days, and 12/300 (4%) at >90 days. Perioperative transfusion was necessary in 15 (5%) children, mostly oncological (n=8). Eight (3%) robotic malfunctions were noted, one leading to conversion (laparotomy). Overall conversion rate was 4%. ASA ≥3, weight ≤15 kg, and surgical oncology did not significantly increase the conversion rate, complications, or intraoperative adverse events (ClassIntra ≥2). ASA score was significantly higher in children with complications (Clavien-Dindo ≥III) than without (p=0.01). Median hospital stay was 2 [IQR=3] days. Three children died after a median follow-up of 20 [IQR=16] months. Conclusions: RALS is safe, even in the most vulnerable children with a wide scope of indications, age, and weight. Robot-specific complications or malfunctions are scarce. [ABSTRACT FROM AUTHOR]

Failure-to-rescue, defined as mortality following a perioperative complication, is a perioperative quality indicator studied in various surgeries, but not in vulvar cancer surgery. The objective of this study was to assess failure-to-rescue in patients undergoing surgical therapy for vulvar cancer. This cross-section study queried the National Inpatient Sample. The study population was 31,077 patients who had surgical therapy for vulvar cancer from 1/2001–9/2015. The main outcomes were (i) perioperative morbidity (29 indicators) and (ii) mortality following a perioperative complication during the index admission for vulvar surgery (failure-to-rescue), assessed with a multivariable binary logistic regression model. The cohort-level median age was 69 years, and 14,337 (46.1%) had medical comorbidity. Perioperative complications were reported in 4736 (15.2%) patients during the hospital admission for vulvar surgery. In multivariable analysis, patient factors including older age, medical comorbidity, and morbid obesity, and treatment factors with prior radiotherapy and radical vulvectomy were associated with perioperative complications (P < 0.05). The number of patients with morbid obesity, higher comorbidity index, and prior radiotherapy increased over time (P-trends < 0.001). Among 4736 patients who developed perioperative complications, 55 patients died during the hospital admission for vulvar surgery (failure-to-rescue rate, 1.2%). In multivariable analysis, cardiac arrest (adjusted-odds ratio [aOR] 27.25), sepsis or systemic inflammatory response syndrome (aOR 11.54), pneumonia (aOR 6.03), shock (aOR 4.37), and respiratory failure (aOR 3.10) were associated with failure-to-rescue (high-risk morbidities). There was an increasing trend of high-risk morbidities from 2.0% to 3.7% over time, but the failure-to-rescue from high-risk morbidities decreased from 9.1% to 2.8% (P-trend < 0.05). Vulvar cancer patients undergoing surgical treatment had increased comorbidity over time with an increase in high-risk complications. However, failure-to-rescue rate has decreased significantly. • Failure-to-rescue (FTR) following surgical morbidity in vulvar cancer surgery has not been previously examined. • Vulvar cancer patients undergoing surgical treatment had increased comorbidity over time. • Cardiac arrest, sepsis, pneumonia, shock, and respiratory failure were associated with increased risks of FTR. • Overall FTR rate following these high-risk morbidity indicators was 5.7%. • The incidence of these high-risk morbidities increased over time, but FTR rate has decreased significantly. [ABSTRACT FROM AUTHOR]

• Detecting patient deterioration is a challenge for novice and experienced nurses. • The modified early warning score is a simple tool to identify patient decline. • Simulation is effective in teaching students to prevent failure to rescue. The aims of this study were to improve nursing students' ability to recognize, communicate and act upon early warning signs of patient deterioration. The Modified Early Warning Score (MEWS) is a simple tool that nursing students can use to detect early patient deterioration. This pretest-posttest observational study revealed improvements in the MEWS scores, MEWS action algorithm, and adapted SBAR (S-situation, B-background, A-assessment, R-response) use. Nursing students may improve in identifying patient deterioration using the MEWS. [ABSTRACT FROM AUTHOR]

The term "failure to rescue" (FTR) has been recently introduced in the field of hepato-biliary surgery to label cases in which major postoperative complications lead to postoperative fatality. Perihilar cholangiocarcinoma (PHC) surgery has consistently high postoperative morbidity and mortality rates in which factors associated with FTR are yet to be discovered. The primary endpoint of this study is to compare the Rescue with the FTR cohort referencing patients' characteristics and management protocols applied. A cohort of 224 consecutive patients undergoing surgery for PHC, between 2010 and 2021, was enrolled. Perioperative variables were analyzed according to the severity of major postoperative complications (Clavien ≥ 3a). Kaplan–Meier survival analyses were performed to determine complications' impact on survival. Major complications were reported in 86 cases (38%). Among the major complications' cohort, 72 cases (84%) were graded Clavien 3a–4 (Rescue group), while 14 (16%) cases were graded Clavien 5 (FTR group). Number of lymph-node metastases (OR = 1.33 (1.08–1.63) p = 0.006), poorly differentiated (G3) adenocarcinoma (OR = 7.55 (1.24–45.8) p = 0.028, reintervention (OR = 16.47 (2.76–98.08) p = 0.002), and prognostic nutritional index < 40 (OR = 3.01 (2.265–3.654) p < 0.001) rates were independent predictors of FTR. Right resection side (OR 2.4 (1.33–4.34) p = 0.004) increased the odds of major complications but not of FTR. No difference in overall survival was identified. A distinction of perioperative factors associated with postoperative complications' severity is crucial. Patients developing severe outcomes seem to have different biological and nutritional profiles, showing that efficient preoperative protocols are strategic to identify and avert the risk of FTR. [ABSTRACT FROM AUTHOR]

In-hospital mortality following percutaneous coronary intervention (PCI) varies across institutions with different annual PCI volumes. The failure to rescue (FTR) rate, defined as the mortality rate following PCI-related complications, may account for the volume-outcome relationship. The Japanese Nationwide PCI Registry, a consecutive, nationally mandated registry between 2019 and 2020, was queried. The FTR rate is defined as 'the number of patients who died following PCI-related complications' divided by 'the number of patients who experienced at least one PCI-related complication.' Multivariate analysis was used to calculate the risk-adjusted odds ratio (aOR) of the FTR rates among hospitals stratified into tertiles as low (≤ 236/year), medium (237–405/year), and high (≥ 406/year). A total of 465,716 PCIs and 1007 institutions were included. A volume-outcome relationship was observed for in-hospital mortality, and the medium-volume (aOR 0.90, 95% confidence interval [CI] 0.85–0.96), as well as high-volume (aOR 0.84, 95% CI 0.79–0.89) hospitals, had significantly lower in-hospital mortality than low-volume hospitals. Complication rates were lower at high-volume centers (1.9%, 2.2%, and 2.6% for high-, medium-, and low-volume centers, respectively; p < 0.001). The overall FTR rate was 19.0%. The FTR rates for the low-, medium-, and high-volume hospitals were 19.3%, 17.7%, and 20.6%, respectively. The medium-volume hospitals had a lower FTR rate (aOR 0.82, 95% [CI] 0.68–0.99), whereas the FTR rate was similar at the high-volume hospitals compared with that of the low-volume hospitals (aOR 1.02, 95% CI 0.83–1.26). In-hospital mortality was low after PCI in high-volume hospitals. However, the FTR rate in high-volume hospitals was not necessarily lower than that in low-volume hospitals. The FTR rate did not account for the volume-outcome relationship in PCI. [ABSTRACT FROM AUTHOR]

Failure to rescue (FTR) is a standardized patient safety indicator (PSI-04) developed by the Agency for Healthcare Research and Quality (AHRQ) to assess the ability of a healthcare team to prevent mortality following a major complication. However, FTR rates vary and are impacted by non-modifiable individual patient characteristics such as baseline frailty. This raises concerns regarding the validity of FTR as an objective quality metric, as not all patients have the same baseline frailty level, or physiological reserve, to recover from major complications. Literature from other surgical specialties has identified flaws in FTR and called for risk-adjusted metrics. Currently, knowledge of factors influencing FTR and its subsequent implementation in neurosurgical patients are limited. The present review assesses trends in FTR utilization to assess how FTR performs as an objective neurosurgery quality metric. This review then proposes how FTR may be best modified to optimize use in neurosurgical patients. A PubMed search was performed to identify articles published until August 9, 2023. Studies that reported FTR as an outcome in patients undergoing neurosurgical procedures were included. A qualitative assessment was performed using the Newcastle Ottawa Scale (NOS). The initial search revealed 1232 citations. After a title and abstract screen, followed by a full text screen, 12 studies met criteria for inclusion. These articles measured FTR across a total of 764,349 patients undergoing neurosurgical procedures. Five studies analyzed FTR with regard to hospital characteristics, and three studies utilized patient characteristics to predict FTR. All studies were considered high quality based on the NOS. Modifications in criteria to measure FTR are necessary since FTR depends on patient characteristics like frailty. This would allow for the incorporation of risk-adjusted FTR metrics that would aid in clinical decision making in neurosurgical patients. [ABSTRACT FROM AUTHOR]

Objective: The aim was to determine the association between risk adjusted hospital perioperative mortality rates, postoperative complications, and failure to rescue (FTR) after inpatient pediatric surgery. Background: FTR has been identified as a possible explanatory factor for hospital variation in perioperative mortality in adults. However, the extent to which this may be the case for hospitals that perform pediatric surgery is unclear. Methods: The Pediatric Health Information System database (2012–2020) was used to identify patients who underwent one of 57 high-risk operations associated with significant perioperative mortality (n=203,242). Academic, pediatric hospitals (n=48) were stratified into quintiles based on risk adjusted inpatient mortality [lower than average, quintile 1 (Q1); higher than average, quintile 5 (Q5)]. Multivariable hierarchical regression was used to evaluate the association between hospital mortality rates, complications, and FTR. Results: Inpatient mortality, complication, and FTR rates were 2.3%, 8.8%, and 8.8%, respectively. Among all patients who died after surgery, only 34.1% had a preceding complication (Q1, 36.1%; Q2, 31.5%; Q3, 34.7%; Q4, 35.7%; Q5, 32.2%; trend test, P =0.49). The rates of observed mortality significantly increased across hospital quintiles, but the difference was <1% (Q1, 1.9%; Q5; 2.6%; trend test, P <0.01). Relative to Q1 hospitals, the odds of complications were not significantly increased at Q5 hospitals [odds ratio (OR): 1.02 (0.87–1.20)]. By comparison, the odds of FTR was significantly increased at Q5 hospitals [OR: 1.60 (1.30–1.96)] with a dose-response relationship across hospital quintiles [Q2—OR: 0.99 (0.80–1.22); Q3—OR: 1.26 (1.03–1.55); Q4—OR: 1.33 (1.09–1.63)]. Conclusions: The minority of pediatric surgical deaths are preceded by a postoperative complication, but variation in risk adjusted mortality across academic, pediatric hospitals may be partially explained by differences in the recognition and management of postoperative complications. Additional work is needed to identify children at greatest risk of postoperative death from perioperative complications as opposed to those at risk from pre-existing chronic conditions. [ABSTRACT FROM AUTHOR]

A cancer diagnosis and its subsequent treatments are life-changing events, impacting the patient and their family. Treatment options available for cancer care are developing at pace, with more patients now able to achieve a cancer cure. This is achieved through the development of novel cancer treatments, surgery, and modern imaging, but also as a result of better understanding treatment/surgical trauma, rescue after complications, perioperative care, and innovative interventions like pre-habilitation, enhanced recovery, and enhanced post-operative care. With more patients living with and beyond cancer, the role of survivorship and quality of life after cancer treatment is gaining importance. The impact cancer treatments can have on patients vary, and the "scars" treatments leave are not always visible. To adequately support patients through their cancer journeys, we need to look past the short-term interactions they have with medical professionals and encourage them to consider their lives after cancer, which often is not a reflection of life before a cancer diagnosis. [ABSTRACT FROM AUTHOR]

Background: Patient activated rapid response (PARR) services allow patients and family members to escalate care in hospital without agreement by their primary care team. Methods: This paper explores the evidence base for PARR and examines the experience of a sample of patients to identify barriers and opportunities for PARR. These are then used to develop a framework for the measurement of PARR that can be applied to quantify clinical impact and develop new research. Results: The observed number of escalation events by patients and family members is small. Interviews with patients suggested concerns of patients in undermining staff and difficulties to recall the mechanics of escalation during periods of acute illness. The Quadruple aim could be used as a framework to quantify impact: In a functioning PARR system earlier recognition of illness can be facilitated by patients and this should lead to 1. a reduction in cardiac arrests and preventable deaths, 2. timely admission to critical care with shorter (cheaper) length of stay, 3. better patient engagement and Patient Reported Experience measures and 4. flatter hierarchies with higher staff satisfaction. Conclusion: PARR services are in the early stages of implementation. We present a framework to measure improvement of services and research. [ABSTRACT FROM AUTHOR]

Purpose: A correlation between the hospital volume and outcome is described for multiple entities of oncological surgery. To date, this has not been analyzed for the surgical treatment of sigmoid diverticulitis. The aim of this study was to explore the impact of the annual caseload per hospital of colon resection on the postoperative incidence of complications, failure to rescue, and mortality in patients with diverticulitis. Methods: Patients receiving colorectal resection independent from the diagnosis from 2012 to 2017 were selected from a German nationwide administrative dataset. The hospitals were grouped into five equal caseload quintiles (Q1–Q5 in ascending caseload order). The outcome analysis was focused on patients receiving surgery for sigmoid diverticulitis. Results: In total, 662,706 left-sided colon resections were recorded between 2012 and 2017. Of these, 156,462 resections were performed due to sigmoid diverticulitis and were included in the analysis. The overall in-house mortality rate was 3.5%, ranging from 3.8% in Q1 (mean of 9.5 procedures per year) to 3.1% in Q5 (mean 62.8 procedures per year; p < 0.001). Q5 hospitals revealed a risk-adjusted odds ratio of 0.85 (95% CI 0.78–0.94; p < 0.001) for in-hospital mortality compared to Q1 during multivariable logistic regression analysis. High-volume centers showed overall lower complication rates, whereas the failure-to-rescue did not differ significantly. Conclusion: Surgical treatment of sigmoid diverticulitis in high-volume colorectal centers shows lower postoperative mortality rates and fewer postoperative complications. [ABSTRACT FROM AUTHOR]

We conducted a thorough literature review on the emerging role of failure to rescue (FTR) as a quality metric for cardiovascular surgery and critical care. For this purpose, we identified all original research studies assessing the implementation of FTR in cardiovascular surgery and critical care from 1992 to 2023. All included studies were evaluated for their quality. Although all studies defined FTR as mortality after a surgical complication, a high heterogeneity has been reported among studies regarding the included complications. There are certain factors that affect the FTR, divided into hospital- and patient-related factors. The identification of these factors allowed us to build a stepwise roadmap to reduce the FTR rate. Recently, FTR has further evolved as a metric to assess morbidity instead of mortality, while being also evaluated in the context of interventional cardiology. All these advances are further discussed in the current review, thus providing all the necessary information to surgeons, anesthesiologists, and physicians willing to implement FTR as a metric of quality in their establishment. [ABSTRACT FROM AUTHOR]

Failure to rescue (FTR) (avoiding death after complications) has been proposed as a measure of hospital quality. Although surviving complications is important, not all rescues are created equal. Patients also place considerable values on being able to return home after surgery and resume their normal lives. From a systems standpoint, nonhome discharge to skilled nursing and other facilities is the biggest driver of Medicare costs. We wanted to determine whether hospitals' ability to keep patients alive after complications was associated with higher rates of home discharge. We hypothesized that hospitals with higher rescue rates would also be more likely to discharge patients home after surgery. We conducted a retrospective cohort study using the nationwide inpatient sample. We included 1,358,041 patients ≥18 y old who had elective major surgery (general, vascular, orthopedic) at 3818 hospitals from 2013 to 2017. We predicted the correlation between a hospital's performance (rank) on FTR and its rank in terms of home discharge rate. The cohort had a median age of 66 y (interquartile range [IQR] 58-73), and 77.9% of patients were Caucasian. Most patients (63.6%) were treated at urban teaching institutions. The surgical case mix included patients having colorectal (146,993 patients; 10.8%), pulmonary (52,334; 3.9%), pancreatic (13,635; 1.0%), hepatic (14,821; 1.1%), gastric (9182; 0.7%), esophageal (4494; 0.3%), peripheral vascular bypass (29,196; 2.2%), abdominal aneurysm repair (14,327; 1.1%), coronary artery bypass (61,976; 4.6%), hip replacement (356,400; 26.2%), and knee replacement (654,857; 48.2%) operations. The overall mortality was 0.3%, the average hospital complication rate was 15.9%, the median hospital rescue rate was 99% (IQR 70%-100%), and the median hospital rate of home discharge was 80% (IQR 74%-85%).There was a small but positive correlation between hospitals' performance on the FTR metric and the likelihood of home discharge after surgery (r = 0.0453; P = 0.006). When considering hospital rates of discharge to home following a postoperative complication, there was a similar correlation between rescue rates and probability of home discharge (r = 0.0963; P < 0.001). However, on sensitivity analysis excluding orthopedic surgery, there was a stronger correlation between rescue rates and home discharge rate (r = 0.4047, P < 0.001). We found a small correlation between a hospital's ability to rescue patients from complication and that hospital's likelihood of discharging patients home after surgery. When excluding orthopedic operations from the analysis, this correlation strengthened. Our findings suggest that efforts to reduce mortality after complications will likely also help patients return home more frequently after complex surgery. However, more work needs to be done to identify successful programs and other patient and hospital factors that affect both rescue and home discharge. [ABSTRACT FROM AUTHOR]

Deterioration after major surgery is common, with many patients experiencing a medical emergency team (MET) activation. Understanding the triggers for MET calls may help design interventions to prevent deterioration. We aimed to identify triggers for MET activation in non-cardiac surgical patients. A retrospective cohort study of adult patients who experienced a postoperative MET call at a single tertiary hospital was undertaken. The trigger and timing of each MET call and patient characteristics were collected. Four hundred and one MET calls occurred after 23,258 surgical procedures, a rate of 1.7% of all non-cardiac surgical procedures, accounting for 11.7% of all MET calls over the study period. Hypotension (41.4%) was the most common trigger, followed by tachycardia (18.5%), altered conscious state (11.0%), hypoxia (10.0%), tachypnoea (5.7%), 'other' (5.7%), clinical concern (4.0%), increased work of breathing (1.5%) and bradypnoea (0.7%). Cardiac and/or respiratory arrest triggered 1.2% of MET activations. Eighty-six percent of patients had a single MET call, 10.2% had two, 1.8% had three and one patient (0.3%) had four. The median interval between post-anaesthetic care unit (PACU) discharge and MET call was 14.7 h (95% confidence interval 4.2 to 28.9 h). MET calls resulted in intensive care unit (ICU) admission in 40 patients (10%), while 82% remained on the ward, 4% had a MET call shortly after ICU discharge and returned there, 2% returned to theatre, and 2% went to a high dependency unit. Hypotension was the most common trigger for MET calls after non-cardiac surgery. Deterioration frequently occurred within 24 h of PACU discharge. Future research should focus on prevention of hypotension and tachycardia after surgery. [ABSTRACT FROM AUTHOR]

Objective: To examine variation in "failure to rescue" (FTR) as a driver of differences in mortality between centres and over time for patients undergoing colorectal cancer surgery. Background: Wide variation exists in postoperative mortality following colorectal cancer surgery. FTR has been identified as an important determinant of variation in postoperative outcomes. We hypothesized that differences in mortality both between hospitals and over time are driven by variation in FTR. Methods: A national population-based study of patients undergoing colorectal cancer resection from 2010 to 2019 in Aotearoa New Zealand was conducted. Rates of 90-day FTR, mortality, and complications were calculated overall, and for surgical and nonoperative complications. Twenty District Health Boards (DHBs) were ranked into quartiles using risk- and reliability-adjusted 90-day mortality rates. Variation between DHBs and trends over the 10-year period were examined. Results: Overall, 15,686 patients undergoing resection for colorectal adenocarcinoma were included. Increased postoperative mortality at high-mortality centers (OR 2.4, 95% CI 1.8–3.3) was driven by higher rates of FTR (OR 2.0, 95% CI 1.5–2.8), and postoperative complications (OR 1.4, 95% CI 1.3–1.6). These trends were consistent across operative and nonoperative complications. Over the 2010 to 2019 period, postoperative mortality halved (OR 0.5, 95% CI 0.4–0.6), associated with a greater improvement in FTR (OR 0.5, 95% CI 0.4–0.7) than complications (OR 0.8, 95% CI 0.8–0.9). Differences between centers and over time remained when only analyzing patients undergoing elective surgery. Conclusion: Mortality following colorectal cancer resection has halved over the past decade, predominantly driven by improvements in "rescue" from complications. Differences in FTR also drive hospital-level variation in mortality, highlighting the central importance of "rescue" as a target for surgical quality improvement. [ABSTRACT FROM AUTHOR]

Missed diagnosis of foreign bodies in esophagus occasionally results in adverse consequences for patients. This study aimed to analyze the clinical characteristics of esophageal foreign body missed diagnosis in 12 cases. Among the 12 patients, 7 didn't undergo esophagus-related examination due to mild pain; One case didn't report a clear history of swallowing foreign bodies. For one case, computed tomography (CT) examination had not reached the esophageal foreign body level. Two cases were missed diagnosis because the foreign bodies were too tiny to develop clearly on CT. One case showed foreign body in esophagus during initial CT examination, but after subsequent gastroscopy, no foreign body was found. Among the 12 patients, 7 had esophageal perforation, 1 of which developed a neck abscess, and 1 had peri-esophageal abscess. It seems that, if foreign bodies in the pharynx or esophagus are suspected and no foreign bodies are found in the laryngoscope, chest CT scan is necessary. It is best to perform examination of full-length esophagus and pharynx, because foreign bodies may exist in the post-cricoid region or the deep part of the pyriform sinus, especially in older cases with longer retention times.

BackgroundHospitals with safety-net status have been associated with inferior surgical outcomes and higher costs. The mechanism of this discrepancy, however, is not well understood. We hypothesized that discrepant rates of failure to rescue after complications of routine cardiac surgery would explain the observed inferior outcomes at safety-net hospitals.MethodsThe National Inpatient Sample was used to identify adult patients who underwent elective coronary artery bypass grafting and isolated or concomitant valve operations between January 2005 and December 2016. Hospitals were stratified into low-, medium-, or high-burden categories based on the proportion of uninsured or Medicaid patients to emulate safety-net status as defined by the Institute of Medicine. Failure to rescue was defined as mortality after occurrence of neurologic, cardiovascular, respiratory, renal, or infectious complications (major and minor complications). Multivariable regression was used to perform risk-adjusted comparisons of the rate of complications, failures to rescue, and resource use for high-burden hospitals versus low-burden and medium-burden hospitals.ResultsOf an estimated 2,012,104 patients undergoing elective major cardiac operations, 2% died, whereas 36% suffered major and minor complications. Safety-net hospitals had higher odds of failure to rescue after major comorbidity (adjusted odds ratio 1.12, 95% confidence interval 1.01-1.23). Occurrence of major and minor complications at safety-net hospitals was associated with increased costs ($2,480 [95% confidence interval $1,178-$3,935]) compared with low-burden hospitals.ConclusionSafety-net hospitals were associated with higher rates of failure to rescue after occurrence of tamponade, septicemia, and respiratory complications. Implementation of care bundles to tackle cardiovascular, respiratory, and renal complications may affect the discrepancy in incidence of and rescue from complications at safety-net institutions.

Abstract Background Quality standards in postoperative outcomes have not yet been defined for gastric cancer surgery. Also, the effect of centralization of gastric cancer surgery on the improvement of postoperative outcomes continues to be debated. Short-term postoperative outcomes in gastric carcinoma patients in centers with low-volume of annual gastrectomies were assessed. The effect of age on major postoperative morbidity and mortality was also analyzed. Methods Patients with gastric or gastroesophageal junction Siewert III type carcinomas who underwent surgical treatment with curative intent between January 2013 and December 2016 were included. Data were obtained from the population-based surgical registry Esophagogastric Carcinoma Registry of the Comunitat Valenciana (RECEG-CV). The RECEG-CV gathers information on demographic characteristics and comorbidity, preoperative study and neoadjuvant treatment, surgical procedure, pathological study, postoperative outcomes, and follow-up. Seventeen hospitals belonging to the public network participated in this registry. Results Data from 591 patients were analyzed. Postoperative major morbidity occurred in 154 (26.1%) patients. Overall 30-day or in-hospital mortality, and 90-day postoperative mortality rates were 8.6% and 10.1% respectively. Failure-to-rescue was 39% and it was significantly higher in patients aged 75 years or older in comparison with younger patients (55.3% vs 23.1% p < 0.001). In the multivariable analysis, age ≥ 75 years (p = 0.029), laparoscopic approach (p = 0.005), and total gastrectomy (p = 0.005) were associated with major postoperative morbidity. Age ≥ 75 years (p = 0.027), pulmonary complications (p = 0.001), cardiac complications (p = 0.001), leakage (p = 0.003), and hemorrhage (p = 0.013) were associated with postoperative mortality. Conclusions Centralization of gastric adenocarcinoma treatment in centers with higher annual caseload should be considered to improve the short-term postoperative outcomes in low-volume centers. Patients aged 75 or older had a significantly increased risk of major postoperative morbidity and mortality, and higher failure-to-rescue.

Background: Failure to rescue (FTR) patients with postoperative complications contribute to a significant proportion of postoperative mortality. Our main objective was to determine the risk factors for FTR among patients undergoing pancreaticoduodenectomy who suffered a life-threatening complication requiring intensive care unit (ICU) management. Materials and Methods: Consecutive patients undergoing pancreaticoduodenectomy from 2011 to 2020 were reviewed retrospectively. Causes of organ failure were described as the one that most commonly contributed to patient's transfer to ICU or death. Two groups were created based on whether patients had FTR and risk factors for FTR were compared. The impact of baseline characteristics, operative characteristics, and risk scoring on FTR was analyzed using multiple logistic regression. Results: There were 19/58 (33%) FTR patients. Baseline, operative characteristics, postoperative complications, and length of hospital and ICU stay were similar between groups. However, a higher proportion of FTR patients experienced a postoperative pancreatic fistula (POPF) (16% vs 2.6%, P =.062). Among patients who experienced a POPF, the FTR group had a trend in delayed time from diagnosis to treatment (7 vs 23 hours, P =.131). Renal complications (OR 6.12, 95% CI, 1.23 to 38.43, P =.035) and time from POPF diagnosis to treatment (OR 1.05, 95% CI, 1.00 to 1.11, P =.036) were independent predictors of FTR by multivariable analysis. Conclusion: The occurrence of certain postoperative complications such as renal complications as well as delayed timing of the management of POPF is predictive of FTR following pancreaticoduodenectomy, especially as delayed timing to treatment is a risk factor for FTR. [ABSTRACT FROM AUTHOR]

Aim: The aim of this review was to synthesise current knowledge of high‐fidelity simulation practices and its impact on nurse clinical competence in the acute care setting. Background: There is no consensus or standardisation surrounding best practices for the delivery of high‐fidelity simulation in the acute care setting. This is an understudied area. Design: An integrative review using Johns Hopkins Nursing Evidence‐Based Practice Model. Methods: Medical subject heading terms 'Clinical Competence', AND 'High Fidelity Simulation Training', AND 'Clinical Deterioration' were systematically searched in PubMed, CINAHL and Embase databases for peer‐reviewed literature published through September 2020. The current study was evaluated using PRISMA checklist. Results: Seven studies met the inclusion criteria. Three main concepts were identified: modes of delivery, approach to learner participation and outcome measurement. Conclusions: This review substantiated the use of high‐fidelity simulation to improve acute care nurses' early identification and management of clinical deterioration. Global variations in course design and implementation highlight the need for future approaches to be standardised at the regional level (i.e., country‐centric approach) where differing scopes of practice and sociocultural complexities are best contextualised. Relevance to clinical practice: These findings add to the growing body of evidence of simulation science. Important considerations in course planning and design for nursing clinical educators were uncovered. This is especially relevant given the current COVID‐19 pandemic and urgent need to train redeployed nurses safely and effectively from other units and specialties to acute care. [ABSTRACT FROM AUTHOR]

Background: Neoadjuvant therapy (NAT) has become common worldwide for resectable advanced esophageal cancer and frequently involves weight loss. Although failure to rescue (death after major complications) is known as an emerging surgical quality measure, little is known about the impact of weight loss during NAT on failure to rescue. This retrospective study aimed to investigate the association of weight loss during NAT and short-term outcomes, including failure to rescue after esophagectomy. Materials and methods: Patients who underwent esophagectomy after NAT between July 2010 and March 2019 were identified from a Japanese nationwide inpatient database. Based on quartiles of percent weight change during NAT, patients were grouped into four categories of gain, stable, small loss, and loss (>4.5%). The primary outcomes were failure to rescue and in-hospital mortality. The secondary outcomes were major complications, respiratory complications, anastomotic leakage, and total hospitalization costs. Multivariable regression analyses were used to compare outcomes between the groups, adjusting for potential confounders, including baseline BMI. Results: Among 15 159 eligible patients, in-hospital mortality and failure to rescue occurred in 302 (2.0%) and 302/5698 (5.3%) patients, respectively. Weight loss (> 4.5%) compared to gain was associated with increased failure to rescue and in-hospital mortality [odds ratios 1.55 (95% CI: 1.10-2.20) and 1.53 (1.10-2.12), respectively]. Weight loss was also associated with increased total hospitalizations costs, but not with major complications, respiratory complications, and anastomotic leakage. In subgroup analyses, regardless of baseline BMI, weight loss (> 4.8% in nonunderweight or >3.1% in underweight) was a risk factor for failure to rescue and in-hospital mortality. Conclusion: Weight loss during NAT was associated with failure to rescue and in-hospital mortality after esophagectomy, independent of baseline BMI. This emphasizes the importance of weight loss measurement during NAT to assess the risk for a subsequent esophagectomy. [ABSTRACT FROM AUTHOR]

Objective: To examine the association of BMI with mortality and related outcomes after oncologic esophagectomy. Summary Background Data: Previous studies showed that high BMI was a risk factor for anastomotic leakage and low BMI was a risk factor for respiratory complications after esophagectomy. However, the association between BMI and in-hospital mortality after oncologic esophagectomy remains unclear. Methods: Data for patients who underwent esophagectomy for esophageal cancer between July 2010 and March 2019 were extracted from a Japanese nationwide inpatient database. Multivariate regression analyses and restricted cubic spline analyses were used to investigate the associations between BMI and short-term outcomes, adjusting for potential confounders. Results: Among 39,406 eligible patients, in-hospital mortality, major complications, and multiple complications (≥2 major complications) occurred in 1069 (2.7%), 14,824 (37.6%), and 3621 (9.2%), respectively. Compared with normal weight (18.5–22.9 kg/m2), severe underweight (<16.0 kg/m2), mild/moderate underweight (16.0–18.4 kg/m2), and obese (≥27.5 kg/m2)were significantly associated with higher in-hospital mortality [odds ratio 2.20 (95% confidence interval 1.65–2.94), 1.25 (1.01–1.49), and 1.48 (1.05–2.09), respectively]. BMI showed U-shaped dose-response associations with mortality, major complications, and multiple complications. BMI also showed a reverse J-shaped association with failure to rescue (death after major complications). Conclusions: Both high BMI and low BMI were associated with mortality, major complications and multiple complications after esophagectomy for esophageal cancer. Patients with low BMI were more likely to die once a major complication occurred. The present results can assist with risk stratification in patients undergoing oncologic esophagectomy. [ABSTRACT FROM AUTHOR]

Failure to Rescue (FTR), defined as mortality following a complication of care, is an important indicator of hospital care quality. Understanding risk factors associated with FTR in the elective Abdominal Aortic Aneurysm (AAA) population may help surgeons prevent operative mortality. Elective open AAA repairs (2008-2018) were identified from Cerner's HealthFacts database using ICD-9 and ICD-10 diagnosis and procedure codes. Patient, hospital, and encounter characteristics were analyzed. Multivariate logistic regression models determined the relative contribution of patient and encounter characteristics leading to FTR. For 1761 patients who underwent open repair for nonruptured AAA, overall mortality was 6.1%. Of patients with one or more complications (40%), mortality was 9.6%, increasing to 21.5% for patients with ≥4 major complications. Complications of care most associated with death were myocardial infarction (MI), gastrointestinal (GI) bleeding, and pulmonary failure. After multivariable adjustment, FTR was associated with advanced age (odds ratio [OR] 1.19 for 5 y, 95% confidence interval [CI] 1.06-1.34); female sex (OR 1.74, 95% CI 1.12-2.70); congestive heart failure (OR 1.65, 95% CI 1.00-2.73); peptic ulcer disease (OR 3.99, 95% CI 1.18-13.5); diabetes (OR 4.90, 95% CI 1.90-12.6), and the number of complications of care. Complications of care were common following open elective AAA repair. The complications with the highest mortality included MI, GI bleeding, and respiratory failure. FTR was associated with female sex, comorbidities, and increasing numbers of complications of care. Often, the lowest occurring complications had the highest FTR. Adopting gender-specific assessment tools, a protocol-driven approach for perioperative GI prophylaxis, and preoperative MI risk mitigation may lead to reduced FTR. [ABSTRACT FROM AUTHOR]

Objective: We aimed to evaluate the implementation of a dedicated Surgical critical care service (SCCS) on failure to rescue (FTR) rates in rural Kenya. Summary Background Data: FTR adversely impacts perioperative outcomes. In the resource-limited contexts of low- and middle-income countries, emergency gastrointestinal surgery carries high morbidity and mortality rates. Quality improvement initiatives that decrease FTR rates are essential for improving perioperative care. Methods: All patients who underwent emergency gastrointestinal surgery between January 2016 and June 2019 at Tenwek Hospital in rural Kenya were reviewed. Critical care capabilities were constant throughout the study period. A supervised surgical resident was dedicated to the daily care of critically ill surgical patients beginning in January 2018. The impact of the SCCS initiation on the outcome of FTR was evaluated, controlling for patient complexity via the African Surgical Outcomes Study Surgical Risk Score. Results: A total of 484 patients were identified, consisting of 278 without and 206 with an active SCCS. A total of 165 (34.1%) patients experienced postoperative complications, including 49 mortalities (10.1%) yielding an FTR rate of 29.7%. The FTR rate decreased after SCCS implementation from 36.8% (95% CI: 26.7%–47.8%) to 21.8% (95% CI: 13.2%–32.6%) (P = 0.035) despite an increase in the average patient African Surgical Outcomes Study score from 14.5 (95% CI, 14.1–14.9) to 15.2 (95% CI, 14.7–15.7) (P =0.03). Conclusions: The implementation of an SCCS in rural Kenya resulted in decreased rates of FTR despite an increase in patient complexity and severity of critical illness. [ABSTRACT FROM AUTHOR]

Objective: To study the impact of a standardized postoperative anesthesia visit on 30-day mortality in medium to high-risk elective surgical patients. Background: Postoperative complications are the leading cause of perioperative morbidity and mortality. Although modified early warning scores (MEWS) were instituted to monitor vital functions and improve postoperative outcome, we hypothesized that complementary anesthesia expertise is needed to adequately identify early deterioration. Methods: In a prospective, multicenter, stepped-wedge cluster randomized interventional study in 9 academic and nonacademic hospitals in the Netherlands, we studied the impact of adding standardized postoperative anesthesia visits on day 1 and 3 to routine use of MEWS in 5473 patients undergoing elective noncardiac surgery. Primary outcome was 30-day mortality. Secondary outcomes included: incidence of postoperative complications, length of hospital stay, and intensive care unit admission. Results: Patients were enrolled between October 2016 and August 2018. Informed consent was obtained from 5473 patients of which 5190 were eligible for statistical analyses, 2490 in the control and 2700 in the intervention group. Thirty-day mortality was 0.56% (n = 14) in the control and 0.44% (n = 12) in the intervention group (odds ratio 0.74, 95% Confidence interval 0.34–1.62). Incidence of postoperative complications did not differ between groups except for renal complications which was higher in the control group (1.7% (n = 41) vs 1.0% (n = 27), P = 0.014). Median length of hospital stay did not differ significantly between groups. During the postanesthesia visits, for 16% (n = 437) and 11% (n = 293) of patients recommendations were given on day 1 and 3, respectively, of which 67% (n = 293) and 69% (n = 202) were followed up. Conclusions: The combination of MEWS and a postoperative anesthesia visit did not reduce 30-day mortality. Whether a postoperative anesthesia visit with strong adherence to the recommendations provided and in a high-risk population might have a stronger impact on postoperative mortality remains to be determined. Trial Registration: Netherlands Trial Registration, NTR5506/ NL5249, https://www.trialregister.nl/trial/5249. [ABSTRACT FROM AUTHOR]

Clinical judgment is imperative for the emergency nurse caring for the acutely ill patients often seen in the emergency department. Without optimal clinical judgment in the emergency department, patients are at risk of medical errors and a failure to rescue. A descriptive observational approach using the Lasater Clinical Judgment Rubric evaluated nurses during a task that required recognition of clinical signs of deterioration and appropriate clinical care for simulated patients. A total of 18 practicing emergency nurses completed only 44.6% of the patient assessments leading to low levels of clinical judgment throughout the simulation. Nurses expressed 4 levels of clinical judgment: exemplary (n = 1), accomplishing (n = 6), developing (n = 9), and beginning (n = 2). On average, nurses completed 69% of required tasks. Assessments were completed less than half the time, demonstrating a breakdown in the noticing phase of clinical judgment. The nurses shifted to task completion focus with minimal use of clinical judgment. As the nurses remained task oriented, several medication and medical errors were noted while caring for the simulated patients. Experience and education did not influence observed clinical judgment among the participants. Given the extreme demands placed on the emergency nurse, it cannot be assumed that nurses have developed or can use clinical judgment when caring for their patients. Time and training targeting clinical judgment are essential for emergency nurse development. [ABSTRACT FROM AUTHOR]

Background: Although the effects of hospital volume on mortality have been studied in other procedures, data on total joint arthroplasty (TJA) are limited. Furthermore, mortality rate among surgical patients with early major complications has become an important patient safety indicator and has been shown to be an important driver of mortality in certain operations. Our objective was to examine the effect of hospital volume on early complications and in-hospital mortality rate after TJA. Material and methods: A total of 5,396,644 patients undergoing elective, unilateral TJA between 2002 and 2011 were identified using the Nationwide Inpatient Sample database. Hospitals were divided by annual volume into tertiles. Major complications associated with postoperative mortality were identified. Risk-adjusted mortality (RAM) was calculated to adjust for hospital case mix. Results: For THAs performed at high-volume centers, RAM was significantly lower (0.03% vs 0.41%, P < .05, high vs low volume) with lower prevalence of major complications (2.2% vs 3.3%, P < .05, high vs low volume). We observed similar results for TKA where RAM was lower (

Rapid response systems (RRSs) were developed to respond to early warnings of unexpected deterioration, but their effectiveness may be limited by factors impacting RRS activation (afferent limb) or response (efferent limb). Despite decades of RRS implementation, patients still experience unrecognized deterioration with associated worse outcomes.This rapid review used modified search strategies to focus on the most valuable studies performed in the United States. Citations were screened by one reviewer with artificial intelligence as a second reviewer at the title/abstract review stage. The full text of eligible articles was then reviewed by a single team member to confirm eligibility. One reviewer completed the data abstraction, and a second reviewer checked the first reviewer's abstraction.Three categories of interventions were identified: implementation of a new RRS, and modifications to the afferent limb and/or efferent limb of an existing RRS. RRSs may have a large impact in reducing in-hospital mortality and an even greater impact in reducing cardiorespiratory arrest on hospital general wards in adults but the effect is unclear in children. Their impact on unanticipated intensive care unit admission is unclear. Modifications to the afferent and/or efferent limb were associated with a reduction in mortality and the incidence of cardiorespiratory arrest for adults.RRS may have a large beneficial effect on hospital mortality and in-hospital cardiorespiratory arrest, but the strength of the evidence is low due to methodological weaknesses of the studies. Innovations in afferent and efferent limb structures show promise for increased benefit. [ABSTRACT FROM AUTHOR]

Objective: To understand the effectiveness of Rescue Improvement Conference, a forum that addresses FTR. Summary of Background Data: Every year over 150,000 patients die after elective surgery in the United States. FTR is the phenomenon whereby delayed recognition and/or response to serious surgical complications leads to a progressive cascade of adverse events culminating in death. Rescue Improvement Conference is an adapted version of the Ottawa-style morbidity and mortality conference, designed to address common contributors to FTR: ineffective communication and inadequate problem solving. Methods: Mixed methods data were used to evaluate Rescue Improvement Conference, a bi-monthly forum that was first introduced in our academic medical center in 2018. Conference effectiveness data were collected via survey and open-text responses after 5 conferences between September 2018 and February 2020. We focused on 5 indicators of effectiveness: educational value, conference takeaways, discussion time, changes to surgical practice, and actionable opportunities for improvement. Twelve surgical faculty and house staff also provided feedback during semi-structured interviews. Qualitative data were analyzed using thematic analysis. Results: Conference attendees (N = 140) felt that Rescue Improvement Conference was effective—all 5 indicators had mean scores above 5 on Likert scales. The qualitative data supports the quantitative findings, and 3 additional themes emerged: Rescue Improvement Conference enables the representation of diverse voices, promotes interdisciplinary collaboration, and encourages multilevel problem solving. Conclusions: Rescue Improvement Conference has the potential to support other surgical departments in developing system-level strategies to recognize and manage postoperative complications by providing stakeholders a forum to identify and discuss factors that contribute to FTR. [ABSTRACT FROM AUTHOR]

Background: Annually in England, over 1.5 million children and young people (CYP) are admitted to hospital. However, a proportion of these CYP will experience failure to rescue (FtR), a failure to recognize, respond and escalate clinical deterioration, which can result in significant harm or death. Aim: To identify and quantify FtR episodes from emergency events at a 110‐bedded tertiary children's hospital located within a University Teaching Hospital and evaluate the impact of targeted interventions on reducing FtR. Methods: A quality improvement approach was adopted. From 170 446 patients admitted between 2011 and 2019, all emergency event calls were systematically reviewed to identify FtR episodes. Root–cause analysis was performed to identify practice deficiencies. The Plan‐Do‐Study‐Act fundamentals were used. Results: A total of 520 emergency events were reviewed over the 9‐year period. One hundred and thirty‐two (n = 132; 25%) were cardiac arrest events, with the majority occurring within the PCCU setting. Three hundred and twelve (60%) of the events were in children who had been inpatient for more than 48 hours. FtR trend declined over the study period from 23.6% in 2011 when the project commenced to 2.5% or less over the following 8 years. Conclusions: Identifying rates of FtR events from routinely collected emergency events data can be used as a patient safety measure to identify emergency concerns. This enables dynamic problem solving through delivery of strategic and targeted interventions. The proposed interventions outlined in this quality improvement study have application to critical care nursing as mechanisms for reducing unplanned admissions to paediatric critical care unit (PCCU), patient mortality, and PCCU and non‐PCCU cardiac arrests. Relevance to Clinical Practice: This study emphasises the importance in understanding the antecedence of emergency events for paediatric inpatient populations. This intelligence can be used to direct targeted interventions to significantly reduce failure to rescue rates. [ABSTRACT FROM AUTHOR]

Continuous prediction surveillance modeling is an emerging tool giving dynamic insight into conditions with potential mitigation of adverse events (AEs) and failure to rescue. The Epic electronic medical record contains a Deterioration Index (DI) algorithm that generates a prediction score every 15 min using objective data. Previous validation studies show rapid increases in DI score (≥14) predict a worse prognosis. The aim of this study was to demonstrate the utility of DI scores in the trauma intensive care unit (ICU) population. A prospective, single-center study of trauma ICU patients in a Level 1 trauma center was conducted during a 3-mo period. Charts were reviewed every 24 h for minimum and maximum DI score, largest score change (Δ), and AE. Patients were grouped as low risk (ΔDI <14) or high risk (ΔDI ≥14). A total of 224 patients were evaluated. High-risk patients were more likely to experience AEs (69.0% versus 47.6%, P = 0.002). No patients with DI scores <30 were readmitted to the ICU after being stepped down to the floor. Patients that were readmitted and subsequently died all had DI scores of ≥60 when first stepped down from the ICU. This study demonstrates DI scores predict decompensation risk in the surgical ICU population, which may otherwise go unnoticed in real time. This can identify patients at risk of AE when transferred to the floor. Using the DI model could alert providers to increase surveillance in high-risk patients to mitigate unplanned returns to the ICU and failure to rescue. [ABSTRACT FROM AUTHOR]

Objective: Compare EGS patient outcomes after index and nonindex hospital readmissions, and explore predictive factors for nonindex readmission. Background: Readmission to a different hospital leads to fragmentation of care. The impact of nonindex readmission on patient outcomes after EGS is not well established. Methods: The Nationwide Readmissions Database (2017) was queried for adult patients readmitted after an EGS procedure. Patients were stratified and propensity-matched according to readmission destination: index versus nonindex hospital. Outcomes were failure to rescue (FTR), mortality, number of subsequent readmissions, overall hospital length of stay, and total costs. Hierarchical logistic regression was performed to account for clustering effect within hospitals and adjusting for patient- and hospital-level potential confounding factors. Results: A total of 471,570 EGS patients were identified, of which 79,127 (16.8%) were readmitted within 30 days: index hospital (61,472; 77.7%) versus nonindex hospital (17,655; 22.3%). After 1:1 propensity matching, patients with nonindex readmission had higher rates of FTR (5.6% vs 4.3%; P < 0.001), mortality (2.7% vs 2.1%; P < 0.001), and overall hospital costs [in $1000; 37 (27–64) vs 28 (21–48); P < 0.001]. Nonindex readmission was independently associated with higher odds of FTR [adjusted odds ratio 1.18 (1.03–1.36); P < 0.001]. Predictors of nonindex readmission included top quartile for zip code median household income [1.35 (1.08–1.69); P < 0.001], fringe county residence [1.08 (1.01–1.16); P = 0.049], discharge to a skilled nursing facility [1.28 (1.20–1.36); P < 0.001], and leaving against medical advice [2.32 (1.81–2.98); P < 0.001]. Conclusion: One in 5 readmissions after EGS occur at a different hospital. Nonindex readmission carries a heightened risk of FTR. Level of Evidence: Level III Prognostic. Study Type: Prognostic. [ABSTRACT FROM AUTHOR]

Purpose: To examine the impact of in situ simulation (ISS) with scripting on nursing staff's knowledge and confidence to initiate rapid response teams (RRTs) immediately after identifying patient condition deterioration. Background/Significance: Failure to rescue (FTR) related to delays in activation of RRT is on the rise, leading to poor patient outcomes. Lack of confidence, knowledge, and empowerment are associated with delayed activation of RRTs. As such, the nursing staff's confidence is integral in activating RRTs and FTR prevention. In situ simulation may help nurses increase their confidence, thus empowering timely RRT initiation. Methods: This quantitative pretest-posttest study used a convenience sample of nurses and nursing assistants. First, participants completed the Rapid Response Team Survey (RRTS) pretest. Then, they participated in the ISS scenario. Lastly, they completed debriefing and the RRTS posttest. Results: Pearson's correlation results showed no significant relationships between the variables. Dependent t-test results showed statistically significant increases between the pretest and posttest means (Part l, t = -5.51, p < .001, MD = 1.32; Part 2, t = -1.04, p < .01, MD = 3.1). These results suggest that ISS with scripting increased participants' knowledge and confidence in early activation of RRTs. Additionally, staff reported feeling more confident and empowered regarding future RRT decision-making and communication with other healthcare colleagues. Discussion: Early activation of RRTs prevents FTR. The results of this study suggest ISS with scripting increases staff's knowledge, confidence, and empowerment to activate RRTs. We recommend that hospital organizations adopt ISS with scripting to empower nurses to activate RRTs to prevent FTR. [ABSTRACT FROM AUTHOR]

Many deaths after surgery can be attributed to "failure to rescue," which may be a better surgical quality indicator than the occurrence of a postoperative complication. Acute kidney injury (AKI) is one such postoperative complication associated with high mortality. The purpose of this study is to identify perioperative risk factors associated with failure to rescue among patients who develop postoperative AKI. We identified adult patients who underwent non–cardiac surgery between 2012 and 2018 and experienced postoperative severe AKI (an increase in blood creatinine concentration of >2 mg/dL above baseline or requiring hemodialysis) from the American College of Surgeons National Surgical Quality Improvement Program database. Multivariable logistic regression was used to identify risk factors for failure to rescue among patients who developed severe AKI. Among 5,765,904 patients who met inclusion criteria, 26,705 (0.46%) patients developed postoperative severe AKI, of which 6834 (25.6%) experienced failure to rescue. Risk factors with the strongest association (adjusted odds ratio >1.5) with failure to rescue in patients with AKI included advanced age, higher American Society of Anesthesiologists class, presence of preoperative ascites, disseminated cancer, septic shock, and blood transfusion within 72 h of surgery start time. About one-fourth of patients who develop severe AKI after non–cardiac surgery die within 30 d of surgery. Both patient- and surgery-related risk factors are associated with this failure to rescue. Further studies are needed to identify early and effective interventions in high-risk patients who develop postoperative severe AKI to prevent the antecedent mortality. [ABSTRACT FROM AUTHOR]

Background: Quality standards in postoperative outcomes have not yet been defined for gastric cancer surgery. Also, the effect of centralization of gastric cancer surgery on the improvement of postoperative outcomes continues to be debated. Short-term postoperative outcomes in gastric carcinoma patients in centers with low-volume of annual gastrectomies were assessed. The effect of age on major postoperative morbidity and mortality was also analyzed. Methods: Patients with gastric or gastroesophageal junction Siewert III type carcinomas who underwent surgical treatment with curative intent between January 2013 and December 2016 were included. Data were obtained from the population-based surgical registry Esophagogastric Carcinoma Registry of the Comunitat Valenciana (RECEG-CV). The RECEG-CV gathers information on demographic characteristics and comorbidity, preoperative study and neoadjuvant treatment, surgical procedure, pathological study, postoperative outcomes, and follow-up. Seventeen hospitals belonging to the public network participated in this registry. Results: Data from 591 patients were analyzed. Postoperative major morbidity occurred in 154 (26.1%) patients. Overall 30-day or in-hospital mortality, and 90-day postoperative mortality rates were 8.6% and 10.1% respectively. Failure-to-rescue was 39% and it was significantly higher in patients aged 75 years or older in comparison with younger patients (55.3% vs 23.1% p < 0.001). In the multivariable analysis, age ≥ 75 years (p = 0.029), laparoscopic approach (p = 0.005), and total gastrectomy (p = 0.005) were associated with major postoperative morbidity. Age ≥ 75 years (p = 0.027), pulmonary complications (p = 0.001), cardiac complications (p = 0.001), leakage (p = 0.003), and hemorrhage (p = 0.013) were associated with postoperative mortality. Conclusions: Centralization of gastric adenocarcinoma treatment in centers with higher annual caseload should be considered to improve the short-term postoperative outcomes in low-volume centers. Patients aged 75 or older had a significantly increased risk of major postoperative morbidity and mortality, and higher failure-to-rescue. [ABSTRACT FROM AUTHOR]

• There is an inverse dose-dependent relationship between FTR and gestational age. • The dose-dependent relationship was consistent for both low- and high-risk procedures. • A lone infection point for FTR was identified at 31-32 weeks with cubic spline analysis. The majority of failure to rescue (FTR), or death after a postoperative complication, in pediatric surgery occurs among infants and neonates. The purpose of this study is to evaluate the association between gestational age (GA) and FTR in infants and neonates. National cohort study of 46,452 patients < 1 year old within the National Surgical Quality Improvement Program–Pediatric database who underwent inpatient surgery. Patients were categorized as preterm neonates, term neonates, or infants. Neonates were stratified based on GA. Surgical procedures were classified as low- (< 1% mortality) or high-risk (≥ 1%). Multivariable logistic regression and cubic splines were used to evaluate the association between GA and FTR. Preterm neonates had the highest FTR (28%) rates. Among neonates, FTR increased with decreasing GA (≥ 37 weeks, 12%; 33–36 weeks, 15%; 29–32 weeks, 30%; 25–28 weeks 41%; ≤ 24 weeks, 57%). For both low- and high-risk procedures, FTR significantly (trend test, p < 0.01) increased with decreasing GA. When stratifying preterm neonates by GA, all GAs ≤ 28 weeks were associated with significantly higher odds of FTR for low- (OR 2.47, 95% CI [1.38–4.41]) and high-risk (OR 2.27, 95% CI [1.33–3.87]) procedures. A lone inflection point for FTR was identified at 31–32 weeks with cubic spline analysis. The dose-dependent relationship between decreasing GA and FTR as well as the FTR inflection point noted at GA 31–32 weeks can be used by stakeholders in designing quality improvement initiatives and directing perioperative care. Level IV, Retrospective cohort study [ABSTRACT FROM AUTHOR]

Objective: To describe the frequency and patterns of postoperative complications and FTR after inpatient pediatric surgical procedures and to evaluate the association between number of complications and FTR. Summary and Background: FTR, or a postoperative death after a complication, is currently a nationally endorsed quality measure for adults. Although it is a contributing factor to variation in mortality, relatively little is known about FTR after pediatric surgery. Methods: Cohort study of 200,554 patients within the National Surgical Quality Improvement Program-Pediatric database (2012–2016) who underwent a high (≥ 1%) or low (< 1%) mortality risk inpatient surgical procedures. Patients were stratified based on number of postoperative complications (0, 1, 2, or ≥3) and further categorized as having undergone either a low- or high-risk procedure. The association between the number of postoperative complications and FTR was evaluated with multivariable logistic regression. Results: Among patients who underwent a low- (89.4%) or high-risk (10.6%) procedures, 14.0% and 12.5% had at least 1 postoperative complication, respectively. FTR rates after low- and high-risk procedures demonstrated step-wise increases as the number of complications accrued (eg, low-risk— 9.2% in patients with ≥3 complications; high-risk—36.9% in patients with ≥ 3 complications). Relative to patients who had no complications, there was a dose-response relationship between mortality and the number of complications after low-risk [1 complication – odds ratio (OR) 3.34 (95% CI 2.62–4.27); 2 – OR 10.15 (95% CI 7.40–13.92); ≥3-27.48 (95% CI 19.06-39.62)] and high-risk operations [1 – OR 3.29 (2.61–4.16); 2–7.24 (5.14–10.19); ≥3–20.73 (12.62–34.04)]. Conclusions: There is a dose-response relationship between the number of postoperative complications after inpatient surgery and FTR, ever after common, "minor" surgical procedures. These findings suggest FTR may be a potential quality measure for pediatric surgical care. [ABSTRACT FROM AUTHOR]

Aims and Objectives: To examine the non‐linear dose‐response associations between nurse staffing levels and patient outcomes using a nationwide inpatient database in Japan. Background: Previous studies showed that higher nurse staffing levels were associated with better patient outcomes. However, it remains unclear whether there are thresholds for the associations between higher nurse staffing levels and improved patient outcomes. Designs: Retrospective observational study design following the STROBE guideline. Methods: We identified all patients aged ≥20 years who underwent one of six major cancer surgeries between July 2010 and March 2018 using data from the Diagnosis Procedure Combination database, a nationwide database for acute‐care inpatients in Japan. Restricted cubic spline regression analyses, the statistical method that allows non‐linear functional form, were performed with several scenarios of cut‐off points to examine the dose‐response associations between patient‐to‐nurse ratio per shift and failure to rescue, 30‐day in‐hospital mortality and postoperative complications. Results: Among 645,687 patients, restricted cubic spline regression analyses showed insignificant associations of patient‐to‐nurse ratio with failure to rescue and 30‐day in‐hospital mortality with no threshold, but a reverse J‐shaped association with postoperative complications with a threshold of patient‐to‐nurse ratio per shift of 5.4. Conclusions: In terms of postoperative complications, additional registered nurses were associated with decreased postoperative complications. However, this incremental benefit of additional registered nurses may disappear if hospitals allocate five to six number of registered nurses in general wards. Relevance to Clinical Practice: This study suggested that additional registered nurses over one per five to six patients may not bring the incremental benefit to decrease postoperative complications. [ABSTRACT FROM AUTHOR]

A cascade of complications is believed to be the primary mechanism underlying failure to rescue (FTR), or death of a patient after a postoperative complication. It is unknown whether specific types of index complications are associated with the incidence of secondary complications and FTR after pediatric surgery. National cohort study of patients within the National Surgical Quality Improvement Program–Pediatric database who underwent inpatient surgery (2012–2019). Index complications were grouped into nine categories (cardiovascular, venous thromboembolism, pulmonary, bleeding/transfusion, renal, central nervous system, wound, infectious, or minor [defined as having an associated mortality rate <1%]). The association between the type of index complication with FTR, secondary complications, reoperation, unplanned readmission, and postoperative length of stay was evaluated with multivariable logistic regression and generalized linear modeling. Among 425,386 patients, 15.5% had at least one complication, 16.6% had one or more secondary complications, 13.9% reoperation, 14.5% readmission, and 2.4% FTR. Secondary complication (10.8–59.7%) and FTR (0.3–31.1%) rates varied by type of index complication. Relative to patients who had an index minor complication, those with an index infectious complication were most likely to have secondary complication (Odds Ratio [OR] 10.3, 95% CI [9.36–11.4]). Index CV complications were most strongly associated with FTR (OR 30.7 [24.0–39.4]). Index wound complications had the greatest association with reoperation (OR 21.9 [20.5–23.4]) and readmission (OR 18.7 [17.6–19.9]). Index pulmonary complications had the strongest association with length of stay (coefficient 9.39 [8.95–9.83]). Different types of index complications are associated with different perioperative outcomes. These data can help identify patients potentially at risk for suboptimal outcomes and can inform pediatric quality improvement interventions. Cohort study. Level II. [ABSTRACT FROM AUTHOR]

Study Aim: The aim of this study is to investigate the impact of alarm configuration tactics in general care settings. Methods: Retrospective analysis of over 150,000 hours of medical/surgical unit continuous SpO2 and pulse rate data were used to estimate alarm rates and impact on individual nurses. Results: Application of an SpO2 threshold of 80% vs 88% produced an 88% reduction in alarms. Addition of a 15 second annunciation delay reduced alarms by an additional 71% with an SpO2 threshold of 80%. Pulse rate alarms were reduced by 93% moving from a pulse rate high threshold of 120–140 bpm, and 95% by lowering the pulse rate low threshold from 60 to 50 bpm. A 15 second annunciation delay at thresholds of 140 bpm and 50 bpm resulted in additional reductions of 80% and 81%, respectively. Combined alarm frequency across all parameters for every 24 hours of actual monitored time yielded a rate of 4.2 alarms for the surveillance configuration, 83.0 alarms for critical care monitoring, and 320.6 alarms for condition monitoring. Total exposure time for an individual nurse during a single shift ranged from 3.6 min with surveillance monitoring, to 1.2 hours for critical care monitoring, and 5.3 hours for condition monitoring. Conclusions: Continuous monitoring can eliminate unwitnessed/unmonitored arrests associated with significant increased mortality in the general care setting. The “alarm problem” associated with these systems is manageable using alarm settings that signify severely abnormal physiology to alert responsible clinicians of urgent situations.

"Practice makes perfect" is an old saying that can be true for complex interventions. There is a strong and persistent relationship between high volume and better outcomes with more than 300 studies being reported on the subject. The more complex the procedure, the greater the volume-outcome relationship is. Failure to rescue was shown to be one of the factors explaining higher mortality rates post complex surgery. High-volume centers provide a better safety net, thanks to the structure and better protocols, and low-volume operators have better results at high-volume centers than at low-volume centers. Finally, effort should be made to regroup complex procedures in high-volume centers, but without compromising patient access to the procedures. Adaptation to local and geographic constraints is important. [ABSTRACT FROM AUTHOR]

Objectives: Out-of-hours discharge from ICU to the ward is associated with increased in-hospital mortality and ICU readmission. Little is known about why this occurs. We map the discharge process and describe the consequences of out-of-hours discharge to inform practice changes to reduce the impact of discharge at night.Design: This study was part of the REcovery FoLlowing intensive CarE Treatment mixed methods study. We defined out-of-hours discharge as 16:00 to 07:59 hours. We undertook 20 in-depth case record reviews where in-hospital death after ICU discharge had been judged "probably avoidable" in previous retrospective structured judgment reviews, and 20 where patients survived. We conducted semistructured interviews with 55 patients, family members, and staff with experience of ICU discharge processes. These, along with a stakeholder focus group, informed ICU discharge process mapping using the human factors-based functional analysis resonance method.Setting: Three U.K. National Health Service hospitals, chosen to represent different hospital settings.Subjects: Patients discharged from ICU, their families, and staff involved in their care.Interventions: None.Measurements and Main Results: Out-of-hours discharge was common. Patients and staff described out-of-hours discharge as unsafe due to a reduction in staffing and skill mix at night. Patients discharged out-of-hours were commonly discharged prematurely, had inadequate handover, were physiologically unstable, and did not have deterioration recognized or escalated appropriately. We identified five interdependent function keys to facilitating timely ICU discharge: multidisciplinary team decision for discharge, patient prepared for discharge, bed meeting, bed manager allocation of beds, and ward bed made available.Conclusions: We identified significant limitations in out-of-hours care provision following overnight discharge from ICU. Transfer to the ward before 16:00 should be facilitated where possible. Our work highlights changes to help make day time discharge more likely. Where discharge after 16:00 is unavoidable, support systems should be implemented to ensure the safety of patients discharged from ICU at night. [ABSTRACT FROM AUTHOR]

As the only healthcare providers caring for hospitalized patients every hour of every day, nurses have a responsibility to keep patients safe. Physical assessment is a basic but essential nursing skill that fosters patient safety. Assessing a patient's current status enables nurses to recognize early patient deterioration. Contemporary nursing practice relies on vital signs and technology to aid in the detection of patient deterioration. The aim is to describe the Methodist Proficient Assessment Competency (MPAC©) quality improvement initiative. Surveys and directly observed patient assessment data were used to evaluate attitudes and practices. One hundred and seventy‐nine pre‐MPAC audits were conducted, followed by 1391 post‐MPAC audits. Pre‐ compared with post‐MPAC audits showed significant improvements in complete physical assessments (78% vs. 94%; p <.001), timeliness (within 4 h; 64% vs. 91%; p <.001) and accuracy (67% vs. 95%; p <.001) of documentation. In conclusion, nurses have a responsibility to quickly identify changes in a patient's condition and intervene to prevent serious adverse events. Taking the needed time to perform a full physical assessment at the beginning of the shift along with timely and accurate documentation, allows nurses to acquire the knowledge they need to establish a patient's current clinical status and usual behaviors, thereby facilitating early recognition of subtle changes that could indicate deterioration. [ABSTRACT FROM AUTHOR]

Objective: The ability to detect and treat complications of surgery early is essential for optimal patient outcomes. The failure-to-rescue (FTR) rate is defined as the death rate among patients who develop at least one complication after the surgical procedure and may be used to monitor a hospital's quality of surgical care. The aim of this observational study was to explore FTR in Norway and to see if we could identify surgical trajectories associated with high FTR.Method: Data on all abdominal surgeries in Norwegian hospitals from 2011 to 2017 were obtained from the Norwegian Patient Registry and linked with the National Population Register. Surgical and other postoperative complication rates and FTR within 30 days (deaths occurring in and out of the hospital) were assessed. We identified surgical trajectories (type of procedures-type of complication-dead/alive at 30 days after operation) associated with the highest volume of deaths (high volume of FTR [FTR-V]) and highest risk of death after a postoperative complication.Results: Of the total 626 052 primary abdominal procedures, 224 871 (35.8%) had at least one complication, which includes 83 037 patients. The most common postoperative complications were sepsis (N = 14 331) and respiratory failure (N = 7970). The high-volume trajectories (FTR-V) were endoscopic retrograde cholangiopancreatography-sepsis-death (N = 294, 13.8%); open colon resections-sepsis-death (N = 279, 28.1%) and procedures with stoma formation-sepsis-death (N = 272, 27%). Similarly, patients operated with embolectomy of the visceral arteries and experiencing postoperative sepsis were associated with an extremely high risk of 30-day FTR of 81.5%. In general, an FTR patient had a higher mean age, an increased rate of emergency surgery and more comorbidity. Hospital size was not associated with FTR.Conclusion: At a national level, there exist high-volume and high-risk surgical trajectories associated with FTR. These trajectories represent major targets for quality improvement initiatives. [ABSTRACT FROM AUTHOR]