Failure to Rescue

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Failure to Rescue

• Jenny Hopkins, RN, CCRN

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Definitions

• Pre-arrest ? life-threatening event that requires
  rapid identification and intervention to prevent
  arrest
• Failure to rescue ? inability to save a patients
  life after the development of a complication that
  was not present on admission

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Recognizing Pre-Arrest Phase

• Importance of practice guidelines for clinical
  conditions such as acute coronary syndrome ?
  evidence-based protocols
• Attuned to at risk patients ? increased
  surveillance and early intervention ? increased
  survival

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Vigilance/Surveillance

• A state of watchful attention, of maximal
  physiological and psychological readiness to act
  and of having the ability to detect and react to
  danger.

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Most in-hospital cardiac arrests are not sudden
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Research Findings and Best Practice

• Somewhere between 50-84 of in-hospital cardiac
  arrests are preceded by physiologic instability
  Med J Aust 2003 179(6) 283-287
• Good Education and Vigilance
• Increasing RRT responses will reduce arrests and
  unexpected transfers outside ICUExempla St.
  Josephs Hospital Denver Colorado

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Anecdotal Findings

• Trending of some physiologic data is missing or
  incomplete in chart review
• Notifying physician of abnormal labs
• Patterns are evident up to 3 days before death
  but patterns are subtle

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Prevention of Failure-to-Rescue

• Good history
• Thorough physical examination
• Lab data
• Look at trends over time
• Pay attention to subtle changes
• Good RN-physician communication

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SBAR

• S Situation
• B Background
• A Assessment
• R Recommendation

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Failure-to-Rescue does not necessarily imply
wrongdoing
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Physical Changes

• Respiratory rate
• Heart rate
• Sodium, potassium
• Oxygen saturation
• Body temperature
• Restlessness, changes in LOC
• Skin changes

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Prevention

• Anticipating the unexpected ? and monitor for
  potential complications
• Recognizing the problem ? synthesizing all the
  patient data (putting the pieces together) paying
  attention to trends and patterns (reflective
  practice)
• Rapid mobilization of resources ? rapid response
  team

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Rapid Response Teams
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Why a RRT?

• Rapid response teams bridge the divide between
  hospital units by bringing the expertise of
  emergency and critical care specialists to the
  hospital unit
• Primary objective is to improve the care and
  safety of individual patients
• Provide an opportunity for on-the-job learning by
  floor nurses as they participate in the team's
  response to a particular clinical event
• Promote a culture of safety by building teamwork
  and spreading knowledge and skills throughout a
  hospital

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Benefits of a RRT

• Decrease morbidity and mortality
• Decreased cardiopulmonary arrests
• Decreased deaths

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Criteria for Calling the RRT

• Staff member concerned/worried about the patient
• Acute change in heart rate lt 50 or gt130 beats
  per minute
• Acute change in systolic blood pressure lt 90
  mm/Hg or gt200 mm/Hg
• Diastolic BP gt100
• Acute change in respiratory rate lt 8 or gt30
  breaths/minute or threatened airway
• Acute change in blood oxygen saturation SpO2 lt
  90 despite oxygen
• Increasing O2 needs
• Acute change in mental status delirium,
  confusion, etc.
• New, repeated, or prolonged seizures
• Urine Output lt50mL/4 hrs
• Cardiac Rhythm Changes
• Acute significant bleeding
• Failure to respond to treatment for an acute
  problem/symptom

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How To Activate Rapid Response

• Dial 2555
• Ask Switchboard to page the Rapid Response Team
  to go to Rm _____

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Rapid Response Team Protocols

• ACLS and arrhythmia protocols will be followed
  unless other orders are written
• Administer oxygen, airway insertion, and use ambu
  bag with positive pressure ventilation
• In an emergency situation, may order and draw
  ABGs when patient is in respiratory distress.
• Administer U.D. Duoneb or U.D. Racemic
  Epinephrine as indicated
•  Chest xray
•  EKG
•  Nasopharyngeal or nasotracheal suction.
• Start an IV of D5W or NS until physician arrives.
• Accucheck, if BS lt 70 , administer 1 amp
  D50
• Naloxone 1/2 - 1 amp IV if patient received
  opiods recently or narcotic overdose suspected
• Romazicon 0.3mg IV for a suspected benzodiazepine
  oversedation.

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Success Depends on Culture

• Good communication
• Collaboration
• Empowers nurses to make decisions and intervene
  early
• Interdisciplinary resources

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Success Depends on Building Expertise

• Assessment skills
• Psychomotor skills
• Knowing when and how to mobilize resources
• Knowledge base

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Updated RRT Stats FY2010

• of RRT calls to date 77 YTD (31 increase)
• Over 400 RRT calls since 12/2005
• RRT call locations 50 3N / 40 2N
• RRT calls by time of day 39 (Day) 34(Eve)
  27 (Nights)
• Nurse Satisfaction YTD 77calls / 28
  surveys4.5-5.0 score for all survey questions
• Outcome changes FY 2010
• 65 stayed on unit (? 1)
• 34 transferred to ICU (?1)
• 84 Survived to discharge from hospital (? 1)