Elsevier

Surgery

Volume 157, Issue 4, April 2015, Pages 752-763
Surgery

Trauma/Critical Care
A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery

https://doi.org/10.1016/j.surg.2014.10.017Get rights and content

Background

The relationship between the ability to recognize and respond to patient deterioration (escalate care) and its role in preventing failure to rescue (FTR; mortality after a surgical complication) has not been explored. The aim of this systematic review was to determine the incidence of, and factors contributing to, FTR and delayed escalation of care for surgical patients.

Methods

A search of MEDLINE, EMBASE PsycINFO, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials was conducted to identify articles exploring FTR, escalation of care, and interventions that influence outcomes. Screening of 19,887 citations led to inclusion of 42 articles.

Results

The reported incidence of FTR varied between 8.0 and 16.9%. FTR was inversely related to hospital volume and nurse staffing levels. Delayed escalation occurred in 20.7–47.1% of patients and was associated with greater mortality rates in 4 studies (P < .05). Causes of delayed escalation included hierarchy and failures in communication. Of five interventional studies, two reported a significant decrease in intensive care admissions (P < .01) after introduction of escalation protocols; only 1 study reported an improvement in mortality.

Conclusion

This systematic review explored factors linking FTR and escalation of care in surgery. Important factors that contribute to the avoidance of preventable harm include the recognition and communication of serious deterioration to implement definitive treatment. Targeted interventions aiming to improve these factors may contribute to enhanced patient outcome.

Section snippets

Data sources

The databases searched included Ovid MEDLINE (1980 to week 2, November 2012), EMBASE (1980 to week 2, November 2012), PsycINFO (1987 to week 2, November 2012), the Cochrane Database of Systematic Reviews (Issue 10, 2012), and the Cochrane Central Register of Controlled Trials (Issue 10, 2012). Conference abstracts and reference lists of included articles were hand searched to identify additional relevant data. The grey literature (work lacking bibliographic control) was searched using Google.

Search strategy

Results

The search produced 19,887 citations with 9,414 remaining after limits were applied and duplicates removed. Of these, 8,566 articles were excluded after title review leaving 848 abstracts for further scrutiny. Abstract review led to exclusion of a further 781 articles, leaving 67 for full-text evaluation. Thirty-eight of these articles met the inclusion criteria. A hand search of relevant article references and associated literature identified 4 additional articles that fulfilled the inclusion

Discussion

This review identified the incidence of FTR, and factors leading to increased rates of FTR and delayed escalation of care. Our approach also evaluated interventions aiming to prevent adverse outcomes on surgical wards. In doing so, a link between delayed escalation of care and FTR was highlighted and suggests the important role that communication and teamwork can play in the avoidance of adverse events.

Multiple studies showed that mortality rates differ significantly between different hospitals

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    Funding: This review article received no direct funding. Johnston, Arora, King, Almoudaris, Davis, and Darzi are affiliated with the Imperial Patient Safety Translational Research Centre, which receives center funding from the National Institute for Health Research (UK). The grant number is 40490.

    Registration: This systematic review was registered with the International Prospective Register of systematic reviews (PROSPERO) ID - CRD42013004080.

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