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Failure to Rescue in the NICU: What Do We know and What Are the Implications?

Alyssa B. Weiss, PhD NNP-BC

Quality care is a foundational element of the nursing profession yet can be impacted by the failure to rescue patients in nurses’ care. The Agency for Healthcare Research and Quality (AHRQ) (2019) describes the concept of failure to rescue (FTR) as the ability of healthcare systems to identify and treat complications which are caused by medical care.

Failure to rescue (FTR) was first described by Silber et al. (1992) as the probability of death following a complication in the hospital. The concept was originally applied to adults in the hospital who died from complications postoperatively, such as pulmonary embolism or sepsis. The original study was a retrospective chart review with statistical results presented that evaluated number and types of surgeries, the types of hospitals performing these interventions, specific procedures, and the complications that caused the demise. Subsequently, Needleman et al. (2002) took nurse-sensitive outcomes and linked them to adequate nurse staffing levels, concluding that patient’s outcomes were improved and FTR decreased when patients spent more time with a nurse. Hospital systems continue to use nurse-sensitive outcomes in the measurement of FTR events.

The impact of nurses on FTR has been extensively studied in adult populations. A recent concept analysis by Mushta et al. (2018) identified nursing failures as a cause of FTR; these failures included ineffective decision making, failure to recognize, failure to escalate, and errors of omission. However, a nurse’s ability to provide vigilant surveillance is largely dependent on staffing decisions, which are often made by management, not bedside nurses (Clarke & Aiken, 2003). An additional contributor to FTR, as described by nurses, is the challenge of using the electronic health record (EHR). Nurses noted difficulty in synthesizing information and conveying their clinical reasoning, challenges in documenting clinical events (which are deemed precursors to FTR), and the inhibition of multidisciplinary communication due to the EHR (Wisner et al., 2019; Carrington & Effken, 2011).

Perinatal and neonatal care differ dramatically from care of adult populations described in most FTR studies. According to the Centers for Disease Control and Prevention National Vital Statistics System for 2018, neonatal deaths occur at a rate of 3.78 per 1000 live births (Ely & Driscoll, 2019). Because FTR is not generally calculated in the perinatal or neonatal context, it is not known to what extent FTR impacts these mortality rates. Gephart et al. (2011) began an evaluation into potential causes of FTR events in the NICU. Through the literature review, the authors discussed factors contributing to FTR. These included clinical deterioration, organizational factors, potential for error in complicated environments, and communication failures.

Contributors to FTR in the NICU

Communication

A prominent theme in the literature review of perinatal and neonatal FTR was communication. Miscommunication has the potential to lead to an FTR event (Simpson, 2005; Gephart et al., 2011; Lyndon, 2019). Examples of miscommunication include issues that are not clearly articulated and when information provided is lacking. A solution to address these issues is structured reporting formats, such as the SBAR (situation, background, assessment, recommendation, reasoning, ratification) (Lyndon, 2019; Ivory, 2014; Gephart et al., 2011). Miscommunication can also occur through how information is received. Utilizing a reverse SBAR format when receiving information (set aside assumptions, be attentive, ask questions, reflect, respond, ratify) can reduce this type of miscommunication (Lyndon, 2019). Effective communication requires verification and clarification of unclear reports (Gephart et al., 2011).

Lack of documentation has been described as a potential cause for FTR. Examples include missed care such as incomplete patient histories, vital signs, standards-based documentation, and assessments (Simpson et al., 2016).  As an example, poor emergency response documentation may lead to assumptions that appropriate escalation did not occur even though proper procedures were followed (Beaulieu, 2009). Workflow interruptions and understaffing are well-described contributors to problems with communication and documentation (Gephart et al., 2011; Simpson et al., 2016).

Timely Recognition

Understanding signs and symptoms of deterioration are imperative in avoiding FTR. Timely recognition is achieved through vigilance and monitoring (Simpson, 2005; Beaulieu, 2009; Gephart et al., 2011; Hastings-Tolsma & Nolte, 2014; Simpson et al., 2016). Factors that contribute to the inability to recognize deterioration in a timely manner include inexperience, understaffing, fatigue, and missed care (Gephart et al., 2011).

Nursing Workload

The increasing workload for nurses is an accepted contributor to FTR events. Hospitalized patients receive the majority of their care by registered nurses (Butler et al., 2018). Increased patient loads, and understaffing have left nurses feeling that their ability to support patients has been significantly decreased (Simpson et al., 2016). This is reflected in the findings of Friedman et al. (2016), who found that risk of FTR was increased in high-volume obstetrical units due to insufficient nurse staffing.

Neonatal FTR Deserving of Study

Factors influencing FTR have been focused on nursing practice but the evidence in this review demonstrates FTR as a systems’ issue due to challenges of communication, timely recognition, and nursing workloads. There is a paucity of formal research in neonatal FTR with much of the current FTR literature focused on adults, not the unique system and patient needs of neonates. The traditional definition of FTR does not align with the care provided to neonatal populations because premature birth is an adverse event at its core and not a complication as understood in adult populations. FTR in the NICU is being studied, and the results will be shared at NANN’s 38th Annual Conference in 2022.

References

• Agency for Healthcare Research and Quality. (2019). https://psnet.ahrq.gov/primer/failure-rescue
• Beaulieu, M. J. (2009). Failure to rescue as a process measure to evaluate fetal safety during labor. MCN. The American Journal of Maternal Child Nursing, 34(1), 18–23. https://doi.org/10.1097/01.NMC.0000343861.64614.c9
• Butler, R., Monsalve, M., Thomas, G. W., Herman, T., Segre, A. M., Polgreen, P. M., & Suneja, M. (2018). Estimating time physicians and other health care workers spend with patients in an intensive care unit using a sensor network. The American Journal of Medicine, 131(8), 972.e9–972.e15. https://doi.org/10.1016/j.amjmed.2018.03.015
• Carrington, J. M., & Effken, J. A. (2011). Strengths and limitations of the electronic health record for documenting clinical events. Computers, Informatics, Nursing:CIN, 29(6), 360–367. https://doi.org/10.1097/NCN.0b013e3181fc4139
• Clarke, S. P. & Aiken, L. H. (2003). Failure to rescue: Needless deaths are prime examples of the need for more nurses at the bedside. American Journal of Nursing, 103(1), 42-47.
• Ely, D. M. & Driscoll, A. K. (2019). Infant mortality in the United States, 2017: Data from the period linked birth/infant death file. National Vital Statistics Reports, 68(10). https://www.cdc.gov/nchs/products/nvsr.htm
• Friedman, A. M., Ananth, C. V., Huang, Y., D’Alton, M. E., & Wright, J. D. (2016). Hospital delivery volume, severe obstetrical morbidity, and failure to rescue. American Journal of Obstetrics and Gynecology, 215(6), 795.e1–795.e14. https://doi.org/10.1016/j.ajog.2016.07.039
• Gephart, S. M., McGrath, J. M., & Effken, J. A. (2011). Failure to rescue in neonatal care. The Journal of Perinatal & Neonatal Nursing, 25(3), 275–282. https://doi.org/10.1097/JPN.0b013e318227cc03
• Hastings-Tolsma, M., & Nolte, A. G. (2014). Reconceptualising failure to rescue in midwifery: a concept analysis. Midwifery, 30(6), 585–594. https://doi.org/10.1016/j.midw.2014.02.005
• Ivory, C. H. (2014). Standardizing the words nurses use to document elements of perinatal failure to rescue. Journal of Obstetric, Gynecologic, and Neonatal Nursing: JOGNN, 43(1), 13–24. https://doi.org/10.1111/1552-6909.12273
• Lyndon, A. (2019). Failure to Rescue, Communication, and Safety Culture. Clinical Obstetrics and Gynecology, 62(3), 507–517. https://doi.org/10.1097/GRF.0000000000000461
• Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002). Nurse-staffing levels and the quality of care in hospitals. The New England Journal of Medicine, 346(22), 1715–1722. https://doi.org/10.1056/NEJMsa012247
• Mushta, J., Rush, K. L., & Andersen, E. (2018). Failure to rescue as a nurse-sensitive indicator. Nursing Forum, 53(1), 84–92. https://doi.org/10.1111/nuf.12215
• Silber, J. H., Williams, S. V., Krakauer, H., & Schwartz, J. S. (1992). Hospital and patient characteristics associated with death after surgery. A study of adverse occurrence and failure to rescue. Medical Care, 30(7), 615–629. https://doi.org/10.1097/00005650-199207000-00004
• Simpson, K. R. (2005). Failure to rescue: implications for evaluating quality of care during labor and birth. The Journal of Perinatal & Neonatal Nursing, 19(1), 24–36. https://doi.org/10.1097/00005237-200501000-00008
• Simpson, K. R., Lyndon, A., & Ruhl, C. (2016). Consequences of inadequate staffing include missed care, potential failure to rescue, and job stress and dissatisfaction. Journal of Obstetric, Gynecologic, and Neonatal Nursing: JOGNN, 45(4), 481–490. https://doi.org/10.1016/j.jogn.2016.02.011
• Wisner, K., Lyndon, A., & Chesla, C. A. (2019). The electronic health record’s impact on nurses’ cognitive work: An integrative review. International Journal of Nursing Students, 94, 74-84. https://doi.org/10.1016/j.ijnurstu.2019.03.003

Disclaimer: The information presented and opinions expressed herein are those of the author and do not necessarily represent the views of the National Association of Neonatal Nurses.

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