Table 39 'Failure to Rescue'

PSI 39: Failure to Rescue
Origin: Review of an AHRQ PSI (3)
Dimension Description
Description of Specific
Aspects of Patient Safety
Complications might occur in any care process – though good hospitals
identify such complications quickly and treat them aggressively to
avoid further complications and deaths.
Aim of the PSI The PSI aims at surveillance of patients who die following the
development of a complication.
Level of Determination of
Patient Safety
Safety can be assessed at the individual and the aggregated patient
level.
Source(s) This indicator was originally proposed by Silber et al. as a more
powerful tool than the risk-adjusted mortality rate. The Indicator is
intended to detect true differences in patient outcomes across hospitals.
The underlying premise was that better hospitals are distinguished not
by having fewer adverse occurrences but by more successfully
treatment of patients who experience complications.
Extent of Clinically
Testing
The project team developing the AHRQ PSI conducted extensive
empirical analyses on this PSI. The team concluded that this PSI
generally performs well on several different dimensions, including
reliability, bias, relatedness of indicators, and persistence over time.
AHRQ-Panellists noted that 1) this PSI is fundamentally different than
other AHRQ PSIs, as it reflects effectiveness in rescuing a patient
from a complication versus preventing a complication and 2) several
adverse incentives may be introduced by implementing this indicator.
In particular, since some type of adjustment may be desirable, this
indicator may encourage the up coding of complications and comorbidities
to inflate the denominator or manipulate risk adjustment.
Others noted that this indicator could encourage irresponsible resource
use and allocation, although this is likely to be a controversial idea.
Finally, panellists emphasised that this indicator should be used
internally by hospitals, as it is not validated for public reporting. (3).
The AHRQ PSI software was applied to Veteran Affairs (VA)
administrative data to identify potential instances of compromised
patient safety; determine occurrence rates of PSI events in the VA;
and examine the construct validity of the PSIs. The study population
was 97% male, with a mean age of 65 years, 54% were age 65 and
older. All together 11411 PSI events were identified, 46% of PSI
events occurred in surgical hospitalisation and 54% in medical
hospitalisation. The observed PSI rate per 1000 discharges was 155.55
for failure to rescue, the highest rate observed among all AHRQ PSIs.
This PSI was significantly associated with the AHRQ PSIs for Death
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in low-mortality DRGs, postoperative pulmonary embolism or deep
vein thrombosis, technical difficulties with procedure and decubitus
ulcer. Significant differences were found for hospitalisations with PSI
and those without PSI events for longer lengths of stay and higher
costs (4).
The performance of the AHRQ PSIs was analysed to: 1) provide a
descriptive analysis of the incidence of PSI events from 2001 to 2004
in the VA; 2) examine trends in national PSI rates at the hospital
discharge level over time; and 3) assess whether hospital
characteristics (teaching status, number of beds, and degree of quality
improvement implementation) and baseline safety-related hospital
performance predict future hospital safety-related performance. Riskadjusted
rates of the PSI for iatrogenic pneumothorax and failure to
rescue demonstrated a significant trend for a decreasing rate over time.
After accounting for patient and hospital characteristics, hospitals'
baseline risk-adjusted PSI rates were the most important predictors of
the 2004 risk-adjusted rates for failure to rescue among seven other
PSIs. It was concluded, that this PSI is a useful tools for tracking and
monitoring patient safety events. Future research should investigate
whether trends reflect better or worse care or increased attention to
documenting patient safety events (5).
The Agency for Healthcare Research and Quality PSI algorithms were
applied to administrative data across four years of 1.92 million
discharges from children's hospitals. The mean risk-adjusted rates of
PSI events ranged from 0.1 events per 1000 discharges for a foreign
body left in during a procedure to 140 events per 1000 discharges for
failure to rescue. The researchers concluded: “PSIs derived from
administrative data are indicators of patient safety concerns and can be
relevant as screening tools for children's hospitals; however, cases
identified by these indicators do not always represent preventable
events. Some, such as a foreign body left in during a procedure,
iatrogenic pneumothorax, infection attributable to medical care,
decubitus ulcer, and venous thrombosis, seem to be appropriate for
paediatric care and may be directly amenable to system changes. In
their present form, two of the indicators, namely, failure to rescue and
death in low-mortality DRGs, are inaccurate for the paediatric
population, do not represent preventable errors in the majority of
paediatric cases, and should not be used to estimate quality of care or
preventable deaths in children's hospitals”(6).
AHRQ is determining the feasibility and practicality in a project
concerning validation of selected AHRQ Quality Indicators (8).
The results suggest that this PSI may be useful as a measure of patient
safety – Though special thoughts should be given to application of this
PSI to the paediatric population. (3-6).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Diagnose Specific as well as other Specific PSIs.
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Data definitions Number of deaths per 1000 patients having developed specified
complications of care during hospitalisation.
Numerator Description Number of in-hospital deaths. (Discharges with a disposition of
“deceased”).
Denominator Description Number of in-hospital deaths (Discharges with a disposition of
“deceased”) plus discharges 18 years and older with potential
complications of care listed in failure to rescue definition (i.e.,
pneumonia, DVT/PE, sepsis, acute renal failure, shock/cardiac arrest,
or GI hemorrhage/acute ulcer).
Exclude cases:
− age 75 years and older
− neonatal patients in MDC 15
− transferred to an acute care facility (Discharge Disposition = 2)
− transferred from an acute care facility (Admission Source = 2)
− admitted from a long-term care facility (Admission Source=3)
Additional exclusion criteria specific to each diagnosis.
Data Source Administrative data.
Identifying the
institutional context
This PSI is relevant to quality improvement.
Care Setting The PSI applies for high quality health care.
Professionals Responsible
for Health Care
Health care workers.
Lowest Level of Health
Care Delivery Addressed
Individual clinical units or departments.
Allowance for Patient
Factors
Risk adjustment for age, sex, DRG, comorbidity categories.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific standards given.
Scoring AHRQ has PSI software for scoring.