Thursday, January 10, 2008

Failure to rescue

In a fascinating white paper published in 2004, Health Grades, Inc. reached the following conclusions from a large review of MedPar data (medicare records):

"Approximately 1.14 million total patient safety incidents [PSIs] occurred among the 37 million hospitalizations in the Medicare population from 2000 through 2002."

"The PSIs with the highest incident rates per 1,000 hospitalizations at risk were Failure to Rescue, Decubitus Ulcer, and Post-operative Sepsis. These three patient safety incidents accounted for almost 60% of all patient safety incidents among Medicare patients hospitalized from 2000 through 2002."

"The 16 PSIs studied accounted for $8.54 billion in excess inpatient cost to the Medicare system over 3 years, or roughly $2.85 billion annually. Decubitus Ulcer ($2.57 billion), Post-operative Pulmonary Embolism or Deep Vein Thrombosis ($1.40 billion), and Selected Infections due to Medical Care ($1.71 billion) were the most costly and accounted for 66% of all excess attributable costs from 2000 through 2002."

Failure to rescue usually occurs in a setting where a patient starts to develop signs and symptoms that are unevaluated clinically by the medical staff. Maybe the patient has a small rise in temperature, or maybe the patient has a sudden chest pain that is unaccompanied by ECG changes, or unusual leg pain, or maybe the patient has a little GI upset, or seems a bit agitated. It takes a great deal of judgment to react wisely when patients develop unexpected changes in physical or mental status.

Still, small problems can easily lead to big problems in a medical setting, and big problems can lead to death. Often, especially after the small problems have gotten out of hand, the response time by the clinical staff is crucial.

There was an excellent report on automatic defibrillators in the New York Times, Jan 3, 2008, by Denise Grady, entitled, "Hospitals Slow in Heart Cases, Research Finds." The author described a Failure to Rescue scenario that occurs commonly in hospitals. A patient suffers a heart attack and a consequent arrhythmia that could be reversed with defibrillation if received in under two minutes. Many hospitals cannot respond with defibrillation within the two minute window. The reasons are systemic and may include policies that forbid floor nurses to defibrillate.

In contrast to hospitals, automatic debribrillators that are kept at ball parks, health clubs, and department stores, permit laypersons to defibrillate because they come with automatic sensors that determine if the patient has a heart rhythm that can be rescued with the defibrillator. The upshot of the NY Times article was that your chance of receiving life-saving defibrillation may be higher at a ballgame (where people witness your event and a defibrillator is quickly available) than in a hospital setting.

- Jules Berman
In June, 2014, my book, entitled Rare Diseases and Orphan Drugs: Keys to Understanding and Treating the Common Diseases was published by Elsevier. The book builds the argument that our best chance of curing the common diseases will come from studying and curing the rare diseases.

I urge you to read more about my book. There's a generous preview of the book at the Google Books site. If you like the book, please request your librarian to purchase a copy of this book for your library or reading room.

- Jules J. Berman, Ph.D., M.D. tags: common disease, orphan disease, orphan drugs, genetics of disease, disease genetics, rules of disease biology, rare disease, pathology, critical period, failure to save, medical errors