2.50
Hdl Handle:
http://hdl.handle.net/10755/159012
Type:
Presentation
Title:
Failure to rescue: A preliminary study
Abstract:
Failure to rescue: A preliminary study
Conference Sponsor:Midwest Nursing Research Society
Conference Year:2006
Author:Bobay, Kathleen, PhD, RN, CS
P.I. Institution Name:Aurora Health Care
Title:Department Head
Contact Address:Marquette University, 2400 S. 90th St,., Suite 306, West Allis, WI, 53227, USA
Contact Telephone:414.328.6752
Co-Authors:Karen Fiorelli, BSN, RN, Clinical Research Coordinator; A. J. Anderson, MS, FAHA; Marie Golanowski, MS, RN, CNAA; and Mary Hagle, PhD, RN, AOCN
Failure to rescue (FTR) has been defined as the inability to save a hospitalized patient's life after the development of a complication that was not present on admission (Clarke, 2004). Typically, elective surgery cases are reviewed for such FTR events. Although FTR is a relatively new concept in the nursing literature, it is believed that FTR occurs as a result of system (structure) or process factors; it may also occur due to a lack of clinical nursing expertise. Published studies to date have focused on discharge summaries, leaving unanswered questions about unit-level nursing actions. Purpose: Research is needed to describe patient conditions before FTR occurrences. This study addresses this issue. Subjects/Methods: This preliminary, descriptive study examined 376 potential cases of FTR in surgical patients that occurred in five Midwestern metropolitan hospitals during 2004. Extensive chart reviews were completed by trained RN reviewers who looked at patient trajectories for three days prior to death. Results: Fewer than anticipated unexpected deaths occurred in the sample (5/376 = 1.3%). Seven key indicators were found that, when trended over time, significantly pointed to a gradual patient decline. These indicators were: heart rate, respiratory rate, body temperature, sodium and potassium levels, oxygen saturation, and urine output. Factors that did not significantly predict patient decline were BUN, creatinine, and pre-op ASA scores. Conclusions: This preliminary study demonstrated key indicators that can be trended by nurses to identify patients who may be at risk for life-threatening complications after surgical procedures. While this may not be new for experienced nurses, this study provides an empirical guide for less experienced nurses. It also forms the basis for further research into structural and process factors that may impact FTR events. [Poster Presentation]
Repository Posting Date:
26-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Midwest Nursing Research Society

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleFailure to rescue: A preliminary studyen_GB
dc.identifier.urihttp://hdl.handle.net/10755/159012-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Failure to rescue: A preliminary study</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Midwest Nursing Research Society</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2006</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Bobay, Kathleen, PhD, RN, CS</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">Aurora Health Care</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Department Head</td></tr><tr class="item-address"><td class="label">Contact Address:</td><td class="value">Marquette University, 2400 S. 90th St,., Suite 306, West Allis, WI, 53227, USA</td></tr><tr class="item-phone"><td class="label">Contact Telephone:</td><td class="value">414.328.6752</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">kathleen.bobay@marquette.edu</td></tr><tr class="item-co-authors"><td class="label">Co-Authors:</td><td class="value">Karen Fiorelli, BSN, RN, Clinical Research Coordinator; A. J. Anderson, MS, FAHA; Marie Golanowski, MS, RN, CNAA; and Mary Hagle, PhD, RN, AOCN</td></tr><tr><td colspan="2" class="item-abstract">Failure to rescue (FTR) has been defined as the inability to save a hospitalized patient's life after the development of a complication that was not present on admission (Clarke, 2004). Typically, elective surgery cases are reviewed for such FTR events. Although FTR is a relatively new concept in the nursing literature, it is believed that FTR occurs as a result of system (structure) or process factors; it may also occur due to a lack of clinical nursing expertise. Published studies to date have focused on discharge summaries, leaving unanswered questions about unit-level nursing actions. Purpose: Research is needed to describe patient conditions before FTR occurrences. This study addresses this issue. Subjects/Methods: This preliminary, descriptive study examined 376 potential cases of FTR in surgical patients that occurred in five Midwestern metropolitan hospitals during 2004. Extensive chart reviews were completed by trained RN reviewers who looked at patient trajectories for three days prior to death. Results: Fewer than anticipated unexpected deaths occurred in the sample (5/376 = 1.3%). Seven key indicators were found that, when trended over time, significantly pointed to a gradual patient decline. These indicators were: heart rate, respiratory rate, body temperature, sodium and potassium levels, oxygen saturation, and urine output. Factors that did not significantly predict patient decline were BUN, creatinine, and pre-op ASA scores. Conclusions: This preliminary study demonstrated key indicators that can be trended by nurses to identify patients who may be at risk for life-threatening complications after surgical procedures. While this may not be new for experienced nurses, this study provides an empirical guide for less experienced nurses. It also forms the basis for further research into structural and process factors that may impact FTR events. [Poster Presentation]</td></tr></table>en_GB
dc.date.available2011-10-26T21:37:01Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-26T21:37:01Z-
dc.description.sponsorshipMidwest Nursing Research Societyen_GB
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