A 12-year-old underwent an ex-lap for an acute abdomen and was subsequently admitted to the floor. The nurse noted irregularities in the patient’s vital signs and sent a message to the resident caring for the patient. The resident did not seem concerned and said he or she would come to the bedside at some point. The patient worsened over the next two hours, a rapid response was called, and the patient was transferred to the ICU and diagnosed with suspected sepsis.

This case report describes clinical decompensation on an inpatient ward during a patient’s first 24 hours post-surgery. At first glance, this case may not appear to involve anesthesiologists because the patient was stable when leaving the OR and PACU. However, anesthesiologists have an increasing hospital-wide presence as intensivists and members of rapid response and code teams, making our specialty critically involved in the care of patients with clinical decompensation. While there are many facets of this case that merit discussion, we will focus on the concept of failure to rescue (FTR).

FTR was first introduced in 1992 as a death following an adverse event, typically a surgical complication (Med Care 1992;30:615-29). The conceptual framework behind FTR is defined as a patient after surgery who may be discharged by three possible pathways – a smooth postoperative course, a postoperative course with a complication that is immediately recognized and treated, or a postoperative course with a complication that escalates until it requires more intensive management before being properly treated (Figure). Clinical deterioration and FTR can occur at any point postoperatively, from the PACU through to the ICU or surgical ward. FTR is widely used as a quality metric, as it acknowledges that, while complications may not always be preventable, early detection and treatment are markers of quality of care in a health system (Anesthesiology 2019;131:426-37). In this case, the patient had a complication, then had a delay in appropriate treatment of the complication requiring escalation of care to the ICU before (presumably) being successfully “rescued” and discharged.

Figure: A Conceptual Framework for Failure to Rescue. Figure from Portuondo et al. (Anesthesiology 2019;131:426-37).

Figure: A Conceptual Framework for Failure to Rescue. Figure from Portuondo et al. (Anesthesiology 2019;131:426-37).

While FTR is explicitly a concept of postoperative care, we can extend a similar framework to intraoperative care. Some clinical changes arise suddenly and acutely – such as hypotension associated with release of an aortic cross clamp – while others arise more gradually with clinical changes apparent in the minutes or even hours before a more urgent crisis arises, like gradual blood loss with under-resuscitation that eventually becomes refractory hypotension and hemorrhagic shock. In this framework, the blood loss is the complication and the delay in aggressive resuscitation is the complication cascade.

Mitigating the risk of FTR requires two key components of care: recognition of the change in clinical status and appropriate treatment (N Engl J Med 2009;361:1368-75). Treatment tends to be the easier of the two components, with a rise in rapid response teams on the inpatient side and aids for OR crisis management for intraoperative events (Anesthesiology 2011;115:421-31; N Engl J Med 2013;368:246-53; Anesth Analg 2020;131:1815-26). The bigger challenge is in identification of the clinical change and determining the appropriate tool/decision aid to use or team member to whom to escalate the issue. On inpatient surgical wards, one proposed identification tool is continuous vital sign monitoring by nurses instead of the standard vital sign check every four hours. In one study, 37% of postoperative patients experienced at least one hour with an SpO2 < 90% in the first 48 hours after surgery when on continuous monitoring, but standard nursing vital sign collection every four hours caught only 5% of patients with hypoxia (Anesth Analg 2015;121:709-15). Continuous monitoring with remote surveillance is technologically feasible, and with the right algorithms it can be associated with identification of patients for whom medical intervention can change the clinical trajectory; however, it is still not standard of care (Anesth Analg 2021;133:933-39). Similarly, in the OR, artificial intelligence tools and clinical decision support tools can be used to predict and/or mitigate intraoperative hypotension, with both tools showing tighter blood pressure management in an RCT versus usual care (JAMA 2020;323:1052-60; J Am Med Inform Assoc 2022;29:1416-24). Additionally, there is increasing use of emergency manuals and/or crisis checklists in the OR. While these clearly help with management steps, they are also designed to assist with identification and diagnosis of a clinical change.

In this case, the clinical change was recognized, yet there remained a delay in appropriate clinical care as the nurse alerted the resident – but the patient was not assessed until their condition deteriorated to the point of having a rapid response called. In a systematic review of factors influencing FTR and escalation in postoperative surgical patients, a delay in care after recognition of clinical deterioration occurred in 20.7%-47.1% of FTR or escalation cases (Surgery 2015;157:752-63). Reasons for delay included teams that are overworked or understaffed, knowledge gaps leading to inappropriate treatment, and hierarchies creating challenges in speaking up and communicating with the appropriate team member, all of which could have contributed to this event (Surgery 2015;157:752-63). Addressing these issues involves system-wide changes, including team communication training, adjusting call schedules to decrease the workload per physician, expanding access to cognitive aids to assist physicians with initial management steps, and expanding access to specialist physicians, such as intensivists, to involve them in the patient’s care earlier on in the clinical course of a complication.

Overall, as anesthesiologists and perioperative physicians, we are uniquely positioned and qualified to assist in the care of clinically deteriorating patients, as we do already as intensivists while managing patients in the PACU, and as members of code teams and rapid response teams. Ideally, the systems that we work in will be set up to promote earlier identification of this clinical deterioration to allow us to intervene at earlier stages and smooth the patient’s postoperative course. We can additionally extend these lessons into our intraoperative care and work to set up our intraoperative system for early detection of a patient approaching an intraoperative crisis.

The following are key recommendations to prevent failure to rescue or mitigate clinical deterioration in the OR:

  • Consider early warning systems or clinical decision support tools in the OR, both computer-based and tools like OR crisis checklists
  • Promote strong teamwork and communication to flatten hierarchies, such as through teamwork training programs
  • Create and implement rapid response teams and increase access to intensive care teams to get the right clinicians to the patient in a case of clinical deterioration.