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Patient Safety Success Story: Dartmouth-Hitchcock Eliminates ‘Dead In Bed’ instances thanks to continuous monitoring

For over ten years, Dartmouth Hitchcock Medical Center (D-H), New Hampshire’s only academic health system, which serves a population of 1.9 million across New England, has worked to eliminate “failure to rescue” (FTR) events from opioid-induced respiratory depression. The concept of failure to rescue captures the idea that, although not every complication of medical care is preventable, health care systems should be able to rapidly identify and treat complications when they occur.[1]

Despite the increased media coverage surrounding opioids, failure to rescue events from patients exhibiting opioid-induced respiratory depression is a significant cause of totally preventable patient death (Joint Commission, 2012; ISMP, 2007; Weinger et al., 2011). Patients receiving opioids in the hospital have almost twice the incidence of cardiorespiratory arrest compared to other patients (Overdyk et al., 2016). It is estimated that between three and five-thousand patients are found “dead in bed” from the opioids they were prescribed to manage their pain – not from illicit use.[2]

But failing to identify and treat opioid-induced respiratory depression is unfortunately common with stories of patients found “dead in bed” in the hospital. That was the case for 12-year-old Leah Coufal. After undergoing successful elective surgery at a prestigious Southern California hospital, Leah was found dead in bed by her mother, Lenore Alexander, who was at her side but drifted to sleep, waking only to find that her daughter had passed. Leah was a victim of undetected respiratory arrest, caused by the narcotics that were intended to ease her pain.[3]

It was a case similar to Leah’s that occurred over ten years ago that spurred Dartmouth-Hitchcock to take action.

“The seminal event that initiated our increased attention to failure to rescue involved a patient in their 30s that was admitted under general care for minor surgery. The patient had a history of anxiety and pre-existing conditions that were assessed and were determined to represent little perioperative risk. After surgery, they were given medication for anxiety and opioids for the pain. Post-op physiological assessments during the first few hours of inpatient admission were normal, but just hours later the patient was found dead by a nurse who entered the room for routine vital signs assessment,” said Susan McGrath, PhD, Director of Research in the Patient Safety Learning Laboratory at Dartmouth-Hitchcock Medical Center at the 6th Annual World Patient Safety, Science & Technology Summit.

The incident led Dartmouth-Hitchcock to seek new methods to eliminate the so-called “dead in bed” or unwitnessed failure to rescue events and increase staff recognition of treatable complications. As a result, Dartmouth-Hitchcock implemented a surveillance system which consisted of continuous monitoring through pulse oximetry.

“The spread of continuous monitoring to all inpatients was partly facilitated by myself being the Chief Patient Safety Officer. We anchored it to be a tool for nurses who were multitasking. There was a 1 to 5 ratio of nurses to patients. The simple way we talked about it is ‘nobody can be watching five patients simultaneously. So, when you’re busy with Mr. Smith, and Mrs. Jones is getting into trouble, you benefit from having this kind of surveillance to redirect your attention.’ It was really there to support nurses who knew they had all had this happen – that they were busy in one place, and something bad was happening in another,” explained George T. Blike, MD, Chief Quality and Value Officer at Dartmouth-Hitchcock Medical Center.

Continuous monitoring had an immediate and lasting effect.

“Implementation of our patient surveillance system, which employs pulse oximetry, resulted in a 48% decrease of transfers to higher levels of care and a 65% reduction in rapid response team activations,” added McGrath.

Even more importantly, Dartmouth-Hitchcock is preparing to publish a new paper documenting that the hospital has not had a ‘dead in bed’ incident for ten years since the implementation of the continuous monitoring system.

However, despite eliminating the ‘dead in bed’ cases, the hospital recognized that there were other reasons why failure to rescue occurred and began to work on equipping staff with the tools and education to recognize and treat complications.

“High mortality rates are tied to a hospital’s inability to recognize and manage complications rather than their existence,” explained Blike.

He added, “We have to do more than just prevent complications. We have to get good at picking them up early and acting quickly.”

The hospital established a learning lab, one of only thirteen in the country, to learn and train staff in the recognition and management of complications that may lead to failure to rescue events such as bleeding, pneumonia, heart attacks, strokes and sepsis.

“The learning lab is intended to accelerate understanding how to solve complex patient safety problems and we feel that failure to rescue is worthy of that.”

And the result of this hard work: eliminating dead in bed for the past ten years, a decreasing trend in failure to rescue numbers and decreased mortality – all of which has saved countless lives.

 


[1] Agency for Healthcare Research and Quality (2017, November) Patient Safety Primer. Retrieved from website: https://psnet.ahrq.gov/primers/primer/38/failure-to-rescue

[2] https://www.kansascity.com/news/business/health-care/article203189944.html#storylink=cpy

[3] Patient Safety Movement Foundation (2014) Leah Coufal’s Story. Retrieved from website: https://psmf.org/advocacy/patients-and-families/patient-stories/lenore-alexander/