Cognitive Aids for the Management of Deteriorating Surgical Patients

INTRODUCTION AND RATIONALE

The suboptimal management of deteriorating surgical patients is an important factor in preventable death and morbidity in hospitals. Several studies have shown that the mortality rate in different hospitals is not associated with different complication rates between these hospitals but with the ability to effectively rescue patients from these complications. This has been called failure to rescue. Misapplication of the early warning score, failure to recognize a deteriorating patient, delays in seeking senior advice and delays in adequate management or inadequate resuscitation are found to be important factors. Strategies focusing on the management of complications once they occur may be essential to improve outcomes.

Recent publications emphasized human factors as a cause that contributed towards failure to rescue. Medical staff often fails to recognize a deteriorating patient. Partly because there is lack of insight in the development of a critically illness. Ludikhuize showed that care-providers mostly rate their care, provided to patients in the hours preceding a life-threatening adverse event, as good. However, independent experts felt that patients often could have been identified as deteriorating, much earlier. It does not, however, seem wholly unexpected that the assessment of a deteriorating patient by an experienced ICU consultant is superior to the assessment made by a ward nurse or junior surgical doctor.

Another important cause of failure to rescue was the failure to react promptly tot a deterioration in care. It has been reported that the Rapid Response Team (RRT) was called in only 30% of cases when criteria for activating the RRT were fulfilled. Sometimes because of an unclear escalation policy, sometimes because of self-doubt and insecurity of the care provider or because of hierarchical barriers.

It is known that the management of intraoperative emergencies improves through the use of cognitive aids.These cognitive aids remind practitioners to best practice management of these emergencies and hereby increase adherence to these practices. Because the CAMDS will assist surgical staff at the bedside in the assessment of deteriorating surgical patients and prompt best practice management of specific complications it is likely that failure to rescue will also decrease. The CAMDS can furthermore prompt a nurse or junior doctor to liaise with seniors and/or critical care staff. Because they can communicate a differential diagnosis and management steps taken so far from the CAMDS this might decrease self-doubt and insecurity in liaising with seniors or critical care staff. A, clear escalation policy on the CAMDS, embraced by the hospital can further assist in the timely escalation of care and breakdown of hierarchical barriers. This will result in a decrease of the likelihood of failure to rescue.