(1286) Failure to Rescue: Determination of Key Drivers of In-Hospital Cardiac Arrest Outside the ICU

Introduction: High-Reliability Organizations are expected to minimize harm in high-risk situations and implement measures to optimize outcomes. A Failure to Rescue (FTR) is the failure to prevent morbidity and mortality resulting from medical care or lack thereof. FTRs represent opportunities for improvement in system organization and care delivery to improve outcomes. Our institution conducted a quality improvement project to identify cases of FTR leading to in-hospital cardiac arrest (IHCA) and conduct PDSA cycles to reduce rates of FTR.

Methods: A multidisciplinary team was created to review all code blues at a large urban academic medical center from 01/2024 to 06/2024 on a biweekly basis. The team featured hospital leaders in patient safety, nursing, pharmacy, palliative care, hospital medicine, and critical care. We defined FTR as IHCA occurring in non-intensive care unit (non-ICU) settings in which delays in care or inappropriate treatment plans contributed to clinical deterioration. Days from admission, time of day, and location of codes were also recorded. Run charts and key driver diagrams were produced to facilitate system improvement to reduce FTR.

Results: In the study period, 69 non-ICU IHCAs were identified. Only 25% of patients survived to discharge. Of the 69, nearly half were identified as FTR (n=34, 49%). Delayed Diagnosis (n=21, 62%) more commonly contributed than Treatment Concerns (n=18, 53%), with both occurring in the minority of FTR (n=5, 15%). The median time from admission to FTR was 8.85 days. FTR were more common on nocturnal shifts (n= 21, 62%). FTR were most common in progressive care units (n=18, 53%) and least so in specialty areas (n=4, 12%).

Conclusions: Our multidisciplinary review identified a predominance of FTR on nocturnal shifts and in progressive care units. Key drivers elicited from this pattern included schedule/shift matters, communication, and appropriate levels of care. Targets of intervention included schedule transparency, escalation of care protocols, and standardized handoffs. Further, we implemented FTR “Physician Drill Downs” which are in-depth reviews to identify opportunities for improvement in diagnosis, documentation, or appropriate level of care to guide further PDSA cycles and system reduction in FTR.