Failure to Rescue as a Process Measure to Evaluate Fetal Safety During Labor
To evaluate a perinatal team's clinical responses to the key components of the failure to rescue process.
This retrospective descriptive study involved a review of medical records and their accompanying fetal monitoring strips for 53 women who had a cesarean birth at term for a nonreassuring fetal heart rate pattern. The instrument was the Fetal Safety Failure to Rescue Process Tool based on the Agency for Healthcare Research and Quality's Failure to Rescue Patient Safety Indicator adapted for perinatal care processes. This tool measured four process measures: careful surveillance, timely identification of complications, appropriate interventions, and activating a team response. A mean total score was computed to determine quality of care based on all four of the process measures.
The perinatal team's mean total score was 6.6 (SD = 1.0, range 3-8); the highest possible score was 8. The lowest score was found in the team's response with appropriate interventions (lateral positioning, intravenous fluid bolus, discontinuation of oxytocin, oxygen administration, amnioinfusion, administration of Terbutaline) based on fetal heart rate pattern. Interrater reliability of the tool was 90%.
This study provided information that may be useful in evaluating processes of care to ensure quality care for mothers and babies during labor. The findings formed the basis for implementing unit-specific educational programs, including (a) certification, continuing education, and documented competence in electronic fetal monitoring education to promote consistency in language and understanding of abnormal fetal heart rate patterns; (b) review of appropriate documentation of nonreassuring fetal heart rate patterns; (c) review and revision, if necessary, of established institutional standards and guidelines for appropriate interventions for nonreassuring fetal heart rate patterns; (d) changes in standardized forms to include times for notification of team members and improved communication, and (e) mechanisms for identifying system failures.
Available from: Marie Hastings-Tolsma
- "Identification of risk factors contributing to the deterioration of labor progress have received much research attention and include both fetal (Beaulieu,2009) and maternal characteristics such as habitus and genetic profiles, technologic monitoring systems, and interventions to alleviate pain such as epidural use. This risk-based approach has worked well in the prevention of adverse maternal and fetal outcomes but has done little to promote normative processes, thus reducing unnecessary interventions and associated expenditures to both the health care system and patients (Glantz, 2012). "
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To reconceptualize the concept of failure to rescue, distinguishing it from its current scientific usage as a surveillance strategy to recognize physiologic decline.
Failure to rescue has been consistently defined as a failure to save a patient's life after development of complications. The term however, carries a richer connotation when viewed within a midwifery context. Midwives have historically believed themselves to be the vanguards of normal, physiologic processes, including birth. This philosophy mandates careful consideration of what it means to promote normal birth and the consequences of failure to rescue women from processes which challenge that outcome.
The Medline, CINAHL, PsycINFO, PubMED, Web of Science and Google Scholar databases were searched from the period of 1992 to 2014 using the key terms of concept analysis, failure-to-rescue, childbirth, midwifery outcomes, obstetrical outcomes, suboptimal care, and patient outcomes. English language reports were used exclusively. The search yielded 45 articles which were reviewed in this paper.
A critical analysis of the published literature was undertaken as a means of determining the adequacy of the concept for midwifery practice and to detail how it relates to other concepts important in development of a conceptual framework promoting normal birth processes.
Failure to rescue within the context of the midwifery model of care requires robust attention to a midwifery managed setting and surveillance based on a caring presence, patient protection, and midwifery partnership with patient.
Clarifying the definition of failure to rescue in childbirth and defining its attributes can help inform midwifery providers throughout the world of the ethical importance of considering failure to rescue in clinical practice. Relevance to midwifery care mandates use of failure to rescue as both a process and outcome measure.
Available from: Catherine Ivory
- "As mentioned previously, only one study has been published using Simpson's (2005) P-FTR. Beaulieu (2009) used the tool in a retrospective review of over 140 records for women who had experienced an unscheduled cesarean section during labor. "
Available from: Sheila M Gephart
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ABSTRACT: Failure to rescue (FTR) has been described as the end result of a series of events relating to the environment of care and nursing quality. Only recently has FTR as a process measure been applied to perinatal care settings. Nurses' continuous presence at the bedside puts them in a privileged position to recognize signs of clinical deterioration and to take action. Many factors contribute to nurses' ability to save lives when infants develop complications. Although such factors are often system-related, nurses may be held responsible if they do not act according to an acceptable standard of care. In the neonatal intensive care unit, FTR has not been applied or adopted as a measure of nursing quality. This article describes how FTR is relevant in the neonatal intensive care unit and outlines nursing and system actions that can be taken to rescue some of the hospital's most vulnerable patients.
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