title: A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery.
abstract: BACKGROUND
  The relationship between the ability to recognize and respond to patient deterioration (escalate care) and its role in preventing failure to rescue (FTR; mortality after a surgical complication) has not been explored. The aim of this systematic review was to determine the incidence of, and factors contributing to, FTR and delayed escalation of care for surgical patients.
  
  
  METHODS
  A search of MEDLINE, EMBASE PsycINFO, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials was conducted to identify articles exploring FTR, escalation of care, and interventions that influence outcomes. Screening of 19,887 citations led to inclusion of 42 articles.
  
  
  RESULTS
  The reported incidence of FTR varied between 8.0 and 16.9%. FTR was inversely related to hospital volume and nurse staffing levels. Delayed escalation occurred in 20.7-47.1% of patients and was associated with greater mortality rates in 4 studies (P < .05). Causes of delayed escalation included hierarchy and failures in communication. Of five interventional studies, two reported a significant decrease in intensive care admissions (P < .01) after introduction of escalation protocols; only 1 study reported an improvement in mortality.
  
  
  CONCLUSIONS
  This systematic review explored factors linking FTR and escalation of care in surgery. Important factors that contribute to the avoidance of preventable harm include the recognition and communication of serious deterioration to implement definitive treatment. Targeted interventions aiming to improve these factors may contribute to enhanced patient outcome.
authors: Centre for Patient Safety and Service Quality, Division of Surgery, Department of Surgery and Cancer, Imperial College, London, UK. Electronic address: m.johnston@imperial.ac.uk.
authors: Maximilian J
authors: MJ
authors: Johnston
authors: Centre for Patient Safety and Service Quality, Division of Surgery, Department of Surgery and Cancer, Imperial College, London, UK.
authors: Sonal
authors: S
authors: Arora
authors: Centre for Health Policy, Division of Surgery, Department of Surgery and Cancer, Imperial College, London, UK.
authors: Dominic
authors: D
authors: King
authors: Division of Surgery, Department of Surgery and Cancer, Imperial College, London, UK.
authors: George
authors: G
authors: Bouras
authors: Centre for Patient Safety and Service Quality, Division of Surgery, Department of Surgery and Cancer, Imperial College, London, UK.
authors: Alex M
authors: AM
authors: Almoudaris
authors: Centre for Patient Safety and Service Quality, Division of Surgery, Department of Surgery and Cancer, Imperial College, London, UK.
authors: Rachel
authors: R
authors: Davis
authors: Division of Surgery, Department of Surgery and Cancer, Imperial College, London, UK.
authors: Ara
authors: A
authors: Darzi
mesh_terms: D002985:Clinical Protocols; D003422:Critical Care / Q000379:methods / Q000458:organization & administration; D057210:Delayed Diagnosis; D006801:Humans; D007400:Interprofessional Relations; D011182:Postoperative Care / Q000379:methods / Q000401:mortality* / Q000592:standards; D011183:Postoperative Complications / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D019984:Quality Indicators, Health Care; D017211:Treatment Failure