E MEETING REPORT
The Anesthesia Patient Safety organizations took part in the September 4–5, 2019
Foundation Stoelting Conference
2019: Perioperative Deterioration—
Early Recognition, Rapid Intervention,
and the End of Failure-to-Rescue
GLOSSARY
ACC = Anesthesia Closed Claims; AI = augmented intel-
ligence; AIRS = Anesthesia Incident ReportS; APSF =
The Anesthesia Patient Safety Foundation; AQI = The
Anesthesia Quality Institute; ASA = American Society of
Anesthesiologists; CFC = clinical futile cycles; CHF = conges-
Downloaded from http://journals.lww.com/anesthesia-analgesia by BhDMf5ePHKbH4TTImqenVCscuGFl+NVZjo9UKqT7VeaZw7MkJMVL9v1kz7yPT/kO on 08/18/2020
tive heart failure; CV = cardiovascular; e-CART = electronic
cardiac arrest risk triage; EHR = electronic health record;
FTR = failure-to-rescue; HCD = human-centered design;
ICU = intensive care unit; MET = Medical Emergency Team;
MI = myocardial infarction; PACU = postanesthesia care
unit; RRT = rapid response team
T he Anesthesia Patient Safety Foundation (APSF)
Annual Stoelting conference brings together diverse
stakeholders to explore key perioperative care safety
issues. The conference provides opportunities to col-
laborate and leverage expertise—catalyzing solutions
to complex problems that continually harm patients.
The 2019 theme: “preventing, detecting, and mitigat-
ing clinical deterioration in the perioperative period”
heads the list of 12 perioperative patient safety priori-
ties defined by APSF’s Board of Directors.1,2
Expert faculty (Supplemental Digital Content,
Table 1, complete faculty list, http://links.lww.com/
AA/D122) laid foundation for an interactive solution-
oriented meeting, informed by deep understanding
of the perioperative patient, caregiver, and clinician
journeys. Personal narratives shared by Buist3 and
Townsend eloquently described their own or loved
ones’ suffering from failure to receive timely and
appropriate medical care. These stories energized
participants, giving a deep sense of the relevance and
importance of the work we had gathered to do.
The conference included presentation of fresh
data, focused debates on controversial topics, and
culminated in a human-centered design workshop
to generate innovative, creative solutions. A total of
136 participants including patients, family members,
clinicians, risk managers, industry representatives,
and representatives from over 25 multiprofessional
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of
this article on the journal’s website (www.anesthesia-analgesia.org).
DOI: 10.1213/ANE.0000000000005008
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meeting.
LEARNING FROM THE ANESTHESIA QUALITY
INSTITUTE DATA SOURCES
Anesthesia Quality Institute (AQI) houses 2 impor-
tant data sources: Anesthesia Closed Claims (ACC)
and Anesthesia Incident ReportS (AIRS).
Domino reviewed the ACC database for severe per-
manent injuries/death claims from 2005 to 2014, with a
deterioration event occurring in postoperative phases
(ie, postanesthesia care unit [PACU] >1 hour, ward,
intensive care unit [ICU]). Failure-to-rescue (FTR)
events occurred in 1 in 5 claims for severe permanent
injuries or death. Compared to patients in other claims
for severe outcomes, patients in FTR events were more
likely to be American Society of Anesthesiologists
(ASA) ≥III or have had orthopedic surgery. Damaging
event FTR claims generally involved diagnosis and
treatment of postoperative respiratory depression,
cardiovascular, or respiratory issues due to patient
comorbidities, postoperative hemorrhage, and spinal
or epidural hematoma (Table). Domino found that
communication and human factors4 (decision making,
workload management, situational awareness, lead-
ership, and teamwork) likely contributed to delayed
diagnosis and treatment of these events.
Guffey reviewed the AIRS database of >1700
reports, where 63% of the FTR cases were felt to be pre-
ventable. FTR cases were categorized into (1) failure
of recognition (eg, untimely recognition of hypoten-
sion), failure to monitor (eg, absence of blood pressure
monitoring), delay in escalation (eg, untimely call for
help), and making a definitive diagnosis (eg, diagnos-
ing postoperative hemorrhage and definite return to
surgery versus continued fluid resuscitation). Failure
of recognition was the most frequent reason, followed
by making a definitive diagnosis. Monitoring or delay
in escalating issues were less frequent causes. Guffey
noted that most AIRS-reported cases reflect occur-
rences in the operating room. He suggested escalation
is more apt to be limited in the PACU—where situa-
tional awareness can be further compromised, and dis-
tractions more abundant than in the operating room.
LEARNING FROM MODELS
Dummett presented Kaiser Permanente’s implemen-
tation progress of an early warning system, which
robustly scores integrated vital signs and laboratory
values through their electronic record; develops pre-
dictive intelligence on the deteriorating patient; and
uses a system of virtual rapid response team (RRT)
nurses. Lessons learned over 5 years5 included the
importance of being sensitive to alarm fatigue and
 APSF Stoelting Conference 2019: Perioperative Deterioration
Table.  Failure-to-Rescue Compared to Other
High-Severity Claims
Injury Severity Score 6–9 (Permanent Disability to Death)
Greater proportion ASA physical status III–V
Greater proportion orthopedic surgery
Types of adverse events in failure-to-rescue claims:
•  Postoperative respiratory depression
•  CV/respiratory issues related to comorbidities
•  Postoperative hemorrhage
•  Epidural/spinal hematoma
Source: Anesthesia Closed Claims (2005–2014).
Abbreviations: ASA, American Society of Anesthesiologists; CV, cardiovascular.
integrating with existing workflows. Dummett
emphasized that optimizing scores is not enough. It is
critically important to create a culture of patient safety
with a lens to rescue and recognize the possibility of
diagnostic error.
Blike shared Dartmouth-Hitchcock’s advance-
ments with their Failure-to-Rescue Patient Safety
Learning Laboratory focusing on metrics—distin-
guishing the difference in denominator between
mortality rate (death/no. of surgeries) and FTR rate
(death/no. patients with complications). He sum-
marized work demonstrating hospital variations in
surgical mortality are due far more to FTR rates than
complication rates.6,7 Although the perfect metric is
still elusive, Blike advocated actively sharing timely,
outcome-based, complication-specific measures. He
cautioned against the use of composite measures and
measures insensitive to palliative-care cases.
Buist, a key investigator in Australia’s early
Medical Emergency Team (MET) studies,8 shared his
personal story as patient, clinician, and researcher.
Buist3 presented a provocative frame, coined “clinical
futile cycles” (CFC), where a dangerous “spinning of
wheels” occurs. Well-intentioned clinical activities—
in keeping with traditional hierarchical referrals—fail
to alter a deteriorating patient’s trajectory. He cited a
cluster-randomized control trial9 where despite new
MET activation procedures, rescue was not statisti-
cally improved. Buist asked that we emphasize the
importance of microcultures within units. The CFC
frame can educate both individuals and systems
toward more timely solutions.
FOCUSED DEBATES
Who to Monitor and How?
Peden argued that simply monitoring more does not
make health care delivery better. She suggested that
effective programs be developed by risk-stratifying
patients, intermittently monitoring (frequency based
on patient risk and use trends), and simultaneously uti-
lizing early warning scoring systems.10–12 Devita coun-
tered with a vision of hospitals being high-reliability
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organizations and that not all patients will predictably
deteriorate.13,14 He argued that intermittent monitoring
results in sampling error, unreliability, and recognition
errors and that recent monitoring systems (eg, elec-
tronic cardiac arrest risk triage [e-CART] score15) have
evolved with better specificity and sensitivity.
Augmented Intelligence: Hype or New Normal
Mathur began his argument of augmented intel-
ligence (AI) hype with Amara’s Law: “we tend to
overestimate the effect of a technology in the short
run and underestimate the effect in the long run.”16
He cautioned overgeneralization of AI’s capability
and to be wary of machine learning from biased data
sets.17 Buist18 countered that human fallibility cannot
be ignored. AI has real-time potential to incorporate
all patient data individualized to a patient with out-
comes that are relevant to a particular clinical ques-
tion. He shared data from an electronic alert system
demonstrating significantly improved clinical rescue
(eg, improved clinician attendance for warning scores
above a threshold level from 29% to 78% and reduced
hospital length of stay).19 Both agreed future collabo-
ration between clinicians and machine-learning scien-
tists with properly designed studies will determine
the true role of AI in perioperative care.
FTR: Afferent or Efferent Limb Issue?
Hravnak argued that the afferent arm (all aspects
of warning clinicians of failure) is the key issue. She
shared a model of patient- and hospital-level fac-
tors that lead to FTR. Delayed calls aggregated into
2 categories: alarm fatigue and communication.20 She
argued for improving specificity and sensitivity of
alarms as essential for future success. Strengthening
the afferent limb through education, resources, tech-
nology, and organizational structures are equally criti-
cal. Safavi defended the efferent limb (all aspects of
responding to a warning) as key. As an analogy, he
shared meta-analyses from beta-blocker therapy fol-
lowing myocardial infarction (MI) and tele-monitoring
congestive heart failure (CHF),22 where the idealized
technical solution (afferent limb) was insufficient to
change outcomes. He conceded that, in contrast to
technology inventions (eg, AI software platforms, bio-
sensor wearables), focusing on organizational culture
(eg, the sociotechnical relationships between alarming
and responding teams)21 holds less glamour and rigor.
Both debaters agreed that timely human response in
both limbs is ultimately what is critically important.23
Human-Centered Design Workshop
Sammann and team facilitated and led the human-
centered design (HCD) workshop.24 They shared core
principles of HCD as a methodology that empathizes
with each stakeholder, understands their unique
ANESTHESIA & ANALGESIA
 EE Meeting Report
challenges and unmet needs, examines the problems
from multiple perspectives, and designs creative solu-
tions to meet the unmet needs of the stakeholders.25
Themes From Preconference Interviews
As preconference work, qualitative research was con-
ducted with diverse stakeholders to better under-
stand FTR from their perspectives. Over 25 clinicians
and patients across multiple specialties, clinical set-
tings, and levels of experience were interviewed and
observed. This work generated overarching themes, 9
key insights, and opportunities (Figure 1).
September 2020 • Volume 131 • Number 3 www.anesthesia-analgesia.org e157
Copyright © 2020 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
“There is no good time to raise the alarm” was one
such insight. Interviewees discussed experiences of
escalating care too early where they were perceived
as overreacting, or instances of escalating care too
late when the patient was already deteriorating. “You
have to make sure your ducks are in a row, otherwise
people will stop listening to you,” a PACU nurse
shared. An intensivist recounted that “sinking gut
feeling” when realizing that a patient could no longer
be “rescued.” These insights exposed design opportu-
nities for conference participants to brainstorm ideas
on how we might build environments that support
and encourage early escalation of care.
Figure 1. HCD failure-to-rescue
insights and design challenges.
Insights were obtained through
qualitative interviews. Design
challenges emerged from these
insights to focus the design-
thinking process toward solu-
tion-oriented prototypes. This
list is in rank order of priority vot-
ing by conference participants.
HCD indicates human-centered
design.
Figure 2. Example of insight
to prototype progression. An
example of a single insight/
design challenge and the diver-
gent and convergent process
of the design-thinking process.
Following divergent brainstorm-
ing, a workgroup team would
select a theme and develop a
prototype. EHR indicates elec-
tronic health record.
 APSF Stoelting Conference 2019: Perioperative Deterioration
In total, conference participants brainstormed
414 independent ideas, clustered into 117 themes.
Ultimately 19 prototypes emerged (Figure  2), falling
into 4 domains:
• Technology: improving data integration, user-
interactive interfaces; exploring how technology
contributes to workflow.
• Culture/recognition: deconstructing hierarchy,
nurturing respectful behaviors, enabling cultures
valuing all voices equally.
• Training: developing habits of reflection, flexibility,
communication, and empathy
• System workflow: bringing wisdom/optimal deci-
sion-making to the bedside by anticipating and
planning for deterioration.
SUMMARY
The Stoelting Conference 2019 convened multidisci-
plinary, professional experts to explore systems for
patient rescue. Through a hybrid conference utiliz-
ing HCD, discussions and innovations anchored in
the needs of clinicians and patients. It is essential that
we build environments that support and encourage
early escalation of care. We recommend that those
designing solutions keep the 9 insights and challenge
opportunities in mind. These solutions should enable
4 overlapping domains: technology, culture, training,
and system/workflow. APSF will continue encourag-
ing iterations of conference prototypes. We will fos-
ter dialog to deepen our understanding of the system
dynamics, moving us reliably toward eliminating
“Failure-to-Rescue.”‍
Della M. Lin, MS, MD
Department of Surgery
John A. Burns School of Medicine
Honolulu, Hawaii
dlinmdconsult@yahoo.com
Carol J. Peden, MB ChB, MD, MPH
Department of Anesthesiology
Keck School of Medicine at
the University of Southern California
Los Angeles, California
Simone M. Langness, MD
Amanda Sammann, MD, MPH
Department of Surgery
The Better Lab
San Francisco, California
Steven B. Greenberg, MD
Department of Anesthesiology,
Critical Care and Pain Medicine
NorthShore University HealthSystem
Evanston, Illinois
Department of Anesthesiology and Critical Care
University of Chicago, Pritzker School of Medicine
Chicago, Illinois
Meghan B. Lane-Fall, MD, MSHP
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Department of Anesthesiology and Critical Care
Perelman School of Medicine
University of Pennsylvania
Philadelphia, Pennsylvania
Jeffrey B. Cooper, PhD
Department of Anesthesia, Critical Care & Pain Medicine
Massachusetts General Hospital
Boston, Massachusetts
ACKNOWLEDGMENTS
We deeply thank Ben Alpers, George Blike, David
Gaba, Devika Patel, Lynn Reede, Patty Reilly, Matthew
Weinger, Bradley Winters, Stacey Maxwell, and Mark
Warner for being essential members of the Stoelting
Conference 2019 Steering Committee. This submission
would not be possible without them.
DISCLOSURES
Name: Della M. Lin, MS, MD.
Contribution: This author was critically involved with plan-
ning and executing the conference and drafted and revised the
manuscript.
Conflicts of Interest: None.
Name: Carol J. Peden, MB ChB, MD, MPH.
Contribution: This author helped with planning and executing
the conference and with concept, drafting, and revision of the
manuscript.
Conflicts of Interest: None.
Name: Simone M. Langness, MD.
Contribution: This author helped with planning and executing
the conference and with concept, drafting, and revision of the
manuscript.
Conflicts of Interest: None.
Name: Amanda Sammann, MD, MPH.
Contribution: This author was critically involved with plan-
ning and executing the conference and with drafting and revi-
sion of the manuscript.
Conflicts of Interest: None.
Name: Steven B. Greenberg, MD.
Contribution: This author helped in planning and executing
the conference and with critical revisions of the manuscript.
Conflicts of Interest:  S. B. Greenberg is the APSF Newsletter
Editor-in-Chief  and an Associate Editor, Safety Section,
Anesthesia & Analgesia.
Name: Meghan B. Lane-Fall, MD, MSHP.
Contribution: This author helped in planning and executing
the conference and with revisions of the manuscript.
Conflicts of Interest: None.
Name: Jeffrey B. Cooper, PhD.
Contribution: This author helped in planning and executing
the conference and with concept, drafting, and revision of the
manuscript.
Conflicts of Interest: None.
This manuscript was handled by: Richard C. Prielipp, MD,
MBA.
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