Why It Matters
Five sequential care steps are projected to cut post-surgical mortality by 25 percent.
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Using the “5Rs for Rescue” to Reduce Post-Surgical Mortality

By Pierre Barker | Tuesday, March 14, 2023
Rescuing Post-Surgical Patients The 5Rs for Rescue Initiative

The number of patients who die from post-surgical complications in low- and middle-income countries is shockingly high. In Africa alone, more than 600,000 people die each year after surgery, mostly from causes that are relatively easy to treat. In fact, more patients die from post-surgical complications in Africa than all deaths from tuberculosis, HIV, and malaria combined. Yet, infectious diseases continue to receive billions of dollars in development aid, while quality of care for surgical patients gets very little attention.

In early February of 2023, a team from the Institute for Healthcare Improvement (IHI) travelled to Addis Abiba, the capital of Ethiopia, to join anesthetists, surgeons, and nurses from 10 hospitals in Ethiopia, South Africa, Tanzania, and Uganda and researchers from the United Kingdom (UK) and South Africa. Together they launched a quality improvement (QI) demonstration project to show that it was possible to rescue patients who were deteriorating in post-surgical wards. In a first-of-its-kind investment, the IHI Board of Directors provided seed funding for IHI’s team to work alongside a large research effort on the causes of post-surgical deaths funded by the National Institute for Health and Care Research based in the UK.

IHI will test how to support the reliable implementation of the “5Rs for Rescue,” five sequential care steps projected to cut post-surgical mortality by 25 percent:

  • Risk stratification
  • Recognize deterioration
  • Respond
  • Reassess
  • Reflect/Redesign

IHI Senior Project Director Paulo Borem, MD, is confident about the prospects of this effort. “We have an engaged group of hospitals and partners,” he noted. “We also have team members who are excited to contribute their improvement experience to this work.” Borem led a team in Brazil that used an approach similar to the 5Rs in 19 public hospitals to reduce maternal mortality. They used QI methods to systematically identify patients at risk, watch them carefully, and respond quickly when they ran into trouble. The project resulted in a 35 percent decrease in deaths of mothers during childbirth. “With both initiatives,” Borem said, “we are trying to help frontline teams avoid ‘failure to rescue.’”

Borem and IHI Senior Director Maureen Tshabalala are leading a team of expert IHI faculty assigned to each of the four countries who have energized hospital teams to take the first step for rescuing patients after surgery. A simple surgical risk calculator, developed by our research partners from the African Surgical Outcomes Study, can identify more than 80 percent of patients likely to get complications after surgery. In the 10 days since our initial launch meeting, the group set up on a widely available messaging app has been crackling with reports of hospital QI teams rapidly deploying the risk tool and taking the first crucial steps on the 5R pathway to rescuing post-surgical patients from preventable deaths.

If the demonstration is successful over the next 12 months, the next step will be to test the scalability of the initiative in 40 more hospitals. Using what is learned from that, the objective will be to undertake a major scale up across more African countries to an expected 300 or more hospitals.

The work has great importance not only for avoiding many the 600,000 potential post-surgical deaths each year. If successful, this initiative will also show how any major hospital-based care failure in low- and middle-income countries can be addressed through QI approaches, and how those learnings can be scaled rapidly across a large geographical area.

Pierre M. Barker, MD, MBChB, is Chief Scientific Officer, Institute for Healthcare Improvement.

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