Very interesting paper in New England Journal of Medicine (NEJM 2009;361:1368-75, Variation in hospital mortality associated with inpatient surgery) that hospitals have widely variable mortality rates, but surprisingly very similar complication rates. What seems to differentiate great hospitals from good ones, is the ability to rescue patients from complications, not preventing complications.

This is a very important finding, because rescue, in hospitals, is often neglected. We assume that the same nurses and staff that perform routine daily medical care, can immediately transition into providers that can handle the rapidly changing variables present in a patient who is declining or crashing. Often saving a patient with a major complication requires aggressive resuscitation, thorough and rapid search for a cause, and immediate intervention. Another problem is that these patients often look “sick” but dont look like they are “dying”. By the time they look like they are dying, it is often too late to effectively intervene.

Also you could gather 10 patients with sepsis, and they will all have different symptoms, vital signs, and lab data. It takes an experienced caregiver, with a very healthy paranoia, to intervene correctly in these situations. Another maxim of rescue (in hospital and out) is the acceptance of over-reaction. I have talked about this before in that the fire-ems community accept a rather large percentage of calls where they “over respond” based on the eventual facts of the situation. Hospitals are only now learning the importance of over-reaction, and the fact that if you are going to catch the 5 patients who are dying from a complication, you may need to vigorously intervene on the 20 patients who just “look like something is wrong”. Waiting until those 5 patients declare themselves as “really sick” will likely eliminate your opportunity to save all of them. Thus, over-reaction will save lives.