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Despite living closer to high-performing centers, minority patients reportedly receive care at lower-quality hospitals. Investigating opportunities for improvement at minority-serving hospitals may help attenuate disparities in care among cardiothoracic surgery patients. We sought to investigate the relationship between hospital quality and failure to rescue (FTR).Over 451,000 cardiac surgery patients from 2000 to 2011 at minority-serving hospitals (MSHs) were identified from the Nationwide Inpatient Sample. After stratifying patients by hospital mortality quartile, outcomes at poorly performing MSHs were compared with those at high-performing MSHs. Propensity score matching was used for comparisons.Though patients at poorly performing centers were more likely Black, there were no significant differences in admission status (urgent vs elective), income, insurance, or risk before matching. There were no differences in comorbidities between low-performing and high-performing MSHs including chronic lung disease, coagulopathy, hypertension, and renal failure. While complications remained similar across mortality quartiles (29%, 32%, 31%, and 36%, respectively; P.0001), FTR increased in a stepwise manner (5.4%, 8.7%, 11.2%, and 15.5%, respectively; P.0001). The same was true after propensity score matching-FTR nearly tripled in the highest-mortality centers (14.4% vs 5.3%; P.0001), while complications only increased 1.2-fold from 31.1% to 36.7% (P = .0058). This finding persisted even when stratified by procedure type and by complication.Improving timely management of complications after cardiac surgery may serve as a promising opportunity for increasing quality of care at MSHs. When considering centralization of care in cardiac surgery, equal emphasis should be placed on collaboration between tertiary care centers and low-quality MSHs to mitigate disparities in care.

Failure to rescue (FTR) is defined as mortality following a complication. Failure to rescue has come under scrutiny as a quality metric to compare trauma centers. In contrast to elective surgery, trauma has an early period of high expected mortality because of injury sequelae rather than a complication. Here, we report FTR in early and late mortality using an externally validated trauma patient database, hypothesizing that centers with higher risk-adjusted mortality rates have higher risk-adjusted FTR rates.The study included 114,220 patients at 34 Levels I and II trauma centers in a statewide quality collaborative (2016-2020) with Injury Severity Score of ≥5. Emergency department deaths were excluded. Multivariate regression models were used to produce center-level adjusted rates for mortality and major complications. Centers were ranked on adjusted mortality rate and divided into quintiles. Early deaths (within 48 hours of presentation) and late deaths (after 48 hours) were analyzed.Overall, 6.7% of patients had a major complication and 3.1% died. There was no difference in the mean risk-adjusted complication rate among the centers. Failure to rescue was significantly different across the quintiles (13.8% at the very low-mortality centers vs. 23.4% at the very-high-mortality centers, p0.001). For early deaths, there was no difference in FTR rates among the highest and lowest mortality quintiles. For late deaths, there was a twofold increase in the FTR rate between the lowest and highest mortality centers (9.7% vs. 19.3%, p0.001), despite no difference in the rates of major complications (5.9% vs. 6.0%, p = 0.42).Low-performing trauma centers have higher mortality rates and lower rates of rescue following major complications. These differences are most evident in patients who survive the first 48 hours after injury. A better understanding of the complications and their role in mortality after 48 hours is an area of interest for quality improvement efforts.Prognostic and Epidemiologic; Level III.

BACKGROUND Emergency general surgery (EGS) presents a challenge for frail, geriatric individuals who often have extensive comorbidities affecting postoperative recovery. Previous studies have shown an association between increasing frailty and adverse outcomes following elective and EGS; no study has explored the same for the geriatric patient population using the modified 5-item frailty index (mFI-5) score. MATERIALS AND METHODS A retrospective cohort study was performed using the 2012-2017 American College of Surgeons - National Surgical Quality Improvement Program database to identify geriatric patients (≥65 years) undergoing EGS procedures within 48 h of admission. The previously validated mFI-5 score was used to assess preoperative frailty. The study cohort was divided into four groups: mFI-5 = 0, mFI-5 = 1, mFI-5 = 2, and mFI-5 ≥ 3; the impact of increasing mFI-5 score on failure-to-rescue (FTR), 30-day complications, readmissions, reoperations, and mortality was assessed. RESULTS A total of 47,216 patients were included: 27.4% with mFI-5 = 0, 45% with mFI-5 = 1, 22.1% with mFI-5 = 2, and 5.5% with mFI-5 ≥ 3. Following multivariate analyses, increasing mFI-5 score was associated with higher odds of FTR (mFI-5 = 1: odds ratio (OR) 1.48, p=0.003; mFI-5 = 2: OR 2.66, p

A nationwide variation in mortality stratified by hospital volume exists after open repair of complex abdominal aortic aneurysms (AAAs). In the present study, we assessed whether the rates of postoperative complications or failure-to-rescue (defined as death after a major postoperative complication) would better explain the lower mortality rates among higher volume hospitals.Using the 2004 to 2018 Vascular Quality Initiative database, we identified all patients who had undergone open repair of elective or symptomatic AAAs, in which the proximal clamp sites were at least above one renal artery. We divided the patients into hospital quintiles according to the annual hospital volume and compared the risk-adjusted outcomes. Multivariable logistic regression, adjusted for patient characteristics, operative factors, and hospital volume, was used to evaluate three outcomes: 30-day mortality, overall complications, and failure-to-rescue.We identified 3566 patients who had undergone open repair of elective or symptomatic complex AAAs (median age, 71 years; 29% women; 4.1% black; 48% Medicare insurance). The unadjusted rates of 30-day postoperative mortality, overall complications, and failure-to-rescue were 5.0%, 44%, and 10%, respectively. Common complications included renal dysfunction (25%), cardiac dysrhythmia (14%), and pneumonia (14%), with the specific failure-to-rescue rate ranging from 12% to 22%. On adjusted analysis, the risk-adjusted mortality rate was 2.5 times greater for the lower volume hospitals relative to the higher volume hospitals (7.4% vs 3.0%; P .01). Although the risk-adjusted complication rates were similar between these hospital groups (30% vs 27%; P = .06), the failure-to-rescue rate was 2.3 times greater for the lower volume hospitals relative to the higher volume hospitals (6.3% vs 2.7%; P = .02).Higher volume hospitals had lower mortality rates after open repair of complex AAAs because they were better at the "rescue" of patients after the occurrence of postoperative complications. Both an understanding of the clinical mechanisms underlying this association and the regionalization of open repair might improve patient outcomes.

Background Failure-to-rescue is a quality indicator measuring the response to postoperative complications. The current study aims to compare failure-to-rescue in patients suffering severe complications after surgery for colorectal cancer between hospitals based on their university status. Methods Patients undergoing colorectal cancer surgery from January 2015 to January 2020 in Sweden were included through the Swedish Colorectal Cancer Registry in the current study. Severe postoperative complications were defined as Clavien-Dindo ≥3. Failure-to-rescue incidence rate ratios were calculated comparing university versus nonuniversity hospitals. Results A total of 23,351 patients were included in this study, of whom 2,964 suffered severe postoperative complication(s). University hospitals had lower failure-to-rescue rates with an incidence rate ratios of 0.62 (0.46–0.84, P = .002) compared with nonuniversity hospitals. There were significantly lower failure-to-rescue rates in almost all types of severe postoperative complications at university than nonuniversity hospitals. Conclusion University hospitals have a lower risk for failure-to-rescue compared with nonuniversity hospitals. The exact mechanisms behind this finding are unknown and warrant further investigation to identify possible improvements that can be applied to all hospitals.

Prior studies of older cancer patients undergoing large operations have reported similar rates of complications to the general population but higher rates of mortality, suggesting higher rates of failure-to-rescue (FTR) with advanced age. Whether age is a marker for frailty, or an independent predictor of FTR, is not clear.The ACS-NSQIP database was queried from 2015-19 for patients undergoing surgery for gastrointestinal (GI) malignancy. Patients were divided into age-stratified cohorts: C1 (18-55), C2 (56-65), C3 (66-75), C4 (76-89). Adjusted odds ratios (aOR) were computed to assess the relationship of the FTR rate and age, while controlling for potential confounders. A second analysis was specified with all covariates converted to Z-scores, which generated scaled adjusted odds ratios (saOR) to determine the strongest predictor of FTR.Multivariable analysis suggests that age is an independent predictor of FTR: C2:C1 aOR = 1.87 (p0.001); C3:C1 aOR = 3.33 (p0.001); C4:C1 aOR = 5.71 (p0.001). The scaled analysis demonstrated that age is the strongest predictor of FTR (saOR = 1.92, p0.001); a one standard deviation increase in age was associated with a 92% increased odds of FTR. The saOR for frailty (1.18, p0.001) and for number of comorbidities (1.10, p = 0.005) also were statistically significant.Chronologic age was independently associated with increased FTR after surgery for GI malignancy and was the strongest predictor of FTR. These results suggest that chronologic age must be carefully considered when evaluating the fitness of a patient for GI cancer surgery.

Summary Mortality after visceral surgery has decreased owing to progress in surgical techniques, anesthesiology and intensive care. Mortality occurs in 5–10% of patients after major surgery and remains a topic of interest. However, the ratio of mortality after postoperative complications in relation to overall complications varies between hospitals because of failure to rescue at the time of the complication. There are multiple factors that lead to complication-related mortality: they are patient-related, disease-related, but are related, above all, to the timeliness of diagnosis of the complication, the organisational aspects of management in private or public hospitals, hospital volume that corresponds to the centralisation of initial management or to the concept of referral centre in case of complications, to the team spirit, to communication between the health care providers and to the management of the complication itself. Several organisational advances are to be considered, such as the development of shorter hospitalisations and notably ambulatory surgery, as well as enhanced recovery programs. Remote monitoring and the contribution of artificial intelligence must also be evaluated in this context. The reduction of mortality after visceral surgery rests on several tactics: prevention of potentially lethal complications, the all-important reduction of failure to rescue, and risk management before, during and after hospitalisations that are increasingly shorter.

OBJECTIVE: This analysis aimed to compare failure to rescue (FTR) after pancreatoduodenectomy across the Atlantic. SUMMARY BACKGROUND DATA: FTR, or mortality after development of a major complication, is a quality metric originally created to compare hospital results. FTR has been studied in North American and Northern European patients undergoing pancreatoduodenectomy (PD). However, a direct comparison of FTR after PD between North America and Northern Europe has not been performed. METHODS: Patients who underwent PD in North America, the Netherlands, Sweden and Germany (GAPASURG dataset) were identified from their respective registries (2014-17). Patients who developed a major complication defined as Clavien-Dindo ≥3 or developed a grade B/C postoperative pancreatic fistula (POPF) were included. Preoperative, intraoperative, and postoperative variables were compared between patients with and without FTR. Variables significant on univariable analysis were entered into a logistic regression for FTR. RESULTS: Major complications occurred in 6188 of 22,983 patients (26.9%) after PD, and 504 (8.1%) patients had FTR. North American and Northern European patients with complications differed, and rates of FTR were lower in North America (5.4% vs 12%, P < 0.001). Fourteen factors from univariable analysis contributing to differences in patients who developed FTR were included in a logistic regression. On multivariable analysis, factors independently associated with FTR were age, American Society of Anesthesiology ≥3, Northern Europe, POPF, organ failure, life-threatening complication, nonradiologic intervention, and reoperation. CONCLUSIONS: Older patients with severe systemic diseases are more difficult to rescue. Failure to rescue is more common in Northern Europe than North America. In stable patients, management of complications by interventional radiology is preferred over reoperation.

What is known and objective Postsurgical recovery is influenced by multiple pre-, intra- and perioperative pharmacotherapeutic interventions, including the administration of medications that can induce respiratory depression postoperatively. We present a succinct overview of the topic, including the nature and magnitude of the problem, contributing factors, current limited options, and potential novel therapeutic approach. Comment Pre-, intra- and perioperative medications are commonly administered for anxiety, anaesthesia, muscle relaxation and pain relief among other reasons. Several of the medications alone or in joint-action can be additive or synergistic producing respiratory depression. Given the large number of surgical procedures that are performed each year, even a small percentage of postoperative respiratory complications translates into a large number of affected patients. What is new and conclusion Due to the large number of surgeries performed each year, and the variety of medications used before, during, and after surgery, the occurrence of postoperative respiratory depression is surprisingly common. It is a significant medical problem and burden on hospital resources. There is a need for new strategies to prevent and treat the acute and collateral problems associated with postoperative respiratory depression.

Colectomies are common yet costly, with high surgical-site infection rates. Safety-net hospitals (SNHs) carry a large proportion of uninsured or Medicaid-insured patients, which has been associated with poorer surgical outcomes. Few studies have examined the effect of safety-net burden (SNB) status on colectomy outcomes. We aimed to quantify the independent effects of hospital SNB and surgical site infection (SSI) status on colectomy outcomes, as well as the interaction effect between SSIs and SNB.We used the Healthcare Cost and Utilization Project's State Inpatient Databases for California, Florida, New York, Maryland, and Kentucky. We included 459,568 colectomies (2009 to 2014) for analysis, excluding patients age18 y and rectal cases. The primary and secondary outcomes were inpatient mortality and complications, respectively.Adjusting for patient, procedure, and hospital factors, colectomy patients were more likely to die in-hospital at high-burden SNHs (adjusted OR [aOR]: 1.38, 95% confidence interval [CI]: 1.25-1.51, P 0.001), compared with low SNB hospitals and to experience perioperative complications (aOR: 1.12, 95% CI: 1.04-1.20, P 0.01). Colectomy patients with SSIs also had greater odds of in-hospital mortality (aOR: 1.92, 95% CI: 1.83-2.02, P 0.001) and complications (aOR: 3.65, 95% CI: 3.55-3.75, P 0.001) compared with those without infections. Patients treated at SNHs who developed a SSI were even more likely to have an additional perioperative complication (aOR: 4.33, 95% CI: 3.98-4.71, P 0.001).Our study demonstrated that colectomy patients at SNHs have poorer outcomes, and for patients with SSIs, this disparity was even more pronounced in the likelihood for a complication. SNB should be recognized as a significant hospital-level factor affecting colectomy outcomes, with SSIs as an important quality metric.

Background Appendicitis is one of the most common emergency surgery conditions worldwide, and the incidence is increasing in low- and middle-income countries. Disparities in access to care can lead to disproportionate morbidity and mortality in resource-limited settings; however, outcomes following an appendectomy in low- and middle-income countries remain poorly described. Therefore, we aimed to describe the characteristics and outcomes of patients with appendicitis presenting to a tertiary care center in Malawi. Methods We conducted a retrospective analysis of the Kamuzu Central Hospital (KCH) Acute Care Surgery database from 2013 to 2020. We included all patients ≥13 years with a postoperative diagnosis of acute appendicitis. We performed bivariate analysis by mortality, followed by a modified Poisson regression analysis to determine predictors of mortality. Results We treated 214 adults at KCH for acute appendicitis. The majority experienced prehospital delays to care, presenting at least 1 week from symptom onset (n = 99, 46.3%). Twenty (9.4%) patients had appendiceal perforation. Mortality was 5.6%. The presence of a postoperative complication the only statistically significant predictor of mortality (RR 5.1 [CI 1.13-23.03], P = 0.04) when adjusting for age, shock, transferring, and time to presentation. Conclusions Delay to intervention due to inadequate access to care predisposes our population for worse postoperative outcomes. The increased risk of mortality associated with resultant surgical complications suggests that failure to rescue is a significant contributor to appendicitis-related deaths at KCH. Improvement in barriers to diagnosis and management of complications is necessary to reduce further preventable deaths from this disease.

Pulmonary complications are the most common adverse event after injury and second greatest cause of failure to rescue (death after pulmonary complications). It is not known whether readily accessible trauma center data can be used to stratify center-level performance for various complications. Performance variation between trauma centers would allow sharing of best practices among otherwise similar hospitals. We hypothesized that high-, average-, and low-performing centers for pulmonary complication and failure to rescue could be identified and that hospital factors associated with success and failure could be discovered.Pennsylvania state trauma registry data (2007-2015) were abstracted for pulmonary complications. Burns and age17 were excluded. Multivariable logistic regression models were developed for pulmonary complication and failure to rescue, using demographics, comorbidities, and injuries/physiology. Expected event rates were compared with observed rates to identify outliers. Center-level variables associated with outcomes of interest were taken from the American Hospital Association Annual Survey Database and assessed for inclusion.Included in the study were 283,121 patients (male [60%] blunt trauma [92%]). Of these patients, 3% (8,381 of 283,121) developed pulmonary complications (center-level range 0.18%-5.8%). The percentage of failure-to-rescue patients was 13.4% (1,120/8,381, center-level range 0.0%-22.6%). For pulmonary complications, 13 out of 27 centers were high performers (95% CI for O:E ratio1) and 7 out of 27 were low (95% CI for an O:E ratio1). For failure-to-rescue patients, 2 out of 27 centers were low performers and the remainder average. There was little concordance between performance for pulmonary complications and failure to rescue. Research programs, large non-teaching hospitals, those with advanced practice providers, and those with health maintenance organizations had reduced failure-to-rescue patients.Factors associated with complications were distinct from those affecting failure to rescue and center-level success in reducing complications often did not translate into success in preventing death once they occurred. Our data demonstrate that high- and low-performing centers and the factors driving success or failure are identifiable. This work serves as a guide for comparing practices and improving outcomes with readily available data.

This article provides a better understanding of how interactions and relationships within hospital microsystems affect rescue. Through structured engagement of clinical champions, these rescue improvement tools may decrease rates of secondary and tertiary complications and enhance staff culture, confidence, and competence. The proposed 3-prong approach sheds light on how health care organizations can better sense, cope with, and respond to the unexpected and changing demands presented by clinically deteriorating postsurgical patients. These interventions lay the groundwork for the further development, testing, and implementation of larger scale rescue-focused initiatives, which could have a direct, population-level impact on mortality.

Failure to rescue (FTR) is gaining popularity as a quality metric. The relationship between patient frailty and FTR after cardiovascular surgery has not been fully explored. This study aimed to utilize a national database to examine the impact of patient frailty on FTR.Of 5,199,534 patients undergoing cardiovascular surgery between 2000 and 2014, 75,851 (1.5%) were identified from the Nationwide Inpatient Sample database as frail based on the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. Propensity-score matching was used to adjust for patient- and hospital-level characteristics and comorbidities when comparing frail and nonfrail patients.Frail patients were on average older (68 ± 12 years vs 65 ± 12 years; P.001) and had more comorbidities including heart failure, and chronic lung, liver, or renal disease. Among 68,472 matched pairs, frail patients had significantly higher rates of FTR (13.4% vs 11.9%; P .001). This contributed to a $39,796 increase in cost per hospitalization (P.001). Renal failure, respiratory failure, pneumonia, and sepsis were most commonly associated with FTR in frail patients. When hospitals were stratified by risk-adjusted mortality, low-mortality (1st quintile) centers had significantly lower FTR rates and costs among frail patients when compared to high-mortality (5th quintile) centers.Frailty contributes significantly to FTR after cardiovascular surgery. Frail patients can expect better outcomes with lower costs at cardiac surgical centers of excellence that can adequately manage postoperative outcomes. Preoperative assessment of frailty may better guide risk estimation and identification of patients who would benefit from appropriate prehabilitative interventions to optimize outcomes.

Increased life expectancy leads to older and frailer surgical patients. Co-management between medical and surgical specialities has proven favourable in complex situations. Selection of patients for co-management is full of difficulties. The aim of this study was to develop a clinical decision support tool to select surgical patients for co-management.Clinical data was collected from patient electronic health records with an ICD-9 code for colorectal surgery from January 2012 to December 2015 at a hospital in Lisbon. The outcome variable consists in co-management signalling. A dataset from 344 patients was used to develop the prediction model and a second data set from 168 patients was used for external validation.Using logistic regression modelling the authors built a five variable (age, burden of comorbidities, ASA-PS status, surgical risk and recovery time) predictive referral model for co-management. This model has an area under the curve (AUC) of 0.86 (95% CI: 0.81 - 0.90), a predictive Brier score of 0.11, a sensitivity of 0.80, a specificity of 0.82 and an accuracy of 81.3%.Early referral of high-risk patients may be valuable to guide the decision on the best level of post-operative clinical care. We developed a simple bedside decision tool with a good discriminatory and predictive performance in order to select patients for comanagement.A simple bed-side clinical decision support tool of patients for co-management is viable, leading to potential improvement in early recognition and management of postoperative complications and reducing the 'failure to rescue'. Generalizability to other clinical settings requires adequate customization and validation.Introdução: O aumento da esperança média de vida leva a que a população cirúrgica seja cada vez mais velha e frágil. Os modelos colaborativos de co-gestão entre especialidades médicas e cirúrgicas têm demonstrado ser favoráveis em situações complexas. A selecção de doentes para co-gestão está repleta de dificuldades. O objectivo deste estudo foi construir uma ferramenta de apoio à decisão para selecionar doentes de submetidos a cirurgia colo-rectal para co-gestão. Material e Métodos: A informação clínica foi colhida dos processos clínicos electrónicos de doentes que tiveram um código ICD-9 de cirurgia colo-rectal no período de janeiro 2012 a dezembro 2015, num hospital em Lisboa. A variável resposta consiste na sinalização para co-gestão. Um conjunto de dados de 344 doentes foi usado para o desenvolvimento do modelo predictivo e, um segundo conjunto de dados de 168 doentes foi usado para a validação externa do modelo. Resultados: Os autores construíram um modelo predictivo, de regressão logística, com cinco variáveis clínicas (idade, carga de co-morbilidades, ASA-PS status, risco cirúrgico e tempo de recobro) para predizer a selecção de doentes para co-gestão. O modelo tem uma área sob a curva (AUC) de 0,86 (95% IC: 0,81 - 0,90), um score predictivo de Brier de 0,11, uma sensibilidade de 0,80, uma especificidade de 0,82 e uma precisão de classificação de 81,3%. Discussão: A sinalização precoce dos doentes de alto risco ajuda a definir o melhor nível de cuidados ao doente operado. Desenvolvemos uma ferramenta de apoio à decisão, simples, aplicável à cabeceira do doente com uma boa capacidade discriminativa e preditiva para seleccionar os doentes para co-gestão. Conclusão: A selecção de doentes para co-gestão entre a cirurgia e a medicina interna permite o reconhecimento e a correcção precoce de complicações pós-operatórias reduzindo o ‘failure to rescue’. A ferramenta, uma vez customizada e validada, poderá ser aplicada em outros cenários clínicos.

Administrative data research on maternal racial disparities supports 2 broad clinical inferences. First, failure to rescue in terms of both death and severe maternal morbidity likely accounts for a significant proportion of maternal disparities. Second, risk for adverse outcomes by race is generally differential with risk for cardiovascular complications particularly high for non-Hispanic black women. These differentials suggest that underlying health conditions may represent an important contributor to overall disparities, and optimal longitudinal care utilization with nonobstetric specialists is required to mitigate risk.

Background Despite advances in surgical technique and perioperative management, pneumonectomy remains associated with significant morbidity and mortality. The purpose of this study was to examine the impact of annual institutional volume of anatomic lung resections on outcomes after elective pneumonectomy. Methods We evaluated all patients who underwent elective pneumonectomy from 2005 to 2014 in the National Inpatient Sample. Patients less than 18 years of age, or with trauma-related diagnoses, mesothelioma, or a nonelective admission were excluded. Hospitals were divided into volume quartiles based on annual institutional anatomic lung resection caseload. We studied the effect of institutional volume on inhospital mortality, complications, and failure to rescue, as well as costs and length of stay. Results During the study period, an estimated 22,739 patients underwent pneumonectomy, with a reduction in national mortality from 7.9% to 5.5% (P trend = .045). Compared with the highest volume centers, operations performed at the lowest volume hospitals were associated with 1.74 increased odds of mortality (95% confidence interval, 1.14 to 2.66). Despite similar odds of postoperative complications, low volume hospital status was associated with increased failure to rescue rates (18.3% vs 12.7%, P = .024) and adjusted odds of mortality (1.70; 95% confidence interval, 1.09 to 2.64) after any complication. Conclusions High volume hospital status is strongly associated with reduced mortality and failure to rescue rates after pneumonectomy. Efforts to centralize care or disseminate best practices may lead to improved national outcomes for this high-risk procedure.

OBJECTIVE To describe the frequency and patterns of postoperative complications and failure to rescue (FTR) after inpatient pediatric surgical procedures and to evaluate the association between number of complications and failure to rescue. SUMMARY AND BACKGROUND FTR, or a postoperative death after a complication, is currently a nationally endorsed quality measure for adults. While it is a contributing factor to variation in mortality, relatively little is known about FTR after pediatric surgery. METHODS Cohort study of 200,554 patients within the National Surgical Quality Improvement Program-Pediatric database (2012-2016) who underwent a high (≥1%) or low (

Background We aimed to examine whether safety-net burden is a significant predictor of failure-to-rescue (FTR) after major abdominal surgery controlling for patient and hospital characteristics, including surgical volume. Methods Data were extracted from the 2007–2011 Nationwide Inpatient Sample. FTR was defined as mortality among patients experiencing major postoperative complications. Differences in rates of complications, mortality, and FTR across quartiles of safety-net burden were assessed with univariate analyses. Multilevel regression models were constructed to estimate the association between FTR and safety-net burden. Results Among 238,645 patients, the incidence of perioperative complications, in-hospital mortality, and FTR were 33.7%, 4.4%, and 11.8%, respectively. All the outcomes significantly increased across the quartiles of safety-net burden. In the multilevel regression analyses, safety-net burden was a significant predictor of FTR after adjustment for patient and hospital characteristics, including hospital volume. Conclusion Increasing hospital safety-net burden is associated with higher odds of FTR for major abdominal surgery.

Background Failure to Rescue (FTR) is a valuable surgical quality improvement metric. The aim of this study is to assess the relationship between center volume and FTR following lung transplantation. Methods Using the database of the United Network for Organ Sharing (UNOS) all adult, primary, isolated lung recipients in the United States between May 2005 and March 2016 were identified. FTR was defined as operative mortality after any of five specific complications. FTR was compared across terciles of transplantation centers stratified based on operative volume. Results 17,185 lung recipients met study criteria. The composite FTR rate (Death following at least one complication) was 20.7%. Following stratification by volume, FTR rates increased from high to middle tercile centers (19.3% vs. 23.0%). Multivariate logistic regression models suggested an independent relationship between higher center volume and lower FTR rates (p Conclusion Higher volume lung transplantation centers have lower rates of failure to rescue.

Background While the use of the failure-to-rescue (FTR) metric, or death after complication, has expanded beyond elective surgery to emergency general surgery (EGS), little is known about the trajectories patients take from index complication to death. Methods We conducted a retrospective cohort study of EGS operations using the National Surgical Quality Improvement Project (NSQIP) dataset, 2011-2017. 16 major complications were categorized as infectious, respiratory, thrombotic, cardiac, renal, neurologic, or technical. We tabulated common combinations of complications. We then use logistic regression analyses to test the hypotheses that (1) increase in the number and frequency of complications would yield higher FTR rates and (2) secondary complications that span a greater number of organ systems or mechanisms carry a greater associated FTR risk. Results Of 329 183 EGS patients, 69 832 (21.2%) experienced at least 1 complication. Of the 11 195 patients who died following complication (16.0%), 8205 (63.4%) suffered more than 1 complication. Multivariable regression analyses revealed an association between the number of complications and mortality risk (odds ratio [OR] 2.37 for 2 complications vs 1, P < .001). There was a similar increase in mortality with increased complication accrual rate (OR 3.29 for 0.2-0.4 complications/day vs Discussion While past FTR analyses have focused primarily on index complication, a broader consideration of ensuing trajectory may enable identification of high-risk cohorts. Efforts to reduce mortality in EGS should focus on attention to those who suffer a complication to prevent a cascade of downstream complications culminating in death.

Mortality in emergency general surgery (EGS) is often attributed to patient condition, which may obscure opportunities for improvement in care. Identifying failure to rescue (FTR), or death after complication, may reveal these opportunities. FTR has been problematic in trauma secondary to low precedence rates (proportion of deaths preceded by complication). We sought to evaluate this in EGS, hypothesizing that precedence is lower in EGS than in similar elective operations.National Inpatient Sample data from January 2014 through September 2015 were used. 150,027 adult operative EGS complete cases were defined by emergent admission, one of seven International Classification of Diseases, ninth revision (ICD-9) procedure group codes for common EGS operations, and timing to operation (48 h); these represent 750,135 patients under the National Inpatient Sample sampling design. Deaths were precedented if one of eight prespecified complications was identified. Chi-squared tests were used to compare precedence rates between selected emergent and elective operations.There was a 2.5% mortality rate in this cohort of operative EGS patients, with an 84.1% (95% CI: 82.7%-85.4%) precedence rate. Among the seven listed procedure groups, those with clinically reasonable elective analogs were cholecystectomy, colon resection, and laparotomy. Emergent versus elective precedence rates were 90.2% versus 82.0% (P = 0.004) for colon resection, 81.3% versus 86.8% (P = 0.26) for cholecystectomy, and 68.8% versus 92.7% (P 0.001) for laparotomy.Precedence rates in EGS were higher than expected and were similar to previously published rates in nonemergent surgery, suggesting that FTR is likely to be reliable using standard methodology. Management of complications after emergency operation may represent significant opportunities to prevent mortality.

Residents of skilled nursing facilities (SNF) with acute abdomen present with more comorbidities and frailty than community-dwelling (CD) counterparts. Outcomes in this population are poorly described.We hypothesized that SNF patients have higher mortality and morbidity than CD patients. This retrospective review of the NSQIP database from 2011 to 2015 compared outcomes of SNF and CD patients presenting with bowel obstruction, ischemia and perforation. Primary outcomes were in-hospital and 30-day mortality and failure-to-rescue (FTR).18,326 patients met inclusion criteria. 904 (5%) presented from SNF. In-hospital (26% vs 10%) and 30-day mortality (33% vs 26%) was higher in SNF patients (p 0.001). The FTR rate was 34% for SNF patients and 20% for CD patients (p 0.001).Presentation from SNF is an independent predictor of mortality and FTR. Presentation from SNF is a potential trigger for early, concurrent palliative care to assist surgeons, patients, and families in decision making and goal-concordant treatment.

Background Cardiac surgeons have a significant history of participating in humanitarian work; however, the outcomes in this arena are not well delineated. We sought to define and describe failure to rescue (FTR) in this setting by analyzing the outcomes of the International Children’s Heart Foundation. Methods From 2008 to 2017, 3009 patients underwent operations during the course of an International Children’s Heart Foundation mission. Of these, 1165 patients had at least one complication. These patients were divided into those who ultimately died (FTR group, n = 107) and those who survived (survivor group, n = 1058). Clinical presentation and outcomes were compared. Results The overall FTR rate was 10%. Patients in the FTR group were significantly younger, weighed less, and were shorter. Children who required a preoperative admission to the intensive care unit were more likely to be in the FTR group. Intraoperative data demonstrated significantly longer cardiopulmonary bypass time among FTR patients, with similar use of intraoperative blood product. Postoperatively, patients in the FTR group had more reintubations than survivors. Cardiopulmonary bypass and intensive care unit times were shown to be significant predictors of FTR. There was a trend between program volume and FTR rate. Program volume appeared to be correlated with FTR. Conclusions Failure to rescue occurs at a rate of 10% in the humanitarian congenital cardiac surgery setting. The FTR patients were younger, required more intubations, and had significantly more diagnoses of transposition of the great arteries. Longer cardiopulmonary bypass time and intensive care unit admission were associated with increased risk of FTR.

Background Obesity has traditionally been considered a cause of increased surgical complexity and poor outcomes following pancreatoduodenectomy (PD). This study aimed at evaluating the role of obesity in terms of mortality and failure to rescue (FTR), with a particular focus on nonmalignant tumors. Methods All patients undergoing elective PD over 10 consecutive years were analyzed. Patients were stratified according to their BMI and categorized into two groups. Predictors of mortality and FTR were assessed through logistic regression. Results Out of 1865 patients included, 151 were obese (8.1%). Overall mortality and FTR were 3.1% and 14.1%, respectively. In obese patients, mortality was 6.0% and FTR 26.5%, significantly higher compared to nonobese (p 70 years, and ASA-PS score were independent predictors of mortality and FTR. Postoperative pancreatic fistula (35.8% vs. 25.8%), postpancreatectomy acute pancreatitis (24.5% vs. 12.5%), and chyle leak (6.0% vs. 3.2%) were more frequent among obese patients. In the subgroup of patients with nonmalignant tumors (n = 443), obesity was the only independent predictor of FTR. Conclusion PD performed in obese patients was associated with higher surgical morbidity and mortality. When dealing with nonmalignant tumors, deferring surgery in obese patients should be strongly considered.

Contains fulltext : 245446.pdf (Publisher’s version ) (Closed access) BACKGROUND: Failure to rescue (FTR) is defined as postoperative complications leading to mortality. This nationwide study aimed to assess factors associated with FTR and hospital variation in FTR after liver surgery. METHODS: All patients who underwent liver resection between 2014 and 2017 in the Netherlands were included. FTR was defined as in-hospital or 30-day mortality after complications Dindo grade ≥3a. Variables associated with FTR and nationwide hospital variation were assessed using multivariable logistic regression. RESULTS: Of 4961 patients included, 3707 (74.4%) underwent liver resection for colorectal liver metastases, 379 (7.6%) for other metastases, 526 (10.6%) for hepatocellular carcinoma and 349 (7.0%) for biliary cancer. Thirty-day major morbidity was 11.5%. Overall mortality was 2.3%. FTR was 19.1%. Age 65-80 (aOR: 2.86, CI:1.01-12.0, p = 0.049), ASA 3+ (aOR:2.59, CI: 1.66-4.02, p

Introduction The interaction of increasing age, Injury Severity Score (ISS), and complications is not well described in geriatric trauma patients. We hypothesized that failure to rescue rate from any complication worsens with age and injury severity. Methods The National Trauma Data Bank (NTDB) was queried for injured patients aged 65 years or older from January 1, 2013 through December 31, 2016. Demographics and injury characteristics were used to compare groups. Mortality rates were calculated across subgroups of age and ISS, and captured with heatmaps. Multivariable logistic regression was performed to identify independent predictors of mortality. Results 614,496 geriatric trauma patients were included; 151,880 (24.7%) experienced a complication. Those with complications tended to be older, female, non-white, have non-blunt mechanism, higher ISS, and hypotension on arrival. Overall mortality was highest (19%) in the oldest (≥86 years old) and most severely injured (ISS ≥ 25) patients, with constant age increasing across each ISS group was associated with a 157% increase in overall mortality ( P < .001, 95% CI: 148-167%). Holding ISS stable, increasing age group was associated with a 48% increase in overall mortality ( P < .001, 95% CI: 44-52%). After controlling for standard demographic variables at presentation, the existence of any complication was an independent predictor of overall mortality in geriatric patients (OR: 2.3; 95% CI: 2.2-2.4). Conclusions Any complication was an independent risk factor for mortality, and scaled with increasing age and ISS in geriatric patients. Differences in failure to rescue between populations may reflect critical differences in physiologic vulnerability that could represent targets for interventions.

Volume-outcome relationships exist for many complex surgical procedures, prompting institutions to adopt surgical volume standards for credentialing. The current Leapfrog Group Hospital volume standard for open abdominal aortic aneurysm repair (OAR) is 15 per year. However, this is primarily based on data from the 1990s and may not be appropriate given the dramatic decline in OAR. We sought to quantify the proportion of hospitals meeting volume standards, the difference in perioperative outcomes between low-volume and high-volume hospitals, and the potential travel burden of volume credentialing on patients.We identified Medicare beneficiaries for individuals aged ≥65 years undergoing OAR in 2013-2014. Hospital "all-payer" annual volume was estimated based on the national proportion of patients undergoing OAR covered by Medicare in the Vascular Quality Initiative. Hospital annual OAR volume was characterized as5/year, 5-9/year, 10-14/year, and ≥15/year (high volume). Adjusted rates of postoperative morbidity, reoperation, failure to rescue, and mortality in 2014 were compared across volume cohorts. Distance between patients' home zip code and high-volume hospitals was calculated.A total of 21,191 OARs were performed at 1,445 hospitals between 2013 and 2014. The average hospital OAR annual volume was 7.8 (standard deviation [SD] ± 9.3) with a median of 4.5. Among the 1,445 hospitals, only 190 (13.1%) performed ≥15 OARs per year whereas 756 hospitals (53.3%) performed5 per year. Among patients who underwent OAR in 2014, 5,395 (53.3%) received care at a hospital that performed15 per year. There was no difference in complication, reoperation, or failure to rescue rates between high-volume and low-volume hospitals. Mortality did not significantly differ among OAR volume cohorts. Hospitals performing5 OARs per year had a mortality rate of 5.7% compared with 5.6% at high-volume hospitals (P = 0.817). One-quarter of patients who received care at a low-volume hospital would have had to travel more than 60 miles to reach a high-volume hospital.By conservative estimates, only 13% of hospitals performing OAR meet current volume standards. Triaging all patients to high-volume hospitals would require shifting over 5,000 patients annually with no associated improvement in perioperative outcomes. Implementation of the current OAR hospital volume standard may significantly burden patients and hospitals without improving surgical outcomes.

Background Pulmonary embolism and deep vein thrombosis are common clinical entities, and the related malpractice suits affect all medical subspecialties. Claims from malpractice litigation were analyzed to understand the demographics of these lawsuits and the common reasons for pursuing litigation. Methods Cases entered into the Westlaw database from March 5, 1987, to May 31, 2018, were reviewed. Search terms included “pulmonary embolism” and “deep vein thrombosis.” Results A total of 277 cases were identified. The most frequently identified defendant was an internist (including family practitioner; 33%), followed by an emergency physician (18%), an orthopedic surgeon (16%), and an obstetrician/gynecologist (9%). The most common etiology for pulmonary embolism was prior surgery (41%). The most common allegation was “failure to diagnose and treat” in 62%. Other negligence included the failure to administer prophylactic anticoagulation while in the hospital (18%), failure to prescribe anticoagulation on discharge (8%), failure to administer anticoagulation after diagnosis (8%), and premature discontinuation of anticoagulation (2%). The most frequently claimed injury was death in 222 cases (80%). Verdicts were found for the defendant in 57% of cases and for the plaintiff in 27% and settled in 16%. Conclusions The most frequently cited negligent act was the failure to give prophylactic anticoagulation, even after discharge. The trends noted in this study may potentially be addressed and therefore prevented by systems-based practice changes. The most common allegation, “failure to diagnose and treat,” suggests that first-contact doctors such as emergency physicians and primary care practitioners must maintain a high index of suspicion for deep vein thrombosis/pulmonary embolism.

Failure to rescue (FTR), defined as death after a major complication in surgical patients, is being used to measure outcomes for quality improvement. Major complications frequently occur in patients undergoing damage control laparotomy (DCL). No previous FTR studies have looked specifically into DCL patients. The aim of this study was to examine risk factors of FTR and identify potential areas for targeted quality improvement in DCL patients. A 10-year retrospective review of all consecutive adult trauma patients who underwent DCL at a Level I trauma center was performed. Demographic and clinical variables were examined for association with FTR. Multi-variate regression analysis was performed to identify risk factors of FTR in DCL patients. A total of 199 DCL patients were analyzed. Overall DCL mortality observed was 11.1 per cent (n = 22/199) and overall FTR for the cohort was n = 16/199. FTR represented 72 per cent (n = 16/22) of the total mortality. The significantly increased risk of FTR was associated with older age ( P = 0.027), lower initial Glasgow Coma Scale score ( P = 0.037), more units of packed red blood cells ( P = 0.028), and respiratory complications ( P = 0.035). Renal and infectious complications did not significantly increase the risk of FTR in this population. FTR is an important benchmark of quality for trauma patients. This study elucidates potential initial characteristics and complications related to FTR in DCL patients. Efforts in achieving zero death from FTR can potentially improve overall mortality in this subset of patients. Future quality interventions to help minimize FTR should target these specific areas.

Patient rescue occurs in phases: recognizing the problem, communicating the concern, and treating the complication. To help improve rescue, we sought to understand facilitators and barriers to managing postoperative complications. We used a criterion-based sample from a large academic medical center. Semistructured interviews ( n = 57) were conducted, which were audio-recorded and transcribed verbatim. Thematic analysis and consensus coding was performed using NVivo 11. We used a framework matrix approach to synthesize our coding and identify themes that facilitate or impede rescue. Clinicians identified root causes for delays in care, such as recognizing patient deterioration, knowing whom to contact and when, and reaching the correct decision-making provider. This study identified significant variation in communication processes across providers caring for surgical patients. Targeted interventions aimed at improving and standardizing these aspects of communication may significantly influence the ability to effectively identify and escalate care for postoperative complications.

Background Complication rates in many complex surgical procedures are associated with the volume of procedures performed. Objectives To investigate the relationship between hospital volume and complications, mortality, and failure to rescue (FTR) rates in patients undergoing vestibular schwannoma (VS) surgery. Design, setting, and participants The Nationwide Inpatient Sample was used to identify 44,336 patients who underwent VS surgery in 1995-2011. Annual case volumes were stratified by quintiles and defined as very low (≤5 cases/year), low (6-12 cases/year) medium (13-22 cases/year), high (23-37 cases/year), and very high-volume (≥38 cases/year). Main outcomes and measures Relationships between hospital volume and in-hospital mortality, postoperative complications, as well as FTR rates, defined as death after a major complication, were examined using multivariate regression analysis. Results Postoperative medical and surgical complications occurred in 5.4% and 14.6% of cases, respectively, and did not differ significantly across volume quintiles. In-hospital mortality decreased with increasing hospital volume, with an incidence of 1.4% for hospitals in the lowest volume quintile compared to 0.1% for hospitals in the top volume quintile. After controlling for all other variables, the odds of in-hospital mortality were lower for medium (OR = 0.19 [0.04-0.93]) and very high-volume hospitals (OR = 0.07 [0.01-0.53]), but not high-volume hospitals (OR = 0.43 [0.05-3.77]). There was no association between hospital volume and the odds of postoperative surgical complications. FTR was associated with hospital volume, with decreasing odds for medium-volume (OR = 0.15 [0.02-0.93]), high-volume (OR = 0.17 [0.04-0.74]), and very high-volume (OR = 0.07 [0.04-0.74]) hospitals. Conclusions Hospital volume does not appear to be associated with complication rates but is associated with decreased likelihood of FTR after VS surgery. Level of evidence NA Laryngoscope, 130:1287-1293, 2020.

Background: Over the years, high-volume pancreatic centers expanded their indications for pancreatoduodenectomy (PD) but with unknown impact on surgical and oncological outcome. Methods: All consecutive PDs performed between 1992–2017 in a single pancreatic center were identified from a prospectively maintained database and analyzed according to three time periods. Results: In total, 1434 patients underwent PD. Over time, more elderly patients underwent PD (P < 0.001) with increased use of vascular resection (10.4 to 16.0%, P < 0.001). In patients with cancer (n = 1049, 74.8%), the proportion pT3/T4 tumors increased from 54.3% to 70.6% over time (P < 0.001). The postoperative pancreatic fistula (16.0%), postpancreatectomy hemorrhage (8.0%) and delayed gastric emptying (31.0%) rate did not reduce over time, whereas median length of stay decreased from 16 to 12 days (P < 0.001). The overall failure-to-rescue rate (6.9%) and in-hospital mortality (2.2%) remained stable (P = 0.89 and P = 0.45). In 523 patients with pancreatic cancer (36.5%), the use of both adjuvant and neoadjuvant chemotherapy increased over time (both p

Medical intensive care unit (MICU) patients develop acute surgical processes that require operative intervention. There are limited data addressing outcomes of emergency general surgery (EGS) in this population. The aim of our study was to characterize the breadth of surgical consults from the MICU and assess mortality after abdominal EGS cases.All MICU patients with an EGS consult in an academic medical center between January 2010 and 2016 were identified from an electronic medical record-based registry. Charts were reviewed to determine reason for consult, procedures performed, and to obtain additional clinical data. A multivariate logistic regression was used to determine patient factors associated with patient mortality.Of 911 MICU patients seen by our service, 411(45%) required operative intervention, with 186 patients undergoing an abdominal operation. The postoperative mortality rate after abdominal operations was 37% (69/186), significantly higher than the mortality of 16% (1833/11192) for all patients admitted to the MICU over the same period (p0.05). Damage-control procedures were performed in 64 (34%) patients, with 46% mortality in this group. The most common procedures were bowel resections, with mortality of 42% (28/66) and procedures for severe clostridium difficile, mortality of 38% (9/24). Twenty-seven patients met our definition of surgical rescue, requiring intervention for complications of prior procedures, with mortality of 48%. Need for surgical rescue was associated with increased admission mortality (odds ratio, 13.07; 95% confidence interval, 2.86-59.77). Twenty-six patients had pathology amenable to surgical intervention but did not undergo operation, with 100% mortality. In patients with abdominal pathology at the time of operation, in-hospital delay was associated with increased mortality (odds ratio, 5.13; 95% confidence interval, 1.11-23.77).Twenty percent of EGS consults from the MICU had an abdominal process requiring an operative intervention. While the MICU population as a whole has a high baseline mortality, patients requiring abdominal surgical intervention are an even higher risk.Prognostic and epidemiological, level III.

Objectives. Two tools to categorize and present quality data, phase of care mortality analysis (POCMA) and failure to rescue (FTR) have been introduced in the cardiothoracic surgical environment, but not tested in Scandinavia. We aimed to investigate whether these tools could be used in a Norwegian patient population and to increase the understanding of why patients die after cardiac surgery. Design. A group of four, including one senior cardiothoracic surgeon and one senior anesthesiologist, scrutinized deaths within 30 days after cardiac surgery at the Clinic of Cardiothoracic Surgery, St. Olav's University Hospital, Norway between February 2012-October 2015 in line with the POCMA-methodology. We used the clinic's internal register to identify patients and utilized all available written information from each patient course. We decided whether each death was surgeon dependent, FTR or a result of a multifactorial etiology, and evaluated the strength of our decisions. Results. We identified 51 deaths out of 1983 operations in our study period, giving unadjusted mortality of 2.6%. Nine deaths were classified as surgeon dependent, 3 FTR and 39 multifactorial. Conclusions. POCMA- and FTR-analyses can be carried out in clinical data which is well documented. The operating surgeon is in many cases not responsible for operative mortality, very few die due to FTR, but most patients die due to a multifactorial etiology.

The Failure to Rescue (FTR) rate is defined as the mortality rate among patients who experience one or more complications. It has been used as an outcome metric for approximately 25 years, primarily in elective surgery populations, and has been shown to be associated with factors that are modifiable on the institutional level. Although the FTR metric was derived in elective surgical populations, modifications have been made in attempts to refine the metric and apply it to broader populations, including medical patients and non-elective surgical patients. However, study among emergency general surgery patients has been limited. In this review, we summarize the current knowledge surrounding FTR, including established risk factors and potential limitations of the metric in emergency general surgery (EGS) populations. We then discuss a conceptual model for FTR events and review strategies to minimize rates. Finally, we provide a brief overview of current areas of study and potential future directions in acute care surgery.

BACKGROUND In adult trauma patients, high- and low-mortality trauma hospitals have similar rates of major complications but differ based on failure to rescue (mortality following a major complication), which has become a marker of hospital quality. The aim of this study is to examine whether failure to rescue is also an appropriate hospital quality indicator in pediatric trauma. METHODS Children younger than 15 years were identified in the 2007 to 2014 National Trauma Databank research data sets. Hospitals were classified as a high, average or low mortality based on risk-adjusted observed-to-expected in-hospital mortality ratios using the modified Trauma Mortality Probability Model. Regression modeling was used to explore the impact of hospital quality ranking on the incidence of major complications and failure to rescue. RESULTS Of 125,057 children, 31,600 were treated at low-mortality outlier hospitals, and 7,014 at high-mortality outlier hospitals. Low-mortality hospitals had a lower rate of major complications compared with high-mortality hospitals (0.5% [low] vs. 0.8% [high]; adjusted odds ratio [OR], 0.71; 95% confidence interval [CI], 0.61-0.83; p < 0.01) and a lower failure-to-rescue rate (17.6% [low] vs. 24.1% [high]; adjusted OR, 0.53 [high; 95% CI 0.34-0.83; p < 0.01]). When patients who died within 48 hours were excluded, low-mortality hospitals had a lower complication rate (OR, 0.81; 95% CI, 0.68, 0.96; p = 0.02), but similar failure-to-rescue rate compared to high-mortality hospitals. There was no correlation between trauma verification level and hospital mortality status based on the model. CONCLUSION For pediatric trauma patients, mortality is more strongly associated with major complication rate than with failure to rescue. Thus, failure to rescue does not appear to be the key driver of hospital quality in this population as it does in the adult trauma population. LEVEL OF EVIDENCE Prognostic and epidemiological, level III.

BACKGROUND: Failure to rescue (FTR) refers to death after a major complication. Defining the optimal context in which to reduce FTR after injury requires knowledge of where and when FTR events occur. MATERIALS AND METHODS: Retrospective observational study of patients >16 y with a minimum Abbreviated Injury Score ≥2 at all 30 level I and II Pennsylvania trauma centers (2007–2015). Location and timing of the first major complication were collected. Complication, mortality, and FTR rates were calculated by location (prehospital, emergency department, operating room, stepdown unit, interventional radiology, intensive care unit (ICU), radiology, and the surgical ward) and by postadmission day. Kruskal—Wallis and chi-squared tests were used to compare variables. RESULTS: Major complications occurred in 15,388 of 178,602 (8.6%) patients. The median age was 58 y (interquartile range [IQR] 37–77 y), 78% were Caucasian, 68% were male, 89% were bluntly injured, and the median Injury Severity Score was 19 (IQR 10–29). Death occurred in 2512 of 15,388 patients with a major complication, for an FTR rate of 16.3%. Compared with non-FTR, FTR had earlier major complications (median day 2 [IQR 0–5 d] versus day 4 [IQR 2–8 d], P < 0.001). FTR rates were highest in the prehospital setting (42%), the operating room (33%), and the emergency department (32%), but the greatest number (1608 of 2512 total FTR events, 64%) occurred in the ICU. Pulmonary (32%) and cardiac (26%) complications most frequently contributed to FTR deaths. CONCLUSIONS: Interventions designed to reduce FTR after injury should focus on pulmonary and cardiac complications in the ICU.

Background Failure to rescue (FTR) is a recently described outcome metric for quality of care. However, predictors of FTR have not been adequately investigated, particularly after pancreaticoduodenectomy. We aim to identify predictors of FTR after pancreaticoduodenectomy. Methods We reviewed all patients who developed serious morbidity after pancreaticoduodenectomy from 2005 to 2012 in the ACS-NSQIP database. Logistic regression was used to identify preoperative and postoperative risks for 30-day mortality within a development cohort (randomly selected 80%). A score was created using weighted beta coefficients. Predictive accuracy was assessed on the validation cohort (remaining 20%) using a receiver operator characteristic curve and calculating the area under the curve (AUC). Results The FTR rate was 7.2% after pancreaticoduodenectomy (n = 5,027). We identified 5 independent risk factors: age ≥65 and albumin ≤3.5 g/dL, preoperatively; and development of shock, renal failure, and reintubation, postoperatively. The generated score had an AUC = 0.83 (95% CI, 0.77–0.89) in the validation cohort. Using the score: 1*Albumin ≤3.5 g/dL + 2*Age ≥ 65 + 2*Shock + 5*Renal failure + 5*Reintubation, FTR rates increased with increasing score (p Conclusion FTR rates have previously been shown to be associated with hospital factors. We show that FTR is also associated with preoperative and postoperative patient-specific factors.