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Objective To understand the effectiveness of Rescue Improvement Conference, a forum that addresses failure to rescue (FTR). Summary background data Every year over 150,000 patients die after elective surgery in the United States. FTR is the phenomenon whereby delayed recognition and/or response to serious surgical complications leads to a progressive cascade of adverse events culminating in death. Rescue Improvement Conference is an adapted version of the Ottawa-style M&M conference, designed to address common contributors to FTR: ineffective communication and inadequate problem solving. Methods Mixed methods data were used to evaluate Rescue Improvement Conference, a bi- monthly forum that was first introduced in our academic medical center in 2018. Conference effectiveness data were collected via survey and open-text responses after five conferences between September 2018 and February 2020. We focused on five indicators of effectiveness: educational value, conference takeaways, discussion time, changes to surgical practice, and actionable opportunities for improvement. Twelve surgical faculty and house staff also provided feedback during semi- structured interviews. Qualitative data were analyzed using thematic analysis. Results Conference attendees (N = 140) felt that Rescue Improvement Conference was effective-all five indicators had mean scores above five on Likert scales. The qualitative data supports the quantitative findings, and three additional themes emerged: Rescue Improvement Conference enables the representation of diverse voices, promotes interdisciplinary collaboration, and encourages multilevel problem solving. Conclusions Rescue Improvement Conference has the potential to support other surgical departments in developing system-level strategies to recognize and manage postoperative complications by providing stakeholders a forum to identify and discuss factors that contribute to FTR.

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.

OBJECTIVES Measures to prevent surgical complications are critical components of optimal patient care, and adequate management when complications occur is equally crucial in efforts to reduce mortality. This study aims to elucidate clinical realities underlying in-hospital variations in failure to rescue (FTR) after cardiac surgery. METHODS Using a statewide database for a quality improvement program, we identified 62 450 patients who had undergone adult cardiac surgery between 2011 and 2018 in 1 of the 33 Michigan hospitals performing adult cardiac surgery. The hospitals were first divided into tertiles according to their observed to expected (O/E) ratios of 30-day mortality: low-mortality tertile (O/E 0.46–0.78), intermediate-mortality tertile (O/E 0.79–0.90) and high-mortality tertile (O/E 0.98–2.00). We then examined the incidence of 15 significant complications and the rates of death following complications among the 3 groups. RESULTS A total of 1418 operative deaths occurred in the entire cohort, a crude mortality rate of 2.3% and varied from 1.3% to 5.9% at the hospital level. The death rates also diverged significantly according to mortality score tertiles, from 1.6% in the low-mortality group to 3.2% in the high-mortality group (P CONCLUSIONS This study demonstrates that timely recognition and appropriate treatment of complications are as important as preventing complications to further reduce operative mortality in cardiac surgery. FTR tools may provide vital information for quality improvement initiatives.

To examine the association of BMI with mortality and related outcomes after oncologic esophagectomy.Previous studies showed that high BMI was a risk factor for anastomotic leakage and low BMI was a risk factor for respiratory complications after esophagectomy. However, the association between BMI and in-hospital mortality after oncologic esophagectomy remains unclear.Data for patients who underwent esophagectomy for esophageal cancer between July 2010 and March 2019 were extracted from a Japanese nationwide inpatient database. Multivariate regression analyses and restricted cubic spline analyses were used to investigate the associations between BMI and short-term outcomes, adjusting for potential confounders.Among 39,406 eligible patients, in-hospital mortality, major complications, and multiple complications (≥2 major complications) occurred in 1069 (2.7%), 14,824 (37.6%), and 3621 (9.2%), respectively. Compared with normal weight (18.5-22.9 kg/m2), severe underweight (16.0 kg/m2), mild/moderate underweight (16.0-18.4 kg/m2), and obese (≥27.5 kg/m2) were significantly associated with higher in-hospital mortality [odds ratio 2.20 (95% confidence interval 1.65-2.94), 1.25 (1.01-1.49), and 1.48 (1.05-2.09), respectively]. BMI showed U-shaped dose-response associations with mortality, major complications, and multiple complications. BMI also showed a reverse J-shaped association with failure to rescue (death after major complications).Both high BMI and low BMI were associated with mortality, major complications, and multiple complications after esophagectomy for esophageal cancer. Patients with low BMI were more likely to die once a major complication occurred. The present results can assist with risk stratification in patients undergoing oncologic esophagectomy.

OBJECTIVE We aimed to evaluate the implementation of a dedicated surgical critical care service (SCCS) on failure to rescue (FTR) rates in rural Kenya. SUMMARY BACKGROUND DATA FTR adversely impacts perioperative outcomes. In the resource-limited contexts of low- and middle-income countries, emergency gastrointestinal surgery carries high morbidity and mortality rates. Quality improvement initiatives that decrease FTR rates are essential for improving perioperative care. METHODS All patients who underwent emergency gastrointestinal surgery between January 2016 and June 2019 at Tenwek Hospital in rural Kenya were reviewed. Critical care capabilities were constant throughout the study period. A supervised surgical resident was dedicated to the daily care of critically ill surgical patients beginning in January 2018. The impact of the SCCS initiation on the outcome of FTR was evaluated, controlling for patient complexity via the African Surgical Outcomes Study (ASOS) Surgical Risk Score. RESULTS A total of 484 patients were identified, consisting of 278 without and 206 with an active SCCS. A total of 165 (34.1%) patients experienced postoperative complications, including 49 mortalities (10.1%) yielding an FTR rate of 29.7%. The FTR rate decreased after SCCS implementation from 36.8% (95% CI 26.7-47.8%) to 21.8% (95% CI 13.2-32.6%) (p = 0.035) despite an increase in the average patient ASOS score from 14.5 (95% CI 14.1-14.9) to 15.2 (95% CI 14.7-15.7) (p = 0.03). CONCLUSIONS The implementation of an SCCS in rural Kenya resulted in decreased rates of FTR despite an increase in patient complexity and severity of critical illness.

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 FTR appears as a major cause of postoperative mortality (POM). Hospital volume has an impact on FTR in pancreatic surgery but no study has investigated this relationship more specifically in DP. Methods We analysed patients with DP between 2009 and 2018 through a nationwide database. FTR definition was mortality among patients who experiment major complications. The cutoff between high and low volume centers was 20 pancreatectomies per year. Results Some 10,632 patients underwent DP, 5048 (47.5%) were operated in 602 (95.4%) low volume centers and 5584 (52.5%) in 29 (4.6%) high volume centers. Overall FTR occurred in 11.2% of patients and was significantly reduced in high volume centers compared to low volume centers (10.2% vs 12.5%, p = 0.047). In multivariate analysis, surgery in a high volume center was a protective factor for POM (OR = 0.570, CI95% [0.505–0.643], p Conclusion Hospital volume has a positive impact on FTR in DP. Patients with higher risk of FTR are men, with high modified Charlson comorbidity index, malignant conditions and open procedures.

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.

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.

Introduction: Morbidity and mortality after bariatric surgery improved worldwide. We aimed to study morbidity and mortality of bariatric surgery in the Middle East. Methods: A two-part survey to st...

Background Center-level outcome metrics have long been tracked in elective surgery (ELS). Despite recent interest in measuring emergency general surgery (EGS) quality, centers are often compared based on elective or combined outcomes. Therefore, quality of care for emergency surgery specifically is unknown. Methods We extracted data on EGS and ELS patients from the 2016 State Inpatient Databases of Florida, New York, and Kentucky. Centers that performed >100 ELS and EGS operations were included. Risk-adjusted mortality, complication, and failure to rescue (FTR, death after complication) rates were calculated and observed-to-expected ratios were calculated by center for ELS and EGS patients. Centers were determined to be high or low outliers if the 90% CI for the observed: expected ratio excluded 1. We calculated the frequency with which centers demonstrated a different performance status between EGS and ELS. Kendall's tau values were calculated to assess for correlation between EGS and ELS status. Results A total of 204 centers with 45,500 EGS cases and 49,380 ELS cases met inclusion criteria. Overall mortality, complication, and FTR rates were 1.7%, 8.0%, and 14.5% respectively. There was no significant correlation between mortality performance in EGS and ELS, with 36 centers in a different performance category (high outlier, low outlier, as expected) in EGS than in ELS. The correlation for complication rates was 0.20, with 60 centers in different categories for EGS and ELS. For FTR rates, there was no correlation, with 16 centers changing category. Conclusions There was minimal correlation between outcomes for ELS and EGS. High performers in one category were rarely high performers in the other. There may be important differences between the processes of care that are important for EGS and ELS outcomes that may yield meaningful opportunities for quality improvement.

Failure to rescue (FTR), defined as death after a complication, is recognized as a principal driver of variation in mortality among hospitals. We evaluated FTR as a quality metric in patients who received durable left ventricular assist devices (LVADs) using the Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support.Data on 13,617 patients who received primary durable LVADs from April 2012 to October 2017 at 131 hospitals that performed at least 20 implants were analyzed from the Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support. Rates of major complications and FTR were compared across risk-adjusted in-hospital mortality terciles (low, medium, high) and hospital volume. Logistic regression was used to estimate expected FTR rates on the basis of patient factors for each major complication.The overall unadjusted in-hospital mortality rate was 6.96%. Risk-adjusted in-hospital mortality rates varied 3.1-fold across terciles (low, 3.3%; high, 10.3%; P trend.001). Rates of major complications varied 1.1-fold (low, 34.0%; high, 38.8%; P .0001). Among patients with a major complication, 854 died in-hospital for an FTR rate of 17.7%, with 2.8-fold variation across mortality terciles (low, 8.5%; high, 23.9%; P .0001). FTR rates were highest for renal dysfunction requiring dialysis (45.3%) and stroke (36.5%). Higher average annual LVAD volume was associated with higher rates of major complications (10 per year, 26.7%; 10-20 per year, 34.0%; 20-30 per year, 34.0%;30 per year, 40.1%; P trend.0001) whereas hospitals implanting10 per year had the highest FTR rate (10 per year, 23.5%; 10-20 per year, 16.5%; 20-30 per year, 17.0%;30 per year, 17.9%; P = .03).FTR might serve as an important quality metric for durable LVAD implant procedures, and identifying strategies for successful rescue after complications might reduce hospital variations in mortality.

Objectives Failure to rescue (FTR) is defined by the number of deaths among patients experiencing major complications after surgery. In this report we analyze FTR and apply a cumulative sum control chart (CUSUM) methodology for monitoring performance in a large series of operated lung carcinoma patients. Methods Prospectively stored records of cases undergoing anatomical lung resection in one center were reviewed. Postoperative adverse events were coded and included as a binary variable (major, or minor complications). The occurrence of 30-day mortality was also recorded. Patients dying after suffering major complications were considered as FTR. Risk-adjusted CUSUM graphs using EuroLung1 and 2 variables were constructed for major complications and FTR. Points of plateauing or trend inversion were checked to detect intentional or non-adverted changes in the process of care. Results 2237 cases included. 9.1% cases suffered major complications. The number of cases considered as failures to rescuing was 46 (2.1% of the total series and 22.5% of cases having major complications). The predictive performance of EuroLung1 and 2 models was as follows: EuroLung1 (major morbidity) C-index 0.70 (95%CI: 0.66–0.73); EuroLung2 (applied to FTR) C-index 0.81 (95%CI: 0.750.87). CUSUM graphs depicted improvement in rescuing complicated patients after case 330 but no improvement in the rate of non-complicated cases until case 720. Conclusions FTR offers a complementary view to classical outcomes for quality assessment in Thoracic Surgery. Our study also shows how the analysis of FTR on time series can be applied to evaluate changes in team performance along time.

BACKGROUND The high operative mortality rate after hepatopancreatoduodenectomy (HPD) is still a major issue. The present study explored why operative mortality differs significantly due to hospital volume. METHOD Surgical case data were extracted from the National Clinical Database (NCD) in Japan from 2011 to 2014. Surgical procedures were categorized as major (≥2 sections) and minor (

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.

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.

Introduction The incidence of complications and mortality in patients undergoing elective surgery in India are unknown. We contributed Indian data to ISOS. Since there were fewer than ten centers, Indian data were not included in the primary analysis. We report postoperative outcomes in the Indian data set of patients following elective surgery. Materials and methods In this prospective 7-day observational study, after obtaining a waiver of informed consent, data were collected for 30 days from consecutive patients >18 years undergoing elective surgery. The primary outcome was in-hospital postoperative complications. The secondary outcomes were in-hospital all-cause mortality, the relationship between postoperative complications and admission to critical care, and the duration of hospital stay. Complications were graded as mild, moderate, and severe. Failure to rescue was defined as mortality in patients admitted to an intensive care unit (ICU) for the treatment of complications. Results Complications occurred in 57 (27.5%) patients, who were older (53 vs 47 years, p < 0.001) and had American Society of Anaesthesiologists grades III and IV physical status (p = 0.029). One hundred and thirty-eight (65.7%) patients underwent a major surgical procedure of which 132 (62.8%) procedures were done for malignancy. Postoperative complications were significantly higher (41.5% vs 22.7%) in patients electively admitted to ICU. The overall mortality rate was 2.4%, whereas the mortality rate was 8.8% in those who developed complications. Conclusion We found that 28% of patients developed postoperative complications. The overall mortality was 2.4% but was higher (8.8%) in those who developed complications. Age and complex surgical procedures independently predicted complications, while lower preoperative hemoglobin appeared to be protective. Study Registration ISRCTN51817007 How to cite this article Agarwal V, Muthuchellappan R, Shah BA, Rane PP, Kulkarni AP, et al. Postoperative Outcomes Following Elective Surgery in India. Indian J Crit Care Med 2021;25(5):528–534.

The management of errors and complications makes a significant contribution to the quality assurance of a surgical department. The structured risk management is an integral component of the surgeon's duties that is reflected by the growing relevance of simulation and other training methods employed during medical specialist advanced training. Basic prerequisites for establishing an error culture that aims at improvement of patient safety and the constructive coping with complications, are the removal of taboos and the transparent processing of complicating courses of treatment. Detecting structural and systemic sources of error is preferrable to the application of approaches that focus on individual responsibility, e.g. shame and blame. There are numerous validated tools available for the prevention, recognition and successful treatment of complications. Team time out protocols for circumventing fatal errors, standardized operating procedures and morbidity and mortality conferences are the most important measures for ensuring patient safety. The standardized, consistent and interdisciplinary handling of unavoidable complications according to the failure to rescue concept is pivotal for the prevention of a fatal course.Das Fehler- und Komplikationsmanagement leistet einen entscheidenden Beitrag zur Qualitätssicherung einer chirurgischen Abteilung. Das strukturierte Risikomanagement ist als fester Bestandteil der chirurgischen Tätigkeit anzusehen, was sich unter anderem in der zunehmenden Bedeutung von Simulations- und anderen Trainingsmethoden im Rahmen der Facharztweiterbildung widerspiegelt. Grundvoraussetzung für die Etablierung einer Fehlerkultur, die auf die Verbesserung der Patientensicherheit und einen konstruktiven Umgang mit Komplikationen abzielt, ist die Enttabuisierung und die transparente Aufarbeitung komplikativer Behandlungsverläufe. Der Fokus sollte sich hierbei auf die Erkennung struktureller und systemischer Fehlerquellen richten und nicht die individuelle Verantwortung in den Vordergrund stellen. Für die Bereiche Komplikationsvermeidung, -erkennung und erfolgreiche -behebung stehen gut validierte Werkzeuge zur Verfügung. Team-time-out-Protokolle zur Vermeidung fataler Fehler, standardisierte Behandlungsabläufe und strukturierte Morbiditäts- und Mortalitätskonferenzen sind hierbei die wesentlichen, konsequent einzuhaltenden Maßnahmen. Für den unvermeidbaren Fall eintretender Komplikationen gilt es gemäß des „Failure-to-rescue“-Konzeptes, durch konsequentes, standardisiertes und interdisziplinär abgestimmtes Handeln fatale Verläufe zu verhindern.

Failure to rescue (FTR) represents death after a serious complication. This study aims to determine the FTR rate in a pediatric surgical population, and if number (1 or 2+) and type of serious complications are associated with FTR.A secondary analysis was performed using the National Surgical Quality Improvement Program Pediatric database from 2012 to 2016. Primary and secondary exposures of interest were number (1 or 2+) and type of serious complications, respectively. Propensity score analysis adjusted for baseline covariates. Primary outcome was FTR.Of 36,167 children with ≥1 serious complication, there were 851 deaths resulting in a FTR rate of 2.4%. Having 2+ serious complications was associated with higher adjusted odds of FTR (OR 1.77, 95% CI 1.52-2.08, p 0.0001). Among those who had one complication, the type of serious complication was significantly associated with FTR. When type of initial serious complication was adjusted, number of serious complications continued to be strongly associated with FTR (OR 2.00, 95% CI 1.67-2.38, p 0.0001).FTR rate within a large, diverse, multi-specialty pediatric surgical population was 2.4%. Both number and type of postoperative complications were associated with FTR. These findings may facilitate early recognition of high-risk patients and identify quality targets for pediatric surgical centers.Retrospective study (secondary analysis), Level II.

OBJECTIVE Compare emergency general surgery (EGS) patient outcomes following index and non-index hospital readmissions, and explore predictive factors for non-index readmission. BACKGROUND Readmission to a different hospital leads to fragmentation of care. The impact of non-index readmsision on patient outcomes following EGS is not well established. METHODS The Nationwide Readmissions Database (2017) was queried for adult patients readmitted following an EGS procedure. Patients were stratified and propensity-matched according to readmission destination: index vs. non-index hospital. Outcomes were failure to rescue (FTR), mortality, number of subsequent readmissions, overall hospital LOS, and total costs. Hierarchical logistic regression was performed to account for clustering effect within hospitals and adjusting for patient- and hospital-level potential confounding factors. RESULTS A total of 471,570 EGS patients were identified, of which 79,127 (16.8%) were readmitted within 30 days: index hospital (61,472; 77.7%) vs. non-index hospital (17,655; 22.3%). Following 1:1 propensity matching, patients with non-index readmission had higher rates of FTR (5.6% vs. 4.3%; p < 0.001), mortality (2.7% vs. 2.1%; p < 0.001), and overall hospital costs (in $1000; 37 [27-64] vs. 28 [21-48]; p < 0.001). Non-index readmission was independently associated with higher odds of FTR (aOR 1.18 [1.03-1.36]; p < 0.001). Predictors of non-index readmission included top quartile for zip code median household income (1.35 [1.08-1.69]; p < 0.001), fringe county residence (1.08 [1.01-1.16]; p = 0.049), discharge to a skilled nursing facility (1.28 [1.20-1.36]; p < 0.001), and leaving AMA (2.32 [1.81-2.98]; p < 0.001). CONCLUSION One in five readmissions after EGS occur at a different hospital. Non-index readmission carries a heightened risk of FTR. LEVEL OF EVIDENCE Level III Prognostic STUDY TYPE:: Prognostic.

Failure to rescue (FTR), or death after major complications, has emerged as a marker of hospital-level quality of care. To evaluate the predictive performance of the ACS-NSQIP modified frailty index (mFI) in determining FTR following an anastomotic leak (AL) after a colectomy for colorectal cancer. Retrospective cohort study. Multicenter interrogation of the 2012–2016 American College of Surgeons (ACS) colectomy procedure targeted National Surgical Quality Improvement Program (NSQIP) database. A total of 50,944 patients who underwent colectomy for colorectal cancer. Frailty as measured by: (1) Age, ASA, and emergency status (model 1), (2) Age, ASA, emergency status, and mFI (model 2), (3) ACS-NSQIP mortality prediction (model 3). Primary outcome was FTR after AL. A total of 1755 patients experienced an AL (3.46%) with a FTR rate of 6.44%. The mean age was 65.6 years (95% CI 65.28–65.58 years), median ASA was 3 (IQR 2–3), 51 patients (2.92%) were partially or totally dependent, 366 (20.86%) were diabetic, 105 (5.98%) had a history of chronic obstructive pulmonary disease (COPD), 32 (1.82%) had a history of congestive heart disease (CHD), and 966 (55.04%) were on hypertensive treatment. The performance of model 1 (AUROC 0.77; 95% CI 0.72–0.81), model 2 (AUROC 0.77; 95% CI 0.73–0.82), and model 3 (AUROC 0.79; 95% CI 0.75–0.83) to predict FTR was not different (p = 0.44). Age and ASA remain the most reliable predictors of failure to rescue anastomotic leak after colectomy for colorectal cancer. Addition of the modified frailty index, or all variables collected by NSQIP, did not significantly improve predictive performance.

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.

Emergent colectomy is performed in thousands of Americans each year and carries significant morbidity and mortality. Although laparoscopy has gained favor in the elective setting, its impact on failure to rescue has not been studied on a population level for emergent colectomy. The purpose of this study was to compare failure to rescue following laparoscopic versus open colectomy in the emergency setting. This was a retrospective cohort study of The American College of Surgeons National Surgical Quality Improvement Program. Adult patients undergoing emergent colectomy between 2005 and 2018 were selected and stratified into laparoscopic or open surgery groups using the Current Procedural Terminology codes. Propensity matching was performed based on the demographic and comorbidity data. Main outcomes were failure to rescue, mortality, overall morbidity, individual complications, and length of hospital stay. After matching, 11,484 cases were included for analysis, of which 3829 were laparoscopic. Overall, open colectomy conferred higher odds of failure to rescue (OR 1.71, 95% CI 1.42–2.08), mortality (OR 1.72, 95% CI 1.44–2.07), and morbidity (OR 1.73, 95% CI 1.60–1.88) vs laparoscopic cases. Open surgery significantly increased the risk of nearly all measured postoperative complications including return to operating room (OR 1.25, 95% CI 1.08–1.45), ventilator use > 48 h (OR 2.43, 95% CI 2.03–2.93), and septic shock (OR 2.34, 95% CI 1.97–2.80). Hospital length of stay was shorter for patients undergoing laparoscopic (10.4 days) vs open (12.3 days) colectomy (p

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.