Prognostic profiling of children with serious post-operative complications: A novel probability model for failure to rescue

Background Failure to rescue (FTR), mortality after a major postoperative complication, is a superior surgical quality metric compared to surgical mortality or complications rates alone. Our objective was to develop and validate a novel pediatric profiling to identify high-risk subjects among the subset of children who develop serious post-operative complications. Methods We performed a retrospective study of children who developed one or more serious postoperative complications following inpatient surgery across NSQIP-Pediatric hospitals (2012–2017). We evaluated the rate of FTR according to pre-operative comorbidity burden. Results We identified 45,504 surgical cases with major post-operative complications (FTR rates: 2.4%). Surgical cases with greater than six pre-operative comorbidities (n = 12,148;28%) accounted for 80% of FTR events. The expected probability of FTR was 0.1%(95%CI:0.1%–0.2%) among low-risk cases, 3.3%(95%CI:3.0%–3.5%) among intermediate-risk cases, and 22.6%(95%CI:20.9%–24.3%) among high-risk cases. About half of surgical cases in the high-risk profile group died within 48 h of surgery. Comparatively, cases in the intermediate-risk group had a much longer time to mortality (10 days). Conclusion We propose a prognostic index to accurately identify children at risk for FTR. The use of such an index may provide surgeons with a window of opportunity to implement aggressive monitoring and therapeutic strategies to reduce mortality. Level of evidence IV