Identification of Patients With Postoperative Complications Who Are at Risk for Failure to Rescue | Critical Care Medicine | JAMA Surgery | JAMA Network
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1.
Silber  JH, Rosenbaum  PR, Schwartz  JS, Ross  RN, Williams  SV.  Evaluation of the complication rate as a measure of quality of care in coronary artery bypass graft surgery.  JAMA. 1995;274(4):317-323.PubMedGoogle ScholarCrossref
2.
Silber  JH, Rosenbaum  PR, Williams  SV, Ross  RN, Schwartz  JS.  The relationship between choice of outcome measure and hospital rank in general surgical procedures: implications for quality assessment.  Int J Qual Health Care. 1997;9(3):193-200.PubMedGoogle ScholarCrossref
3.
Almoudaris  AM, Burns  EM, Bottle  A,  et al.  Single measures of performance do not reflect overall institutional quality in colorectal cancer surgery.  Gut. 2013;62(3):423-429.PubMedGoogle ScholarCrossref
4.
Wright  JD, Ananth  CV, Ojalvo  L,  et al.  Failure to rescue after major gynecologic surgery.  Am J Obstet Gynecol.2013;209(5):420.e421-428. PubMedGoogle ScholarCrossref
5.
Donabedian  A.  An Introduction to Quality Assurance in Health Care. New York, NY: Oxford University Press; 2003.
6.
Ahmed  EO, Butler  R, Novick  RJ.  Failure-to-rescue rate as a measure of quality of care in a cardiac surgery recovery unit: a five-year study.  Ann Thorac Surg. 2014;97(1):147-152.PubMedGoogle ScholarCrossref
7.
Henneman  D, Snijders  HS, Fiocco  M,  et al.  Hospital variation in failure to rescue after colorectal cancer surgery: results of the Dutch Surgical Colorectal Audit.  Ann Surg Oncol. 2013;20(7):2117-2123.PubMedGoogle ScholarCrossref
8.
Ghaferi  AA, Birkmeyer  JD, Dimick  JB.  Complications, failure to rescue, and mortality with major inpatient surgery in medicare patients.  Ann Surg. 2009;250(6):1029-1034.PubMedGoogle ScholarCrossref
9.
Sheetz  KH, Waits  SA, Krell  RW, Campbell  DA  Jr, Englesbe  MJ, Ghaferi  AA.  Improving mortality following emergent surgery in older patients requires focus on complication rescue.  Ann Surg. 2013;258(4):614-617, discussion 617-618.PubMedGoogle Scholar
10.
Reddy  HG, Shih  T, Englesbe  MJ,  et al.  Analyzing “failure to rescue:” is this an opportunity for outcome improvement in cardiac surgery?  Ann Thorac Surg.2013;95(6):1976-1981; discussion 1981. PubMedGoogle ScholarCrossref
11.
Gonzalez  AA, Dimick  JB, Birkmeyer  JD, Ghaferi  AA.  Understanding the volume-outcome effect in cardiovascular surgery: the role of failure to rescue.  JAMA Surg. 2014;149(2):119-123.PubMedGoogle ScholarCrossref
12.
Ghaferi  AA, Birkmeyer  JD, Dimick  JB.  Hospital volume and failure to rescue with high-risk surgery.  Med Care. 2011;49(12):1076-1081.PubMedGoogle ScholarCrossref
13.
Sukumar  S, Roghmann  F, Trinh  VQ,  et al.  National trends in hospital-acquired preventable adverse events after major cancer surgery in the USA.  BMJ Open. 2013;3(6).PubMedGoogle Scholar
14.
Khuri  SF, Henderson  WG, Daley  J,  et al; Principal Site Investigators of the Patient Safety in Surgery Study.  The Patient Safety in Surgery Study: background, study design, and patient populations.  J Am Coll Surg. 2007;204(6):1089-1102.PubMedGoogle ScholarCrossref
15.
Shiloach  M, Frencher  SK  Jr, Steeger  JE,  et al.  Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program.  J Am Coll Surg. 2010;210(1):6-16.PubMedGoogle ScholarCrossref
16.
Blackstone  EH.  Comparing apples and oranges.  J Thorac Cardiovasc Surg. 2002;123(1):8-15.PubMedGoogle ScholarCrossref
17.
Austin  PC.  An introduction to propensity score methods for reducing the effects of confounding in observational studies.  Multivariate Behav Res. 2011;46(3):399-424.PubMedGoogle ScholarCrossref
18.
American College of Surgeons National Surgical Quality Improvement Program.  User Guide for the 2012 ACS NSQIP Participant Use Data File. Chicago, IL: American College of Surgeons;2013.
19.
Silber  JH, Williams  SV, Krakauer  H, Schwartz  JS.  Hospital and patient characteristics associated with death after surgery: a study of adverse occurrence and failure to rescue.  Med Care. 1992;30(7):615-629.PubMedGoogle ScholarCrossref
20.
Trinh  QD, Bianchi  M, Hansen  J,  et al.  In-hospital mortality and failure to rescue after cytoreductive nephrectomy.  Eur Urol. 2013;63(6):1107-1114.PubMedGoogle ScholarCrossref
21.
Donabedian  A.  The quality of care: how can it be assessed? 1988.  Arch Pathol Lab Med. 1997;121(11):1145-1150.PubMedGoogle Scholar
22.
Gopaldas  RR, Bhamidipati  CM, Dao  TK, Markley  JG.  Impact of surgeon demographics and technique on outcomes after esophageal resections: a nationwide study.  Ann Thorac Surg. 2013;95(3):1064-1069.PubMedGoogle ScholarCrossref
23.
Waits  SA, Sheetz  KH, Campbell  DA,  et al.  Failure to rescue and mortality following repair of abdominal aortic aneurysm.  J Vasc Surg.2014;59(4):909-914.e1. PubMedGoogle ScholarCrossref
24.
Brooke  BS, Dominici  F, Pronovost  PJ, Makary  MA, Schneider  E, Pawlik  TM.  Variations in surgical outcomes associated with hospital compliance with safety practices.  Surgery. 2012;151(5):651-659.PubMedGoogle ScholarCrossref
25.
Pucher  PH, Aggarwal  R, Singh  P, Darzi  A.  Enhancing surgical performance outcomes through process-driven care: a systematic review.  World J Surg. 2014;38(6):1362-1373.PubMedGoogle ScholarCrossref
26.
Griffiths  P, Jones  S, Bottle  A.  Is “failure to rescue” derived from administrative data in England a nurse sensitive patient safety indicator for surgical care? observational study.  Int J Nurs Stud. 2013;50(2):292-300.PubMedGoogle ScholarCrossref
27.
Aiken  LH, Cimiotti  JP, Sloane  DM, Smith  HL, Flynn  L, Neff  DF.  Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments.  J Nurs Adm. 2012;42(10)(suppl):S10-S16.PubMedGoogle Scholar
28.
Carthon  JM, Kutney-Lee  A, Jarrín  O, Sloane  D, Aiken  LH.  Nurse staffing and postsurgical outcomes in black adults.  J Am Geriatr Soc. 2012;60(6):1078-1084.PubMedGoogle ScholarCrossref
29.
Yasunaga  H, Hashimoto  H, Horiguchi  H, Miyata  H, Matsuda  S.  Variation in cancer surgical outcomes associated with physician and nurse staffing: a retrospective observational study using the Japanese Diagnosis Procedure Combination Database.  BMC Health Serv Res. 2012;12:129.PubMedGoogle ScholarCrossref
30.
Silber  JH, Rosenbaum  PR, Romano  PS,  et al.  Hospital teaching intensity, patient race, and surgical outcomes.  Arch Surg. 2009;144(2):113-120, discussion 121.PubMedGoogle ScholarCrossref
31.
Castleberry  AW, Clary  BM, Migaly  J,  et al.  Resident education in the era of patient safety: a nationwide analysis of outcomes and complications in resident-assisted oncologic surgery.  Ann Surg Oncol. 2013;20(12):3715-3724.PubMedGoogle ScholarCrossref
32.
Gopaldas  RR, Overbey  DM, Dao  TK, Markley  JG.  The impact of academic calendar cycle on coronary artery bypass outcomes: a comparison of teaching and non-teaching hospitals.  J Cardiothorac Surg. 2013;8:191.PubMedGoogle ScholarCrossref
33.
Wakeam  E, Hevelone  ND, Maine  R,  et al.  Failure to rescue in safety-net hospitals: availability of hospital resources and differences in performance.  JAMA Surg. 2014;149(3):229-235.PubMedGoogle ScholarCrossref
34.
Volpp  KG, Rosen  AK, Rosenbaum  PR,  et al.  Did duty hour reform lead to better outcomes among the highest risk patients?  J Gen Intern Med. 2009;24(10):1149-1155.PubMedGoogle ScholarCrossref
35.
Henneman  D, van Leersum  NJ, Ten Berge  M,  et al.  Failure-to-rescue after colorectal cancer surgery and the association with three structural hospital factors.  Ann Surg Oncol. 2013;20(11):3370-3376.PubMedGoogle ScholarCrossref
36.
Bhamidipati  CM, Stukenborg  GJ, Ailawadi  G, Lau  CL, Kozower  BD, Jones  DR.  Pulmonary resections performed at hospitals with thoracic surgery residency programs have superior outcomes.  J Thorac Cardiovasc Surg.2013;145(1):60-66, 67.e1-2; discussion 66-67. PubMedGoogle ScholarCrossref
37.
Bonacchi  M, Spina  R, Torracchi  L, Harmelin  G, Sani  G, Peris  A.  Extracorporeal life support in patients with severe trauma: an advanced treatment strategy for refractory clinical settings.  J Thorac Cardiovasc Surg. 2013;145(6):1617-1626.PubMedGoogle ScholarCrossref
38.
Silber  JH, Kaestner  R, Even-Shoshan  O, Wang  Y, Bressler  LJ.  Aggressive treatment style and surgical outcomes.  Health Serv Res. 2010;45(6, pt 2):1872-1892.PubMedGoogle ScholarCrossref
39.
Almoudaris  AM, Mamidanna  R, Bottle  A,  et al.  Failure to rescue patients after reintervention in gastroesophageal cancer surgery in England.  JAMA Surg. 2013;148(3):272-276.PubMedGoogle ScholarCrossref
Original Investigation
Association of VA Surgeons
November 2014

Identification of Patients With Postoperative Complications Who Are at Risk for Failure to Rescue

Author Affiliations
  • 1Department of Surgery, University of Kentucky, Lexington
  • 2Department of Surgery, Lexington Veteran’s Affairs Medical Center, Lexington, Kentucky
JAMA Surg. 2014;149(11):1103-1108. doi:10.1001/jamasurg.2014.1338
Abstract

Importance  A minority of patients who experience postoperative complications die (failure to rescue). Understanding the preoperative factors that lead to failure to rescue helps surgeons predict and avoid operative mortality.

Objective  To provide a mechanism for identifying a high-risk group of patients with postoperative complications who are at a substantially increased risk for failure to rescue.

Design, Setting, and Patients  Observational study evaluating failure to rescue in patients entered into the American College of Surgeons National Surgical Quality Improvement Program database. The large sample of surgical patients included in this study underwent a wide range of operations during a 5-year period in more than 200 acute care hospitals. We examined and identified patients at high risk for failure to rescue using propensity stratification. We also developed a risk-scoring system that allowed preoperative identification of patients at the highest risk for failure to rescue.

Main Outcomes and Measures  Risk-scoring system that predicts failure to rescue.

Results  Of the 1 956 002 database patients, there were 207 236 patients who developed serious postoperative complications. Deaths occurred in 21 731 patients with serious complications (10.5% failure to rescue). Stratification of patients into quintiles, according to their propensity for developing serious complications, found that 90% of operative deaths occurred in the highest-risk quintile, usually within a week of developing the initial complication. A risk-scoring system for failure to rescue, based on regression-derived variable odds ratios, predicted patients in the highest-risk quintile with good predictive accuracy. Only 31.8% of failure-to-rescue patients had a single postoperative complication. Perioperative deaths increased exponentially as the number of complications per patient increased. Patients with complications who had surgical residents involved in their care had reduced rates of failure to rescue compared with patients without resident involvement.

Conclusions and Relevance  Twenty percent of high-risk patients account for 90% of failure to rescue (Pareto principle). More than two-thirds of patients with failure to rescue have multiple complications. On average, a few days elapse before death following a complication. A risk-scoring system based on preoperative variables predicts patients in the highest-risk category of failure to rescue with good accuracy. In high-risk patients who develop complications, our results suggest that early intervention, preferably in a high-level intensive care facility with a surgical training program, offers the best chance to reduce failure-to-rescue rates.

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