Failure to Rescue: Look at the Intermediary Steps

Certifying and accrediting organizations have begun looking at a new quality metric: failure to rescue (FTR).

FTR is a provider’s or an institution’s inability to prevent patients who have postoperative complications from dying. As with all new metrics, the people who used them and the healthcare providers whose work is reflected in the measure have concerns.

Quality managers claimed that FTR explained hospitals' variable mortality rates. Questions about how they are measured (they rely on administrative data collected primarily for billing purposes) and possible correlations between a hospital’s complication rate and ultimate mortality are under review.

It's a circular situation: does FTR cause mortality, or does mortality — especially the rare and unexpected death – occur because of the initial postsurgical complications.

Investigators from hospitals across the nation assessed the potential link between hospitalization for secondary (as opposed to primary or initial) complications and mortality.

A study published in the Annals of Surgery, indicated that secondary complications, like mortality, vary considerably among hospitals and may contribute to FTR to a greater degree than primary complications do.

The investigators defined secondary complications as complications that followed a primary or ‘‘index’’ complication. Previous work had looked at primary complications and mortality, and found only weak associations. These investigators hypothesized that secondary complications could be intermediate outcomes in the rescue process, demonstrate how rescue fails, and provide specific improvement targets.

Using American College of Surgeons’ National Surgical Quality Improvement Program data (2008—2012), these investigators looked at five common index complications in a population of 524,860 patients who underwent 62 types of elective surgery. They then identified common secondary complications and compared hospitals' secondary complication and mortality rates.

Five complications were examined: surgical site infection (SSI), urinary tract infection (UTI), postoperative transfusion/bleeding events (TBE; defined as requirement for four or more units of packed red blood cell transfusion within 72 hours after surgery), pneumonia, and acute myocardial infarction (MI).

They included the first four because they are common, and myocardial infarction because it is high risk. The overall complication rate was 18.6% (96,967 patients), and of these, more than half were one of these five complications.

The investigators classified hospitals into quintiles based on their risk- and reliability-adjusted rates of secondary complications, and compared secondary complication rates with mortality.

Hospitals with higher rates of secondary complications tended to be associated with higher adjusted mortality rates.

Rates of secondary complications varied tremendously between hospitals:

· Acute MI led to secondary complications in 23.86% in the lowest quintile hospitals to 64.45% of patients in the highest.

· Patients who developed pneumonia as the index complication had secondary complication rates from 22.93% to 57.99%.

· Variation after index SSI ranged from 14.81% to 58.98%.

· Urinary tract infection was less likely overall to result in secondary complications, ranging from 8.6% to 38.41%.

· Transfusion/bleeding events led to secondary complications in 12.88% to 27.14% of patients.

The investigators indicated their most important finding was that hospitals that experienced higher rates of secondary complications had significantly higher overall mortality rates. They suggested that failure to arrest secondary complications varies considerably among hospitals and can be used as a benchmark.