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Failure to rescue

Failure to rescue (FTR), defined as mortality after a surgical complication, was introduced to the medical literature in 1992

hospitals with the lowest postoperative mortality did not necessarily have the fewest complications. Rather, interhospital variation in mortality was driven primarily by rates of survival in patients who developed complications after surgery

FTR differs from traditional metrics (including the STS score and EuroSCORE II) by focusing on the quality of an entire health care system rather than an individual surgeon

although certain patient characteristics associated with poor outcomes are unmodifiable (age, disease severity), many factors associated with FTR are hospital-related and actionable

For FTR to be a useful quality metric, complications included in its definition should meet several criteria:

1. The complication must have the potential to cause mortality.
   • Minor complications, such as superficial surgical site infections and hemodynamically stable arrhythmias, almost never lead to death and thus will falsely decrease FTR rates.
2. The complication must be rescuable.
   • If there exists no established treatment for a complication, then there is no opportunity for rescue.
3. The complication must be a new medical problem that was not present before surgery.
   • An exacerbation or sequelae of a preoperative comorbidity does not represent a new postoperative complication.
4. The complication must be objective and unambiguous.
   • To calculate FTR rate accurately, the number of mortalities (the numerator) and complications (the denominator) must be precise.
   • Although mortality is objective, definitions of certain complications can be subjective or variable. A higher or lower number of complications reported per mortality will falsely decrease or increase the FTR rate, respectively.

Examples

renal failure in cardiac surgery: ?complication from comorbidities (low EF, CKD)?
re-operation in cardiac surgery: rescue for complication rather than complication itself

Factors affecting FTR

• system-specific
  • hospital volume
    • Clinicians at high-volume centres who encounter complications more frequently are likely more adept at diagnosis and management
    • hospitals with greater surgical volume might have standardized pathways to streamline postoperative care
• institution-specific
  • physician and nurse staffing
    • in-house intensivist
  • presence of trainees
    • mixed data on the effect of teaching status on FTR is due to variations in level of trainee support
    • a trainee must be able to recognize complications and communicate effectively with senior physicians to escalate care
• patient-specific
  • presence of frailty and comorbidities

A Systematic Approach to Rescue

Traditional 2-pronged strategy for patient rescue:

• Afferent limb: recognition of a complication
• Efferent limb: subsequent management

1. (anticipation) + Early recognition
2. Timely escalation of care
   • communication / consultation
   • re-location
   • invasive monitoring
3. Effective management
   1. stabilisation
   2. diagnosis + treatment of underlying pathology
4. Mitigation of additional complications
   • early removal of CVC
   • SBT
   • early mobilisation
   • stress ulcer prophylaxis

Patient rescue is a complex process involving macrosystem and microsystem factors. Macrosystem factors, such as nurse to patient ratios, hospital size, and institutional technological capabilities, often cannot be modified easily. Conversely, microsystem factors, including interpersonal and organizational dynamics, are more actionable targets for rescue improvements

Future direction

FTR from mortality vs FTR from morbidity

References

Failure to Rescue A Quality Metric for Cardiac Surgery and Cardiovascular Critical Care