Failure to rescue in trauma: Coming to terms with the second term.

INTRODUCTION: The failure to rescue (FTR) rate is the probability of death after a major complication and was defined in elective surgical cohorts. In elective surgery, the precedence rate (proportion of deaths preceded by major complications) approaches 100%, but recent studies in trauma report rates of only 20-25%. We hypothesised that use of high quality data would result precedence rates in higher than those derived from national datasets, and we further sought to characterise the nature of those deaths not preceded by major complications.

METHODS: Prospectively collected data from 2006 to 2010 from a single level I trauma centre were used. Patients age >16 years with AIS ≥2 who survived beyond the trauma bay were included. Complications, mortality, FTR, and precedence rates were calculated. Chart abstraction was performed for registry deaths without recorded complications to verify the absence of complications and determine the cause of death, after which outcomes were re-calculated.

RESULTS: A total of 8004 patients were included (median age 41 (IQR 25-75), 71% male, 82% blunt, median ISS 10 (IQR 5-18)). Using registry data the precedence rate was 55%, with 132/293 (45%) deaths occurring without antecedent major complications. On chart abstraction, 11/132 (8%) patients recorded in the registry as having no complication prior to death were found to have major complications. Complication and FTR rates after chart abstraction were statistically significantly different than those derived from registry data alone (complications 16.5% vs. 16.3, FTR 12.3 vs.13, p=0.001), but this difference was unlikely to be clinically meaningful. Patients dying without complications predominantly (87%) had neurologic causes of demise.

CONCLUSIONS: Use of data with near-complete ascertainment of complications results in precedence rates much higher than those from national datasets. Patients dying without precedent complications at our centre largely succumbed to progression of neurologic injury. Attempts to use FTR to compare quality between centres should be limited to high quality data.

LEVEL OF EVIDENCE: Level III.

RETROSPECTIVE COHORT STUDY: Outcomes.