A metric of our own

Abstract

Background Failure to rescue (FTR) is defined as death after an adverse event. The original metric was derived in elective surgical populations and reclassifies deaths not preceded by recorded adverse events as FTR cases under the assumption these deaths resulted from missed adverse events. This approach lacks face validity in trauma because patients often die without adverse events as a direct result of injury. Another common approach simply excludes deaths without recorded adverse events, but this approach reduces the reliability of the FTR metric. We hypothesized that a hybrid metric excluding expected deaths but otherwise including patients without recorded adverse events in FTR analysis would improve face validity and reliability relative to existing methods. Methods Using 3 years of single-state adult trauma registry data from 30 trauma centers, we constructed 3 FTR metrics: 1.) Excluding deaths not preceded by adverse events (FTR-E), 2.) Reclassifying deaths not preceded by adverse events (FTR-R), and 2.) Including deaths not preceded by adverse events in FTR analysis except those with predicted mortality >50% (FTR-T). Mortality, adverse event, and FTR rates were calculated under each method, and reliability was tested using Spearman’s correlation for split-sample center rankings. Results A total of 89,780 patients were included (median age 57 (IQR 26–73), 85% Caucasian, 59% male, 92% blunt, median ISS 9 (IQR5–14)). FTR rates varied by metric (FTR-E: 11.2%; FTR-R 31.2%; FTR-T 21.4%)), as did the proportion of deaths preceded by adverse events (FTR-E 28%; FTR-R: 100%; FTR-T: 60%). Spit-sample reliability was higher FTR-T than FTR-E (rho=0.59 vs) (rho=0.27, p<0.001). Conclusions A trauma-specific FTR metric increases face validity and reliability relative to other FTR methods which may be employed in trauma populations. Future trauma outcomes studies examining FTR rates should use a metric designed for this cohort. Level of Evidence Level III

Failure to rescue in trauma: Early and late mortality in low- and high-performing trauma centers

“…Subsequently, the group proposed a new metric for FTR in trauma known as FTR-Trauma (FTR-T); however, the FTR-T metric relies on a complex calculation that estimates potential missed adverse events (complications) in patients who die. 20 The FTR-T has not been widely adopted as a potential quality metric in trauma, and does not resolve the underlying issue of missed capture of complications in trauma registries and databases.…”

“…The complication rates in those who died reported by Holena et al 19 (55–58%) are higher than those in our study, likely because their list of complications included several complications that have low associated mortality in MTQIP and hence were not included as a major complication in our study, for example, urinary tract infection and wound infection. Subsequently, the group proposed a new metric for FTR in trauma known as FTR-Trauma (FTR-T); however, the FTR-T metric relies on a complex calculation that estimates potential missed adverse events (complications) in patients who die 20 . The FTR-T has not been widely adopted as a potential quality metric in trauma, and does not resolve the underlying issue of missed capture of complications in trauma registries and databases.…”

A reference guide to rapidly implementing an institutional dashboard for resource allocation and oversight during COVID-19 pandemic surge

“…As the myriad of data elements essential to patient care become more rapidly and easily accessible, this dashboard can theoretically prevent and/or mitigate adverse events and the deaths that may follow, thereby improving Failure to Rescue metrics. 15 …”

Mortality in severely injured patients: nearly one of five non-survivors have been already discharged alive from ICU

“…FTR rates are considered as a quality indicator superior to complication or mortality rates as they are more associated with institutional factors [ 38 – 41 ]. The rate was based on elective surgical populations and reclassified deaths not caused by adverse events.…”

“…The rate was based on elective surgical populations and reclassified deaths not caused by adverse events. Holena et al [ 38 ] demonstrated that this approach lacks validity in trauma because patients often die as a direct consequence of injury without any adverse events. They also argued that another common approach to simply exclude deaths without recorded adverse events reduces the reliability of the FTR rate.…”