Trauma complications and in-hospital mortality: failure-to-rescue

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Abstract

Background

Reducing medical errors and minimizing complications have become the focus of quality improvement in medicine. Failure-to-rescue (FTR) is defined as death after a surgical complication, which is an institution-level surgical safety and quality metric that is an important variable affecting mortality rates in hospitals. This study aims to examine whether complication and FTR are different across low- and high-mortality hospitals for trauma care.

Methods

This was a retrospective cohort study performed at trauma care hospitals registered at Japan Trauma Data Bank (JTDB) from 2004 to 2017. Trauma patients aged ≥ 15 years with injury severity score (ISS) of ≥ 3 and those who survived for > 48 h after hospital admission were included. The hospitals in JTDB were categorized into three groups by standardized mortality rate. We compared trauma complications, FTR, and in-hospital mortality by a standardized mortality rate (divided by the institute-level quartile).

Results

Among 184,214 patients that were enrolled, the rate of any complication was 12.7%. The overall mortality rate was 3.7%, and the mortality rate among trauma patients without complications was only 2.8% (non-precedented deaths). However, the mortality rate among trauma patients with any complications was 10.2% (FTR). Hospitals were categorized into high- (40 facilities with 44,773 patients), average- (72 facilities with 102,368 patients), and low- (39 facilities with 37,073 patients) mortality hospitals, using the hospital ranking of a standardized mortality rate. High-mortality hospitals showed lower ISS than low-mortality hospitals [10 (IQR, 9–18) vs. 11 (IQR, 9–20), P < 0.01]. Patients in high-mortality hospitals showed more complications (14.2% vs. 11.2%, P < 0.01), in-hospital mortality (5.1% vs. 2.5%, P < 0.01), FTR (13.6% vs. 7.4%, P < 0.01), and non-precedented deaths (3.6% vs. 1.9%, P < 0.01) than those in low-mortality hospitals.

Conclusions

Unlike reports of elective surgery, complication rates and FTR are associated with in-hospital mortality rates at the center level in trauma care.

Related collections

Most cited references 15

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Complications, failure to rescue, and mortality with major inpatient surgery in medicare patients.

J Birkmeyer, Amir Ghaferi, Justin B Dimick (2009)

We sought to determine whether hospital variations in surgical mortality were due to differences in complication rates or failure to rescue rates (ie, case-fatality rates in patients with a complication). Wide variations in mortality after major surgery are becoming increasingly apparent. The clinical mechanisms underling these variations are largely unexplored. We studied all Medicare beneficiaries undergoing 6 major operations in 2005 to 2006: pancreatectomy, esophagectomy, abdominal aortic aneurysm repair, coronary artery bypass grafting, aortic valve replacement, and mitral valve replacement. We ranked hospitals according to risk-adjusted mortality and divided them into 5 equal groups. We then compared the incidence of complications and rates of failure to rescue between the top 20% of hospitals ("best") and bottom 20% of hospitals ("worst"). Analyses were conducted for all operations combined and for each individual procedure. For all 6 operations combined, the worst hospitals had mortality rates 2.5-fold higher than the best hospitals (8.0% vs. 3.0%). However, complication rates were similar at worst and best hospitals (36.4% vs. 32.7%). In contrast, failure to rescue rates were much higher at the worst compared with the best hospitals (16.7% vs. 6.8%). These findings persisted in analyses with individual operations and specific complications. Reducing variations in mortality will require strategies to improve the ability of high-mortality hospitals to manage postoperative complications.

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Hospital and patient characteristics associated with death after surgery. A study of adverse occurrence and failure to rescue.

J. H. Silber, S Williams, H Krakauer … (1992)

We asked if the factors that predict overall mortality following two common surgical procedures are different from those that predict adverse occurrences (complications) during the hospitalization or death after an adverse occurrence, which we refer to as "failure to rescue." We examined 5,972 Medicare patients undergoing elective cholecystectomy or transurethral prostatectomy using three outcome measures: 1) the death rate (number of deaths/number of patients); 2) the adverse occurrence rate (number of patients who developed an adverse occurrence/number of patients); and 3) the failure rate (number of deaths in patients who developed an adverse occurrence/number of patients with an adverse occurrence). The death rate was associated with both hospital and patient characteristics. The adverse occurrence rate was associated primarily with patient characteristics. In contrast, failure to rescue was associated more with hospital characteristics, and was less influenced by patient admission severity of illness as measured by the MedisGroups score. We concluded that factors associated with hospital failure to rescue are different from factors associated with adverse occurrences or death. Understanding the reasons behind variation in mortality rates across hospitals should improve our ability to use mortality statistics to help hospitals upgrade the quality of care.

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Real money: complications and hospital costs in trauma patients.

P Taheri, Jill L Jakubus, H.-W. Wahl … (2008)

Major postoperative complications are associated with a substantial increase in hospital costs. Trauma patients are known to have a higher rate of complications than the general surgery population. We used the National Surgical Quality Improvement Program (NSQIP) methodology to evaluate hospital costs, duration of stay, and payment associated with complications in trauma patients. Using NSQIP principles, patient data were collected for 512 adult patients admitted to the trauma service for > 24 hours at a Level 1 trauma center (2004-2005). Patients were placed in 1 of 3 groups: no complications (none), >or=1 minor complication (minor, eg, urinary tract infection), or >or=1 major complication (major, eg, pneumonia). Total hospital charges, costs, payment, and duration of stay associated with each complication group were determined from a cost-accounting database. Multiple regression was used to determine the costs of each type of complication after adjusting for differences in age, sex, new injury severity score, Glasgow coma scale score, maximum head abbreviated injury scale, and first emergency department systolic blood pressure. A total of 330 (64%) patients had no complications, 53 (10%) had >or= 1 minor complication, and 129 (25%) had >or= 1 major complication. Median hospital charges increased from $33,833 (none) to $81,936 (minor) and $150,885 (major). The mean contribution to margin per day was similar for the no complication and minor complication groups ($994 vs $1,115, P = .7). Despite higher costs, the patients in the major complication group generated a higher mean contribution to margin per day compared to the no complication group ($2,168, P < .001). The attributable increase in median total hospital costs when adjusted for confounding variables was $19,915 for the minor complication group (P < .001), and $40,555 for the major complication group (P < .001). Understanding the costs associated with traumatic injury provides a window for assessing the potential cost reductions associated with improved quality care. To optimize system benefits, payers and providers should develop integrated reimbursement methodologies that align incentives to provide quality care.

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Author and article information

Contributors

Toshikazu Abe: abetoshi111@gmail.com

Akira Komori: akg.6412@gmail.com

Atsushi Shiraishi: siris.accm@tmd.ac.jp

Takehiro Sugiyama: tsugiyama@md.tsukuba.ac.jp

Hiroki Iriyama: iriyamahiroki@yahoo.co.jp

Takako Kainoh: kitaharatakako@yahoo.co.jp

Daizoh Saitoh: ds0711@ndmc.ac.jp

Journal

Journal ID (nlm-ta): Crit Care

Title: Critical Care

Publisher: BioMed Central (London )

ISSN (Print): 1364-8535

ISSN (Electronic): 1466-609X

Publication date (Electronic): 15 May 2020

Publication date PMC-release: 15 May 2020

Publication date Collection: 2020

Volume: 24

Electronic Location Identifier: 223

Affiliations

[1 ]GRID grid.20515.33, ISNI 0000 0001 2369 4728, Department of Health Services Research, Faculty of Medicine, , University of Tsukuba, ; 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8577 Japan

[2 ]GRID grid.410857.f, ISNI 0000 0004 0640 9106, Department of Emergency and Critical Care Medicine, , Tsukuba Memorial Hospital, ; Tsukuba, Japan

[3 ]GRID grid.258269.2, ISNI 0000 0004 1762 2738, Department of General Medicine, , Juntendo University, ; Tokyo, Japan

[4 ]GRID grid.414927.d, ISNI 0000 0004 0378 2140, Emergency and Trauma Center, , Kameda Medical Center, ; Kamogawa, Japan

[5 ]GRID grid.45203.30, ISNI 0000 0004 0489 0290, Diabetes and Metabolism Information Center, Research Institute, , National Center for Global Health and Medicine, ; Tokyo, Japan

[6 ]GRID grid.26999.3d, ISNI 0000 0001 2151 536X, Department of Public Health/Health Policy, Graduate School of Medicine, , The University of Tokyo, ; Tokyo, Japan

[7 ]GRID grid.416614.0, ISNI 0000 0004 0374 0880, Department of Traumatology and Emergency Medicine, , National Defense Medical College, ; Tokorozawa, Japan

Article

Publisher ID: 2951

DOI: 10.1186/s13054-020-02951-1

PMC ID: 7226721

PubMed ID: 32414401

SO-VID: 2514ff58-af5f-4a83-8353-12e9d2f235b9

License:

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