BALTIMORE – The variation among hospitals in mortality for emergent bowel resection may be explained in part by failure-to-rescue (FTR) rates, according to a study presented at the American Association for Surgery of Trauma annual meeting.
Ambar Mehta, a medical student at Johns Hopkins University School of Medicine in Baltimore, and a team of colleagues reviewed case data on 105,925 bowel resections that occurred between 2010 and 2013 using the
Hospitals included were ranked by mortality for emergency bowel resection with the top quintile representing lowest mortality (1.5%) and bottom quintile representing the highest (14.9%).
Failure to rescue was defined as death after a major postoperative complication, according to Mr. Mehta. Overall failure-to-rescue rates were 9.8-fold higher in the bottom quintile hospitals, compared with those in the top quintile (33.4% vs. 3.4%). Patients studied were majority white (78.9%), female (53.9%), and younger than 65 years (52%).
Although FTR rates were significantly higher in the bottom quintile hospitals, complication rates were comparable (41.6% for bottom vs. 33.3% for top), suggesting that it was not complications per se that drove mortality but other postop factors.
Complications measured were acute renal failure, pulmonary failure, pneumonia, hemorrhage, gastrointestinal bleeding, pulmonary embolism, surgical site infections, and myocardial infarction.
Risk ratios for failure to rescue showed a similar increasing trend in correlation with mortality, with the hospitals in the lowest quintile showing a risk of 13 (P less than .01), compared with a risk of 3.2 (P less than .01) among hospitals in the highest quintile.
Correlation between failure to rescue and mortality was still evident when investigators adjusted analysis to compare hospitals that conducted more than 10 resections annually, causing investigators to suggest a need for changes in resection procedures.
“Our data suggest rates of failure to rescue correlate to rates of hospital mortality and we believe that system-level initiatives such as focusing on teamwork and team culture can reduce nationwide variations in mortality,” said Mr. Mehta.
Discussant , vice president for Trauma and Surgical Services at the University of Pittsburgh, acknowledged the link between mortality and failure to rescue among bowel resection patients and brought up the question of how to avoid such issues in the first place.
“This study validates the principle that a patient will generally tolerate an operation but not the first complication,” said Dr. Peitzman. “How do we avoid the first complication [and] what do you recommend in our acute care surgery practices and hospital structures to rescue our patients?”
Understanding why the complications happen at all is the first step to preventing them, Mr. Mehta said. Emergency general surgery–specific programs or mentorship programs may be a good start to cutting down on the inherent risk increase of emergent procedures.
Having greater than 20 beds designated to the intensive care unit and having a greater ratio of nursing staff to patients may be other viable solutions, according to a study Mr. Mehta cited; however, he asserted, focusing on team protocols seems to be the most successful course.
When asked by audience members about the idea of regionalizing care, Dr. Mehta said more data would be needed. “Regionalization has definitely shown benefits in a trauma setting,” said Mr. Mehta. “Copying a model of that idea for nontrauma [emergency general surgery] procedures may work, but it would require studies in a multicenter program.”
The study was limited by the use of administrative claims data, including being unable to determine if deaths were caused by a failure to rescue or whether families determined to end care after an initial complication. Investigators were also unable to identify which surgical diagnoses led to the procedure, nor could they adjust for varying hospital resources.
Investigators reported no relevant financial disclosures.