Improving mortality following emergent surgery in older patients requires focus on complication rescue

To determine whether a hospital's ability to rescue patients from major complications underlies variation in outcomes for elderly patients undergoing emergent surgery.

Perioperative mortality rates in elderly patients undergoing emergent general/vascular operations are high and vary widely across Michigan hospitals.

We identified 23,224 patients undergoing emergent general/vascular surgical procedures at 41 hospitals within the Michigan Surgical Quality Collaborative between 2006 and 2011. Hospitals were ranked by risk- and reliability-adjusted 30-day mortality rates and grouped into tertiles. We stratified patients by age (<75 and ≥75 years). Risk-adjusted major complication and failure-to-rescue (ie, mortality after major complication) rates were determined for each tertile of hospital mortality.

Risk-adjusted mortality rates in elderly patients varied 2-fold across all hospitals. Complication rates correlated poorly with mortality. Failure-to-rescue rates, however, were markedly higher in high-mortality hospitals (29% lowest tertile vs 41% highest tertile; P < 0.01). When compared with younger patients, overall failure-to-rescue rates were almost 2-fold greater in the elderly (36.1% ≥75 vs 18.7% <75; P < 0.01).

A hospital's failure to rescue patients from major complications seems to underlie the variation in mortality rates across Michigan hospitals after emergent surgery. Although higher failure-to-rescue rates in the elderly may signify their diminished physiological reserve for surviving critical illness, the wide variation across hospitals also highlights the importance of systems aimed at the early recognition and effective management of major complications in this vulnerable population.