Where We Fail: Location and Timing of Failure to Rescue in Trauma

Failure to rescue (FTR) is an outcome metric that reflects a center's ability to prevent mortality after a major complication. Identifying the timing and location of FTR events could help target efforts to reduce FTR rates. We sought to characterize the timing and location of FTR occurrences at our center, hypothesizing that FTR rates would be highest early after injury and in settings of lower intensity of care. We used data, prospectively collected from 2009 to 2013, on patients ≥16 years old with minimum Abbreviated Injury Score ≥2 from a single institution. Major complications (per Pennsylvania Trauma Systems Foundation definitions), mortality, and FTR rates were examined by location [prehospital, emergency department, operating room, intensive care unit (ICU), and interventional radiology] and by day post admission. Kruskal-Wallis and chi-squared tests were used to compare variables (P = 0.05). Major complications occurred in 899/6150 (14.6%) of patients [median age: 42, interquartile range (IQR): 25-57; 56% African American, 73% male, 76% blunt; median Injury Severity Score: 10, IQR: 5-17]. Of 899, 111 died (FTR = 12.4%). Compared with non-FTR cases, FTR cases had earlier complications (median day 1 (IQR: 0-4) versus 5 (IQR: 2-8), P < 0.001). FTR rates were highest in the prehospital (55%), emergency department (38%), and operating room (36%) settings, but the greatest number of FTR cases occurred in the ICU (52/111, 47%). FTR rates were highest early after injury, but the majority of cases occurred in the ICU. Efforts to reduce institutional FTR rates should focus on complications that occur in the ICU setting.