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A metric of our own: Failure to rescue after trauma
Daniel N Holena1, Elinore J Kaufman, M Kit Delgado
1From the Division of Traumatology (D.N.H., P.M.R.), Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; The Penn Injury Science Center at the University of Pennsylvania (D.N.H., M.K.D., D.J.W., P.M.R.), Philadelphia, Pennsylvania; Department of Surgery (E.J.K.), Weill-Cornell School of Medicine, New York, New York; Department of Emergency Medicine (M.K.D.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics (D.J.W.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; and Department of Emergency Medicine (B.G.C.), Jefferson University School of Medicine, Philadelphia, Pennsylvania.
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 (3) including deaths not preceded by adverse events in FTR analysis except those with predicted mortality or greater than 50% (FTR-T). Mortality, adverse event, and FTR rates were calculated under each method, and reliability was tested using Spearman correlation for split-sample center rankings.
Results:
A total of 89,780 patients were included (median age, 57 years [interquartile range, 26-73 years]; 85% were white; 59% were male; 92% had blunt mechanism of injury; median Injury Severity Score, 9 [interquartile range, 5-14]). The 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 (ρ = 0.59 vs. = 0.27, p < 0.001).
Conclusions:
A trauma-specific FTR metric increases face validity and reliability relative to other FTR methods that may be used in trauma populations. Future trauma outcomes studies examining FTR rates should use a metric designed for this cohort.
Level Of Evidence:
Retrospective cohort study, outcomes, level III.
Insights
A new trauma-specific Failure to Rescue (FTR) metric improves accuracy and reliability in assessing patient outcomes. This hybrid approach better reflects trauma care realities than existing methods.
Area of Science:
- Trauma care outcomes research
- Surgical quality metrics
- Patient safety analysis
Background:
- Failure to Rescue (FTR) is defined as death following an adverse event.
- Existing FTR metrics lack validity in trauma due to direct injury deaths and exclusion of certain cases.
- A novel hybrid metric was developed to enhance face validity and reliability for trauma populations.
Purpose of the Study:
- To develop and validate a trauma-specific Failure to Rescue (FTR) metric.
- To compare the face validity and reliability of three distinct FTR metrics in a trauma cohort.
- To improve the assessment of patient outcomes in trauma care.
Main Methods:
- A retrospective cohort study analyzed adult trauma registry data from 30 centers over 3 years.
- Three FTR metrics were constructed: FTR-E (exclusion), FTR-R (reclassification), and FTR-T (hybrid).
- Reliability was assessed using Spearman correlation for split-sample center rankings.
Main Results:
- The study included 89,780 patients; FTR rates varied significantly by metric (FTR-E: 11.2%, FTR-R: 31.2%, FTR-T: 21.4%).
- The hybrid metric (FTR-T) demonstrated higher reliability (ρ = 0.59) compared to the exclusion metric (FTR-E: ρ = 0.27).
- The proportion of deaths preceded by adverse events also varied by metric (FTR-E: 28%, FTR-R: 100%, FTR-T: 60%).
Conclusions:
- A trauma-specific FTR metric enhances face validity and reliability compared to existing methods.
- The developed hybrid metric (FTR-T) is recommended for future trauma outcomes studies.
- This trauma-tailored approach offers a more accurate assessment of patient safety and outcomes in trauma care.
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1. Clinical Evaluation:
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