Abdominal surgical trajectories associated with failure to rescue. A nationwide analysis

The ability to detect and treat complications of surgery early is essential for optimal patient outcomes. The failure-to-rescue (FTR) rate is defined as the death rate among patients who develop at least one complication after the surgical procedure and may be used to monitor a hospital's quality of surgical care. The aim of this observational study was to explore FTR in Norway and to see if we could identify surgical trajectories associated with high FTR.

Data on all abdominal surgeries in Norwegian hospitals from 2011 to 2017 were obtained from the Norwegian Patient Registry and linked with the National Population Register. Surgical and other postoperative complication rates and FTR within 30 days (deaths occurring in and out of the hospital) were assessed. We identified surgical trajectories (type of procedures-type of complication-dead/alive at 30 days after operation) associated with the highest volume of deaths (high volume of FTR [FTR-V]) and highest risk of death after a postoperative complication.

Of the total 626 052 primary abdominal procedures, 224 871 (35.8%) had at least one complication, which includes 83 037 patients. The most common postoperative complications were sepsis (N = 14 331) and respiratory failure (N = 7970). The high-volume trajectories (FTR-V) were endoscopic retrograde cholangiopancreatography-sepsis-death (N = 294, 13.8%); open colon resections-sepsis-death (N = 279, 28.1%) and procedures with stoma formation-sepsis-death (N = 272, 27%). Similarly, patients operated with embolectomy of the visceral arteries and experiencing postoperative sepsis were associated with an extremely high risk of 30-day FTR of 81.5%. In general, an FTR patient had a higher mean age, an increased rate of emergency surgery and more comorbidity. Hospital size was not associated with FTR.

At a national level, there exist high-volume and high-risk surgical trajectories associated with FTR. These trajectories represent major targets for quality improvement initiatives.