Fears of definitive fracture fixation site contamination from external fixator pins do not appear to be clinically grounded. When needed, we recommend the use of a temporary external fixation construct with pin placement that provides for the best reduction and stability of the fracture, regardless of plans for future surgery.

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.

Introduction Failure to rescue (FTR: the conditional probability of death after complication) has been studied in trauma cohorts, but the impact of age and pre-existing conditions (PECs) on risk of FTR is not well-known. We assessed the relationship between age and PECs on the risk of experiencing serious adverse events (SAE) subsequent FTR in trauma patients with the hypothesis that increased comorbidity burden and age would be associated with increased FTR. Materials and Methods We performed a retrospective cohort analysis at an urban level 1 trauma center in PA. All patients age ≥ 16 years with minimum abbreviated injury scale score ≥ 2 from 2009–2013 were included. Univariate logistic regression models for SAE and FTR were developed using age, PECs, demographics, and injury physiology. Variables found to be associated with the endpoint of interest (p≤0.2) in univariate analysis were included in separate multivariable logistic regression models for each outcome. Results SAE occurred in 1,136/7533 (15.1 %) of patients meeting inclusion criteria (median age 42 (IQR 26–59), 53% African American, 72% male, 79% blunt, median ISS 10 (IQR 5–17)). Of those who experienced a SAE, 129/1136 patients subsequently died (FTR = 11.4%). Development of SAE and FTR was associated with age ≥ 70 (OR 1.58–1.78, 95% CI 1.13–2.82). Renal disease was the only pre-existing condition associated with both SAE and FTR. Conclusions Trauma patients with renal disease are most at increased risk for both SAE and FTR, but other PECs associated with SAE are not necessarily those associated with FTR. Future interventions designed to reduce FTR events should target this high-risk cohort.

Introduction The Failure to Rescue (FTR) rate is the probability of death after a major complication and was defined in elective surgical cohorts. In elective surgery, the precedence rate (proportion of deaths preceded by major complications) approaches 100%, but recent studies in trauma report rates of only 20–25%. We hypothesized that use of high quality data would result precedence rates in higher than those derived from national datasets, and we further sought to characterize the nature of those deaths not preceded by major complications. Methods Prospectively collected data from 2006–2010 from a single level I trauma centre were used. Patients age >16 years with AIS ≥2 who survived beyond the trauma bay were included. Complications, mortality, FTR, and precedence rates were calculated. Chart abstraction was performed for registry deaths without recorded complications to verify the absence of complications and determine the cause of death, after which outcomes were re-calculated. Results A total of 8004 patients were included (median age 41(IQR 25–75), 71% male, 82% blunt, median ISS 10(IQR5–18)). Using registry data the precedence rate was 55%, with 132/293 (45%) deaths occurring without antecedent major complications. On chart abstraction, 11/132 (8%) patients recorded in the registry as having no complication prior to death were found to have major complications. Complication and FTR rates after chart abstraction were statistically significantly different than those derived from registry data alone (complications 16.5% vs. 16.3, FTR 12.3 vs.13p=0.001), but this difference was unlikely to be clinically meaningful. Patients dying without complications predominantly (87%) had neurologic causes of demise. Conclusions Use of data with near-complete ascertainment of complications results in precedence rates much higher than those from national datasets. Patients dying without precedent complications at our centre largely succumbed to progression of neurologic injury. Attempts to use FTR to compare quality between centres should be limited to high quality data. Level of Evidence Level III