Complications and Failure to Rescue After Inpatient Pediatric Surgery

Abstract

Objective: To describe the frequency and patterns of postoperative complications and FTR after inpatient pediatric surgical procedures and to evaluate the association between number of complications and FTR. Summary and Background: FTR, or a postoperative death after a complication, is currently a nationally endorsed quality measure for adults. Although it is a contributing factor to variation in mortality, relatively little is known about FTR after pediatric surgery. Methods: Cohort study of 200,554 patients within the National Surgical Quality Improvement Program-Pediatric database (2012-2016) who underwent a high (≥ 1%) or low ( < 1%) mortality risk inpatient surgical procedures. Patients were stratified based on number of postoperative complications (0, 1, 2, or ≥3) and further categorized as having undergone either a low-or high-risk procedure. The association between the number of postoperative complications and FTR was evaluated with multivariable logistic regression. Results: Among patients who underwent a low-(89.4%) or high-risk (10.6%) procedures, 14.0% and 12.5% had at least 1 postoperative complication, respectively. FTR rates after low-and high-risk procedures demonstrated step-wise increases as the number of complications accrued (eg, low-risk-9.2% in patients with ≥3 complications; high-risk-36.9% in patients with ≥ 3 complications). Relative to patients who had no complications, there was a dose-response relationship between mortality and the number of complications after low-risk [1 complicationodds ratio (OR) 3.34 (95% CI 2.62-4.27); 2 -OR 10.15 (95% CI 7.40-13.92); ] and high-risk operations ≥3 )].Conclusions: There is a dose-response relationship between the number of postoperative complications after inpatient surgery and FTR, ever after common, "minor" surgical procedures. These findings suggest FTR may be a potential quality measure for pediatric surgical care.

Variation in Complications and Mortality According to Infant Diagnosis

“…Measuring quality in pediatric surgery remains a challenge due to the overall low rate of adverse outcomes, such as postoperative complications and mortality. [5][6][7][8] Previous pediatric QI initiatives have addressed this limitation by prioritizing high yield targets representing a significant burden of pediatric morbidity and health care costs, such as appendicitis, gastrostomy, colorectal procedures, and specific neonatal conditions (eg, CDH, gastroschisis). 9,13 In this context, our study aimed to identify potential high-priority targets for the development of future QI projects in the pediatric surgical population and our findings offer several novel conclusions.…”

“…Consistent with recent data demonstrating approximately a third of all pediatric deaths are not preceded by a coded complication in NSQIP-P, our study identified less than half of infant perioperative mortality was preceded by a postoperative complication. 7,8,11 As such, while FTR could potentially represent a promising target for appropriately chosen disease processes, additional work is needed to understand the relationship between FTR and pediatric surgical quality across hospitals.…”

“…[5][6][7][8] For example, previous work has identified the postoperative mortality rate for pediatric surgical patients is <1%. [6][7][8] Therefore, designing impactful pediatric surgical QI programs requires information that can help to prioritize the diagnoses and conditions associated with the highest burden of morbidity and mortality. 9,10 Prior work suggests the majority of postoperative mortality in children occurs among infants (ie children <1 y old).…”

Failure to rescue following emergency surgery: A FRAM analysis of the management of the deteriorating patient

“…Much is known about the incidence of FTR (Portuondo et al, 2020, Massarweh et al, 2016, Rosero et al, 2020, Chung et al, 2017, Ghaferi et al, 2009b, Sheetz et al, 2013, Ghaferi et al, 2009a, factors affecting its prevalence (Wakeam et al, 2014a, Blegen et al, 2013, Ghaferi et al, 2011, Johnston et al, 2015b, Sheetz et al, 2016, and potential causes and contributory factors (Burke et al, 2020, Johnston et al, 2015a, Johnston et al, 2014. The latter include potential failure of the following: to notice that the patient is unwell, to measure vital signs, to calculate early warning scores correctly, to check notes, to escalate in a timely fashion or to arrange definite care management.…”

“…FTR has been proposed as an alternative metric for surgical quality as opposed to mortality rate (Silber et al, 2007), because it is more tightly linked to postsurgical complication rates (Ghaferi et al, 2009b, Ghaferi et al, 2011, rather than patient factors. Across surgical settings, FTR rates have been found to range between 8% -18% (Johnston et al, 2015b, Portuondo et al, 2020.…”