Failure to rescue

Posted 12 years ago

Earlier this week, I learned about a new indicator to measure surgical quality. "Failure the rescue" stands for our inability to save a patient’s life as a consequence of a surgical complication.

A recently published paper suggests that the risk of death from a surgical complication was double as high in a low-volume hospital than in a high-volume hospital.

Surgical volume (number of procedures performed yearly) is a well-recognised parameter determining outcomes of surgery. It seems that the relationship between surgical volume and outcomes is particularly strong in high-risk surgery. Why is that so?

High volume surgeons may perform better in a smaller spectrum of surgical procedures. They may have better technical skills but also have better back up mechanisms and assistance in case things turn bad. No one can simply be the best in everything and surgeons should be able to realistically self-assess and know what their limitations are.

High volume surgeons may also be better in clinical decision-making. The decision to offer a patient a laparotomy rather than a laparoscopic procedure (if feasible) increases a patient’s risk for surgical complications substantially.

High volume surgeons may also be more familiar with current guidelines. Most guidelines are based on evidence and may change from time to time. Keeping up to date with all guidelines is simply impossible. As a gynaecological oncologist and pelvic surgeon I find it impossible to keep up to date with current guidelines on areas such as contraception, HRT or sexually transmitted diseases.

High volume surgeons and centres may be better equipped to deal with surgical complications. Surgical complications are not uncommon and they are especially common in obese and morbidly obese patients, in patients with high ASA score, those who require a laparotomy (as opposed to a laparoscopy), in patients with pre-existing medical co-morbidities and in cancer patients.

The authors of the above-mentioned paper collected data from 36,000 patients treated for ovarian cancer at 1100 U.S. hospitals within an 11-year time period. Failure of rescue was defined as death in patients with any complication (medical, non-medical) divided by the total number of patients who developed a complication.

The overall perioperative complication rate was 22.8% and increased from 19.2% (1998) to 26.8% (2009) during the study period. The complication rate increased with surgical volume from 20.4% in low-volume hospitals to 24.6% at high-volume hospitals. By contrast, the mortality rate (1.6%) was significantly less in high-volume hospitals.

The failure-to-rescue rate decreased with time, from 8.7% in 1998 to 6.0% in 2009. It was 8.0% in low-volume but only 4.9% in high-volume hospitals. After adjustment for various risk factors, patients treated at a low-volume hospital were 48% more likely to die from a complication.

Does this paper make sense for the work I do? Yes, it actually does make sense. I do remember patients where through enormous efforts of an entire team we rescued the patient and saved her life. Once, I cut short my holiday to return because I thought I could rescue a patient; and it worked. When my colleagues and I talk and debrief about patients and cases, I also became aware that my gynaecological oncology colleagues do the same from time to time. With enormous efforts of them and their teams, they have been able to rescue patients and save their life when they developed a complication previously.

Why is it then, that you might say, "I can’t relate to this; this never happens to me." The concept of patients dying from perioperative complications may be unfamiliar to surgeons whose type of surgery does not or hardly ever cause live-threatening complications. The numbers in the above publication refer to ovarian cancer surgery that will always attract significant complications and they would be significantly lower if we focussed on general gynaecological surgery.

Even within the general gynaecology spectrum of procedures, some procedures are risky. Think of the patient who had a previous rectal resection or Hartman’s resection and now requires a hysterectomy. Or the patient who needs surgery for a presumed benign but very tender pelvic mass and who had a stroke or a DVT or a PE after every single surgical procedure she had in the past. These patients are normally referred to a tertiary centre because we assume that we can deal with complications better in a big hospital.

The failure-of-rescue model is something I’d like to think about further. How about you?