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Canadian Journal of Cardiology

Failure to Rescue: A Quality Metric for Cardiac Surgery and Cardiovascular Critical Care

Published:January 05, 2023DOI:https://doi.org/10.1016/j.cjca.2023.01.001

      Abstract:

      Failure to rescue, defined as mortality following a surgical complication, is a widely accepted quality metric across many specialties and is becoming an important metric in cardiac surgery. The failure to rescue metric provides a target for improvements in patient outcomes after complications occur. To be used appropriately, the failure to rescue metric must be defined using a pre-specified set of life-threatening and rescuable complications. Successful patient rescue requires a systematic approach of complication recognition, timely escalation of care, effective medical management, and mitigation of additional complications. This process requires contributions from cardiac surgeons, intensivists, and other specialists including cardiologists, neurologists, and anesthesiologists. Factors affecting failure to rescue rates in cardiac surgery and cardiovascular critical care include nurse staffing ratios, intensivist coverage, advanced specialist support, hospital and surgical volume, the presence of trainees, and patient comorbidities. Strategies to improve patient rescue include working to understand the mechanisms of failure to rescue, anticipating postoperative complications, prioritizing microsystem factors, enhancing early escalation of care, and educating and empowering junior clinicians. When used appropriately, the failure to rescue quality metric can help institutions focus on improving processes of care that minimize morbidity and mortality from rescuable complications following cardiac surgery.
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      References:

        • Silber J.H.
        • Williams S.V.
        • Krakauer H.
        • Schwartz J.S.
        Hospital and patient characteristics associated with death after surgery: a study of adverse occurrence and failure to rescue.
        Med Care. 1992; 30: 615-629
        • Silber J.H.
        • Rosenbaum P.R.
        • Schwartz J.S.
        • Ross R.N.
        • Williams S.V.
        Evaluation of the complication rate as a measure of quality of care in coronary artery bypass graft surgery.
        JAMA. 1995; 274: 317-323
        • Ghaferi A.A.
        • Birkmeyer J.D.
        • Dimick J.B.
        Complications, failure to rescue, and mortality with major inpatient surgery in Medicare patients.
        Ann Surg. 2009; 250: 1029-1034
      1. Reddy HG Shih T, Englesbe MJ et al. Analyzing “failure to rescue”: is this an opportunity for outcome improvement in cardiac surgery?. Ann Thorac Surg 2013;95(6):1976–1981.

        • Edwards F.H.
        • Ferraris V.A.
        • Kurlanksy P.A.
        • et al.
        Failure to rescue rates after coronary artery bypass grafting: an analysis from the Society of Thoracic Surgeons adult cardiac surgery database.
        Ann Thorac Surg. 2016; 102: 458-464
        • Likosky D.S.
        • Strobel R.J.
        • Wu X.
        • et al.
        Interhospital failure to rescue after coronary artery bypass grafting.
        J Thorac Cardiovasc Surg. 2021; (Preprint)https://doi.org/10.1016/j.jtcvs.2021.01.064
      2. Hatchimonji JS. Kaufman EJ, Sharoky CE, Ma L, Garcia Whitlock AE, Holena DN. Failure to rescue in surgical patients: a review for acute care surgeons. J Trauma Acute Care Surg 2019;87(3):699-706.

        • Ahmed E.O.
        • Butler R.
        • Novick R.J.
        Failure-to-rescue rate as a measure of quality of care in a cardiac surgery recovery unit: a five-year study.
        Ann Thoracic Surg. 2014; 97: 147-152
        • Kurlansky P.A.
        • O’Brien S.M.
        • Vassileva C.M.
        • et al.
        Failure to rescue: a new Society of Thoracic Surgeons quality metric for cardiac surgery.
        Ann Thorac Surg. 2022; 113: 1935-1942
        • Shahian D.M.
        • Jacobs J.P.
        • Badhwar V.
        • et al.
        The Society of Thoracic Surgeons 2018 Adult Cardiac Surgery risk models: Part 1 - background, design, considerations, and model development.
        Ann Thorac Surg. 2018; 105: 1411-1418
      3. Online STS Adult Cardiac Surgery Risk Calculator: New Version (4.20). Available at: https://riskcalc.sts.org/stswebriskcalc/calculate. Accessed December 12, 2022.

        • Nashef S.A.M.
        • Roques F.
        • Sharples L.D.
        • et al.
        EuroSCORE II.
        Eur J Cardiothorac Surg. 2012; 41: 734-744
      4. Ad N, Holmes SD, Patel J, Pritchard G, Shuman DJ, Halpin L. Comparison of EuroSCORE II, original EuroSCORE, and the Society of Thoracic Surgeons risk score in cardiac surgery patients. Ann Thorac Surg 2016;102(2):573-579.

        • Portuondo J.I.
        • Shah S.R.
        • Singh H.
        • Massarweh N.N.
        Failure to rescue as a surgical quality indicator: current concepts and future directions for improving surgical outcomes.
        Anesthesiology. 2019; 131: 426-437
        • Engelman D.T.
        • Ali W.B.
        • Williams J.B.
        • et al.
        Guidelines for perioperative care in cardiac surgery: enhanced recovery after surgery society recommendations.
        JAMA Surg. 2019; 154: 755-766
        • Westaby S.
        • De Silva R.
        • Petrou M.
        • Bond S.
        • Taggart D.
        Surgeon-specific mortality data disguise wider failings in delivery of safe surgical services.
        Eur J Cardiothorac Surg. 2015; 47: 341-345
      5. Agency for Healthcare Research and Quality (AHRQ) quality indicators. Patient safety indicators: technical specifications. Available at: http://www.qualityindicators.ahrq.gov. Accessed September 29, 2022.

      6. Aiken LH, Clarke SP, Cheung RB, Sloane DM Silber JH. Educational levels of hospital nurses and surgical patient mortality. JAMA 2003;290(12):1617-1623.

        • Ward S.T.
        • Dimick J.B.
        • Zhang W.
        • Campbell D.A.
        • Ghaferi A.A.
        Association between hospital staffing models and failure to rescue.
        Ann Surg. 2019; 270: 91-94
        • Needleman J.
        • Buerhaus P.
        • Mattke S.
        • Stewart M.
        • Zelevinsky K.
        Nurse-staffing levels and the quality of care in hospitals.
        N Engl J Med. 2002; 346: 1715-1722
        • Pronovost P.J.
        • Angus D.C.
        • Dorman T.
        • Robinson K.A.
        • Dremsizov T.T.
        • Young T.L.
        Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review.
        JAMA. 2002; 288: 2151-2162
        • Benoit M.A.
        • Bagshaw S.M.
        • Norris C.M.
        • et al.
        Postoperative complications and outcomes associated with a transition to 24/7 intensivist management of cardiac surgery patients.
        Crit Care Med. 2017; 45: 993-1000
      7. Patel P, Itagaki S, Serrao G, Varghese R. Post-operative cardiac catheterization after open adult cardiac surgery (Abst). Annual Meeting of the American College of Cardiology 2021; Atlanta, GA.

        • Guadino M.
        • Nesta M.
        • Burzotta F.
        • et al.
        Results of emergency postoperative re-angiography after cardiac surgery procedures.
        Ann Thorac Surg. 2015; 99: 1576-1582
        • Kashani H.H.
        • Mosienko L.
        • Grocott B.B.
        • Glezerson B.A.
        • Grocott H.P.
        Postcardiac surgery acute stroke therapies: a systematic review.
        J Cardiothorac Vasc Anesth. 2020; 34: 2349-2354
        • Wilkinson D.A.
        • Koduri S.
        • Anand S.K.
        • et al.
        Mechanical thrombectomy improves outcome for large vessel occlusion stroke after cardiac surgery.
        J Stroke Cerebrovasc Dis. 2021; 30105851
        • LaPar D.J.
        • Quader M.
        • Rich J.B.
        • et al.
        Institutional variation in mortality after stroke after cardiac surgery: an opportunity for improvement.
        Ann Thorac Surg. 2015; 100: 1276-1282
      8. Patel P, Gross CR, Nomoto K, Oloomi M, Zafirova Z, Varghese R. Time of postoperative arrests affects successful rescue of patients after cardiac surgery (Abst). Annual Meeting of the Society of Critical Care Medicine 2022.

        • Ghaferi A.A.
        • Birkmeyer J.D.
        • Dimick J.B.
        Hospital volume and failure to rescue with high-risk surgery.
        Med Care. 2011; 49: 1076-1081
        • Sheetz K.H.
        • Dimick J.B.
        • Ghaferi A.A.
        Impact of hospital characteristics on failure to rescue following major surgery.
        Ann Surg. 2016; 263: 692-697
        • Gonzalez A.A.
        • Dimick J.B.
        • Birkmeyer J.D.
        • Ghaferi A.A.
        Understanding the volume-outcome effect in cardiovascular surgery: the role of failure to rescue.
        JAMA Surg. 2014; 149: 119-123
        • Johnston M.J.
        • Arora S.
        • King D.
        • et al.
        A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery.
        Surgery. 2015; 157: 752-763
        • Johnston M.
        • Arora S.
        • King D.
        • Stroman L.
        • Darzi A.
        Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study.
        Surgery. 2014; 155: 989-994
        • Dewan K.C.
        • Navale S.M.
        • Hirji S.A.
        • et al.
        The role of frailty in failure to rescue after cardiovascular surgery.
        Ann Thorac Surg. 2021; 111: 472-478
        • Massarweh N.N.
        • Anaya D.A.
        • Kougias P.
        • Bakaeen F.G.
        • Awad S.S.
        • Berger D.H.
        Variation and impact of multiple complications on failure to rescue after inpatient surgery.
        Ann Surg. 2017; 266: 59-65
        • Seese L.
        • Sultan I.
        • Gleason T.G.
        • et al.
        The impact of major postoperative complications on long-term survival after cardiac surgery.
        Ann Thorac Surg. 2020; 110: 128-135
        • Taenzer A.H.
        • Pyke J.B.
        • McGrath S.P.
        A review of current and emerging approaches to address failure-to-rescue.
        Anesthesiology. 2011; 115: 421-431
        • Ruel M.
        • Chan V.
        • Boodhwani M.
        • et al.
        How detrimental is reexploration for bleeding after cardiac surgery?.
        J Thorac Cardiovasc Surg. 2017; 154: 927-935
        • Salter B.S.
        • Gross C.R.
        • Weiner M.M.
        • et al.
        Temporary mechanical circulatory support devices: practical considerations for all stakeholders.
        Nat Rev Cardiol. 2022; (Preprint)https://doi.org/10.1038/s41569-022-00796-5
        • Crawford T.C.
        • Magruder J.T.
        • Grimm J.C.
        • et al.
        Complications after cardiac operations: all are not created equal.
        Ann Thorac Surg. 2017; 103: 32-40
        • Fordyce C.B.
        • Katz J.N.
        • Alviar C.L.
        • et al.
        Prevention of complications in the cardiac intensive care unit.
        Circulation. 2020; 142: e379-e406
        • Ervin J.N.
        • Vitous C.A.
        • Wells E.E.
        • Krein S.L.
        • Friese C.R.
        • Ghaferi A.A.
        Rescue improvement conference: a novel tool for addressing failure to rescue.
        Ann Surg. 2021; (Preprint)https://doi.org/10.1097/SLA.0000000000004832
        • Ghaferi A.A.
        • Wells E.E.
        Improving postoperative rescue through a multifaceted approach.
        Surg Clin North Am. 2021; 101: 71-80
        • Thakar C.V.
        • Arrigain S.
        • Worley S.
        • Yared J.
        • Paganini E.P.
        A clinical score to predict acute renal failure after cardiac surgery.
        J Am Soc Nephrol. 2005; 16: 162-168
        • Thomson R.
        • Fletcher N.
        • Valencia O.
        • Sharma V.
        Readmission to the intensive care unit following cardiac surgery: a derived and validated risk prediction model in 4,869 patients.
        J Cardiothorac Vasc Anesth. 2018; 32: 2685-2691
        • Johnston M.
        • Arora S.
        • Anderson O.
        • King D.
        • Behar N.
        • Darzi A.
        Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients.
        Ann Surg. 2015; 261: 831-838
        • Hall K.K.
        • Lim A.
        • Gale B.
        The use of rapid response teams to reduce failure to rescue events: a systematic review.
        J Patient Saf. 2020; 16: S3-7
        • Lyons P.G.
        • Edelson D.P.
        • Churpek M.M.
        Rapid response systems.
        Resuscitation. 2018; 128: 191-197
        • Manners J.
        • Khandker N.
        • Barron A.
        • et al.
        An interdisciplinary approach to inhospital stroke improves stroke detection and treatment time.
        J Neurointerv Surg. 2019; 11: 1080-1084
        • Sessler D.I.
        • Saugel B.
        Beyond ‘failure to rescue’: the time has come for continuous ward monitoring.
        Br J Anaesth. 2019; 122: 304-306
        • Loftus T.J.
        • Tighe P.J.
        • Filiberto A.C.
        • et al.
        Opportunities for machine learning to improve surgical ward safety.
        Am J Surg. 2020; 220: 905-913
        • Chiu Y.D.
        • Villar S.S.
        • Brand J.W.
        • et al.
        Logistic early warning scores to predict death, cardiac arrest or unplanned intensive care unit re-admission after cardiac surgery.
        Anaesthesia. 2020; 75: 162-170
        • Woldhek A.L.
        • Rijkenberg S.
        • Bosman R.J.
        • van der Voort P.H.J.
        Readmission of ICU patients: a quality indicator?.
        J Crit Care. 2017; 38: 328-334
        • Smith M.E.
        • Wells E.E.
        • Friese C.R.
        • Krein S.L.
        • Ghaferi A.A.
        Interpersonal and organizational dynamics are key drivers of failure to rescue.
        Health Aff (Milwood). 2018; 37: 1870-1876
        • Devaraj L.R.
        • Cooper C.
        • Begin A.S.
        Creating psychological safety on medical teams in times of crisis.
        J Hosp Med. 2021; 16: 47-49
        • Ribeiro I.B.
        • Ngu J.M.C.
        • Lam B.
        • Edwards R.A.
        Simulation-based skill training for trainees in cardiac surgery: a systematic review.
        Ann Thorac Surg. 2018; 105: 972-982
        • Feins R.H.
        • Burkhart H.M.
        • Conte J.V.
        • et al.
        Simulation-based training in cardiac surgery.
        Ann Thorac Surg. 2017; 103: 312-321
        • O’Neal J.B.
        • Shaw A.D.
        • Billings F.T.
        Acute kidney injury following cardiac surgery: current understanding and future directions.
        Crit Care. 2016; 20: 187
      9. Silber JH, Arriaga AF, Niknam BA, Hill AS, Ross RN, Romano PS. Failure-to-rescue after acute myocardial infarction. Med Care;56(5):416-423.

      10. Hira RS, Kataruka A, Maynard C, Dolgner S, Doll J. Failure to rescue after PCI: insights from the Washington State cardiac care outcomes assessment program (Abstr). Annual Meeting of the American College of Cardiology 2021.

        • Totonchi Z.
        • Baazm F.
        • Chitsazan M.
        • Seifi S.
        • Chitsazan M.
        Predictors of prolonged mechanical ventilation after open heart surgery.
        J Cardiovasc Thorac Res. 2014; 6: 211-216
        • Knapik P.
        • Ciesla D.
        • Borowik D.
        • Czempik P.
        • Knapik T.
        Prolonged ventilation post cardiac surgery - tips and pitfalls of the prediction game.
        J Cardiothorac Surg. 2011; 6: 158