title: The importance of the first complication: understanding failure to rescue after emergent surgery in the elderly.
abstract: BACKGROUND
  Perioperative mortality in the elderly is high after emergency surgery and varies considerably among hospitals-an observation partially explained by differences in failure to rescue. We hypothesize that failure to rescue after certain types of complications underlies the disproportionately poor outcomes observed in elderly patients.
  
  
  METHODS
  We identified 23,217 patients undergoing emergent general or vascular surgery procedures at 41 hospitals within the Michigan Surgical Quality Collaborative between 2007 and 2012. Patients' first complications were identified and categorized by type. We compared failure to rescue rates at the patient-level between patients younger than 75 and 75 years of age and older. We then compared failure to rescue rates after specific complications across hospitals grouped in tertiles by risk-adjusted 30-day mortality.
  
  
  RESULTS
  Risk-adjusted failure to rescue rates were significantly higher in the elderly after a first infectious (21.7% vs 10.3%; p < 0.01) or pulmonary (38.2% vs 20.4%; p < 0.01) complication when compared with younger patients. At the hospital level, high-mortality centers failed to rescue elderly patients more frequently than low-mortality centers after a first infectious (35.6% vs 22.2%; p < 0.01) and pulmonary (24.3 vs 14.3; p < 0.01) complication. Failure to rescue rates after cardiovascular complications did not differ significantly across patient ages or tertiles of hospital mortality.
  
  
  CONCLUSIONS
  Hospitals fail to rescue elderly patients at higher rates than younger patients after infectious and pulmonary complications. Efforts to recognize and manage these specific complications have the potential to improve emergency surgical care of the elderly in Michigan.
authors.affiliation: Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI. Electronic address: ksheetz@med.umich.edu.
authors.forename: Kyle H
authors.initials: KH
authors.lastname: Sheetz
authors.affiliation: Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI.
authors.forename: Robert W
authors.initials: RW
authors.lastname: Krell
authors.affiliation: Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Englesbe
authors.affiliation: Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI.
authors.forename: John D
authors.initials: JD
authors.lastname: Birkmeyer
authors.affiliation: Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI.
authors.forename: Darrell A
authors.initials: DA
authors.lastname: Campbell
authors.affiliation: Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor, MI.
authors.forename: Amir A
authors.initials: AA
authors.lastname: Ghaferi
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D004638:Emergency Treatment; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality*; D012189:Retrospective Studies