title: Failure to rescue in trauma: Coming to terms with the second term.
abstract: BACKGROUND
  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 hypothesised that use of high quality data would result precedence rates in higher than those derived from national datasets, and we further sought to characterise the nature of those deaths not preceded by major complications.
  
  
  METHODS
  Prospectively collected data from 2006 to 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 (IQR 5-18)). 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.13, p=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.
  
  
  METHODS
  Level III.
  Outcomes.
authors.affiliation: Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; The Leonard Davis Institute, Wharton School of Business at the University of Pennsylvania, Philadelphia, PA, United States. Electronic address: Daniel.holena@uphs.upenn.edu.
authors.forename: Daniel N
authors.initials: DN
authors.lastname: Holena
authors.affiliation: Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States.
authors.forename: Emily
authors.initials: E
authors.lastname: Earl-Royal
authors.affiliation: Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; The Leonard Davis Institute, Wharton School of Business at the University of Pennsylvania, Philadelphia, PA, United States; Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States.
authors.forename: M Kit
authors.initials: MK
authors.lastname: Delgado
authors.affiliation: Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States.
authors.forename: Carrie A
authors.initials: CA
authors.lastname: Sims
authors.affiliation: Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States.
authors.forename: Jose L
authors.initials: JL
authors.lastname: Pascual
authors.affiliation: Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; The Leonard Davis Institute, Wharton School of Business at the University of Pennsylvania, Philadelphia, PA, United States.
authors.forename: Jesse Y
authors.initials: JY
authors.lastname: Hsu
authors.affiliation: The Leonard Davis Institute, Wharton School of Business at the University of Pennsylvania, Philadelphia, PA, United States; Department of Emergency Medicine, Jefferson University School of Philadelphia Medicine, PA, United States.
authors.forename: Brendan G
authors.initials: BG
authors.lastname: Carr
authors.affiliation: Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States.
authors.forename: Patrick M
authors.initials: PM
authors.lastname: Reilly
authors.affiliation: Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; The Leonard Davis Institute, Wharton School of Business at the University of Pennsylvania, Philadelphia, PA, United States.
authors.forename: Douglas
authors.initials: D
authors.lastname: Wiebe
mesh_terms: D000328:Adult; D000368:Aged; D015897:Comorbidity; D017558:Elective Surgical Procedures / Q000401:mortality*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D012151:Resuscitation / Q000401:mortality*; D012189:Retrospective Studies; D014193:Trauma Centers; D017211:Treatment Failure; D014481:United States / Q000453:epidemiology
keywords: Failure to rescue; Methodology; Outcomes