Department of Surgery, University of Kentucky, Lexington2Department of Surgery, Lexington Veteran's Affairs Medical Center, Lexington, Kentucky.
Department of Surgery, University of Kentucky, Lexington.
JAMA Surg. 2014 Nov;149(11):1103-8. doi: 10.1001/jamasurg.2014.1338.
A minority of patients who experience postoperative complications die (failure to rescue). Understanding the preoperative factors that lead to failure to rescue helps surgeons predict and avoid operative mortality.
To provide a mechanism for identifying a high-risk group of patients with postoperative complications who are at a substantially increased risk for failure to rescue.
DESIGN, SETTING, AND PATIENTS: Observational study evaluating failure to rescue in patients entered into the American College of Surgeons National Surgical Quality Improvement Program database. The large sample of surgical patients included in this study underwent a wide range of operations during a 5-year period in more than 200 acute care hospitals. We examined and identified patients at high risk for failure to rescue using propensity stratification. We also developed a risk-scoring system that allowed preoperative identification of patients at the highest risk for failure to rescue.
Risk-scoring system that predicts failure to rescue.
Of the 1,956,002 database patients, there were 207,236 patients who developed serious postoperative complications. Deaths occurred in 21,731 patients with serious complications (10.5% failure to rescue). Stratification of patients into quintiles, according to their propensity for developing serious complications, found that 90% of operative deaths occurred in the highest-risk quintile, usually within a week of developing the initial complication. A risk-scoring system for failure to rescue, based on regression-derived variable odds ratios, predicted patients in the highest-risk quintile with good predictive accuracy. Only 31.8% of failure-to-rescue patients had a single postoperative complication. Perioperative deaths increased exponentially as the number of complications per patient increased. Patients with complications who had surgical residents involved in their care had reduced rates of failure to rescue compared with patients without resident involvement.
Twenty percent of high-risk patients account for 90% of failure to rescue (Pareto principle). More than two-thirds of patients with failure to rescue have multiple complications. On average, a few days elapse before death following a complication. A risk-scoring system based on preoperative variables predicts patients in the highest-risk category of failure to rescue with good accuracy. In high-risk patients who develop complications, our results suggest that early intervention, preferably in a high-level intensive care facility with a surgical training program, offers the best chance to reduce failure-to-rescue rates.
少数经历术后并发症的患者死亡（抢救失败）。了解导致抢救失败的术前因素有助于外科医生预测和避免手术死亡率。
提供一种机制，以识别术后并发症高风险患者群体，这些患者的抢救失败风险显著增加。
设计、设置和患者：观察性研究评估美国外科医师学院国家手术质量改进计划数据库中患者的抢救失败。这项研究中的大量手术患者在五年期间在 200 多家急症护理医院接受了广泛的手术。我们通过倾向分层检查并确定抢救失败风险高的患者。我们还开发了一种风险评分系统，允许术前识别抢救失败风险最高的患者。
预测抢救失败的风险评分系统。
在 1956002 名数据库患者中，有 207236 名患者出现严重术后并发症。21731 名严重并发症患者死亡（抢救失败率为 10.5%）。根据发生严重并发症的倾向将患者分层到五分位数，发现 90%的手术死亡发生在风险最高的五分位数，通常在发生初始并发症后的一周内。基于回归衍生变量比值比的抢救失败风险评分系统具有良好的预测准确性，可以预测风险最高的五分位数患者。只有 31.8%的抢救失败患者只有单一术后并发症。随着患者每例并发症的数量增加，围手术期死亡率呈指数级增加。与无住院医师参与治疗的患者相比，有住院医师参与治疗的并发症患者抢救失败率降低。
20%的高危患者占抢救失败的 90%（帕累托原则）。超过三分之二的抢救失败患者有多种并发症。通常，在并发症发生后几天内死亡。基于术前变量的风险评分系统可以很好地预测抢救失败风险最高的患者。对于发生并发症的高危患者，我们的研究结果表明，早期干预，最好在具有外科培训计划的高水平重症监护病房进行，为降低抢救失败率提供了最佳机会。
