L. W. Ma1, B. P. Smith1, J. S. Hatchimonji1, E. J. Kaufman1, C. E. Sharoky1, D. N. Holena1 1University Of Pennsylvania,Philadelphia, PA, USA
Introduction: Failure-to-rescue (FTR) is defined as death after a complication and has been used to evaluate quality of care in adult patients after injury. The role of FTR as a quality metric in pediatric populations is unknown. The aim of this study was to define the relationship between rates of mortality, complications, and FTR at centers managing pediatric (<18 years of age) trauma in a nationally representative database. We hypothesized that centers with high mortality would have higher FTR rates but complication rates would be similar between high- and low-mortality centers.
Methods: We performed a retrospective cohort study of the 2016 National Trauma Data Bank. We included patients <18 years with an Injury Severity Score (ISS) of ≥9. We excluded centers with a pediatric patient volume of <50 patients or that reported no complications. We calculated the complication, FTR, mortality, and precedence (the proportion of deaths preceded by a complication) rates for each center and then divided the centers into tertiles of mortality. We compared complication and FTR rates between high and low tertiles of mortality using the Kruskal-Wallis test.
Results: In total, we included 25,792 patients from 171 centers in the study. Patients were 67% male, 65% white, had a median age of 10 (IQR 5-15), and had a median ISS of 10 (IQR 9-17), a median GCS motor score of 6 (IQR 6-6), and a median systolic blood pressure of 120 (IQR 109-132). Overall, 948 patients had at least one complication for an overall complication rate of 4% (center level 0-19%), while 47 patients died after a complication for an overall FTR rate of 5% (center level 0-60%). High-mortality centers had both higher FTR rates (8% vs 0.5%, p = .013) and higher complication rates (5% vs 3%, p = .011) than lower-mortality hospitals. The overall precedence rate was 15% with a median rate of 0% (IQR 0%-20%).
Conclusion: Both complication and FTR rates are low in the pediatric injury population. However, complication and FTR rates are both higher at higher-mortality centers. The low overall complication rates and precedence rates likely limit the utility of FTR as a valid center-level metric in this population, but further investigation into individual FTR cases may reveal important opportunities for improvement.
