American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Featured Commentary

The online formats of SRGS include access to What You Should Know (WYSK): commentaries on articles published recently in top medical journals. These commentaries, written by practicing surgeons and other medical experts, focus on the strengths and weaknesses of the research, as well as on the articles' contributions in advancing the field of surgery.

Below is a sample of one of the commentaries published in the current edition of WYSK.


Kuo LE, Kaufman E, Hoffman RL, et al. Failure-to-rescue after injury is associated with preventability: The results of mortality panel review of failure-to-rescue cases in trauma. Surgery. 2017;161(3):782-790.
Ingraham AM, Greenberg CC. Failure to rescue and preventability: Striving for the impossible? Surgery. 2017;161(3):793-794.
Hornor MA, Bilimoria KY. Moving beyond failure to rescue. Surgery. 2017;161(3):791-792.

Commentary by: Brian Harbrecht, MD, FACS

Surgeons have been leaders in attempts to define, measure, and improve the quality of medical/surgical care for longer than most of us have been in practice. These efforts span a wide spectrum of activities, from individual surgeon peer review through departmental morbidity and mortality conferences to national quality programs like ACS NSQIP® and ACS TQIP®. Failure to rescue (FTR) has become a popular term in the lexicon of quality as a measure of the quality of medical care. Kuo et al evaluated FTR in the trauma population at their institution to assess its utility as an indicator of quality of care. The authors concluded that FTR is strongly associated with deaths being judged as preventable or potentially preventable by the peer review process at their established Level I trauma center. The article, and the accompanying editorials, are worth reading by all surgeons, as we are increasingly involved in quality of care discussions in our institutions.

How to properly define and measure quality is a complex and elusive goal. As an academic general surgeon and trauma medical director, I am intensely interested in the issue of quality of care, as are most surgeons. I find it challenging to criticize attempts to measure quality of care lest one be accused of being an out-of-touch dinosaur not in tune with modern surgical concepts; however, using FTR as a quality of care index is problematic and much of the problem lies in the definition of FTR. Kuo and colleagues cast their net broadly and defined death after any complication as FTR. Problems with the accuracy of definitions of complications (i.e., pneumonia), with the documentation of complications in the medical record, or registry capture of complications are well-known. Implied in this analysis and the debate about quality of care is the assumption that all complications are due to suboptimal care. Particularly when dealing with severely injured patients, complications can and frequently do occur even in the presence of optimal care. A patient with a spinal cord injury, bilateral rib fractures, and pulmonary contusions who spends weeks on a ventilator despite an ICU ventilator bundle, early tracheostomy, and modern ventilator management strategies is highly likely to develop pneumonia. Is that suboptimal care or a consequence of being severely injured? Conversely, suboptimal care can occur in the absence of trauma registry-defined complications, particularly if deaths are not thoroughly reviewed and analyzed.

An additional underlying assumption of FTR is that the death event is etiologically related to the complication. Most surgeons have cared for patients who have developed urinary tract infections or deep venous thrombosis in the postoperative period who then go on to die from unrelated events. As the United States population ages and the quality of functional recovery after injury, not just recovery itself, becomes a primary goal of hospital care, optimal care may involve death if the alternative is a poor quality survival or poor functional outcome. These limitations in the quality debate cannot be ignored and are difficult to measure in most databases.

Surgeons should continue to be active in ongoing efforts to measure and improve the quality of care on behalf of their patients. Surgical input into what quality measures are truly valid for surgical patients will be essential to future debate on this issue. The authors have made a valiant attempt to move this debate forward in what one hopes will be the first of many investigations into this area.