Complications and Failure to Rescue After Inpatient Pediatric Surgery

Jorge I. Portuondo, MD; Sohail R. Shah, MD, MSHA; Mehul V. Raval, MD, MS; I-wen E. Pan, PhD; Huirong Zhu, PhD; Sara C. Fallon, MD, MS; Alex H. S. Harris, PhD; Hardeep Singh, MD, MPH; Nader N. Massarweh, MD, MPH


Annals of Surgery. 2022;276(4):e239-e246. 

In This Article

Abstract and Introduction


Objective: To describe the frequency and patterns of postoperative complications and FTR after inpatient pediatric surgical procedures and to evaluate the association between number of complications and FTR.

Summary and Background: FTR, or a postoperative death after a complication, is currently a nationally endorsed quality measure for adults. Although it is a contributing factor to variation in mortality, relatively little is known about FTR after pediatric surgery.

Methods: Cohort study of 200,554 patients within the National Surgical Quality Improvement Program-Pediatric database (2012–2016) who underwent a high (≥ 1%) or low (< 1%) mortality risk inpatient surgical procedures. Patients were stratified based on number of postoperative complications (0, 1, 2, or ≥3) and further categorized as having undergone either a low- or high-risk procedure. The association between the number of postoperative complications and FTR was evaluated with multivariable logistic regression.

Results: Among patients who underwent a low- (89.4%) or high-risk (10.6%) procedures, 14.0% and 12.5% had at least 1 postoperative complication, respectively. FTR rates after low- and high-risk procedures demonstrated step-wise increases as the number of complications accrued (eg, low-risk— 9.2% in patients with ≥3 complications; high-risk—36.9% in patients with ≥ 3 complications). Relative to patients who had no complications, there was a dose-response relationship between mortality and the number of complications after low-risk [1 complication – odds ratio (OR) 3.34 (95% CI 2.62–4.27); 2 – OR 10.15 (95% CI 7.40–13.92); ≥3–27.48 (95% CI 19.06–39.62)] and high-risk operations [1 – OR 3.29 (2.61–4.16); 2–7.24 (5.14–10.19); ≥3–20.73 (12.62–34.04)].

Conclusions: There is a dose-response relationship between the number of postoperative complications after inpatient surgery and FTR, ever after common, "minor" surgical procedures. These findings suggest FTR may be a potential quality measure for pediatric surgical care.


Identifying useful measures of surgical quality remains an important challenge as the US health care system transitions toward value-based care models. Many surgical quality improvement (QI) programs continue to primarily focus on the prevention of postoperative complications.[1,2] Although these programs recommend a variety of evidence-based process measures, most have either been ineffective at reducing complication rates or for identifying high performing hospitals.[3–6] For adults, failure to rescue (FTR), or the death of a patient after a postoperative complication, was first described in the early 1990's, but has only relatively recently become a nationally endorsed, publicly reported quality measure and a commonly used outcome in the surgical literature.[7–12] In many ways, FTR may represent a more clinically relevant target for QI initiatives because it implicitly accounts for the fact that postoperative complications do occur, even when everything has been done correctly, and it is the prompt recognition and treatment of these complications that can profoundly impact a patient's eventual out-come.[13]

Although the literature regarding FTR in adult patients has evolved, little is known about the prevalence of FTR in pediatric surgical patients. The Agency for Healthcare Research and Quality has indicated, "Many specialty surgical services…. have developed context-specific approaches to measuring FTR," yet very little has been done to evaluate the validity of FTR in pediatric surgical patients and the data that do exist are derived from specific subsets of pediatric patients undergoing highly specialized surgical procedures.[14–18] Furthermore, there may be important differences regarding the environment in which pediatric surgery occurs that could influence patient outcomes. Specifically, there are over 200 free standing children's hospitals constituting just under 5% of all hospitals in the US.[19] Each children's hospital is a referral center in its own right with staffing, intensive care units, ancillary services, and technology unique to such specialized centers. As such, existing data about the frequency and patterns of FTR derived from adult cohorts treated at hospitals in the general community may not be generalizable to pediatric patients.

Although FTR is a national surgical quality measure for adult surgery, given the lack of data regarding postoperative complications and FTR among pediatric surgical patients and the inability to generalize from adult data, there is uncertainty regarding the applicability and utility of FTR as a potential quality measure for pediatric surgery. To better understand whether FTR could be used as a pediatric surgical quality measure, it is first necessary to delineate its prevalence and patterns across the spectrum of pediatric surgery. In this context, we used data from an established, national, surgical QI clinical registry to evaluate complication and FTR rates among pediatric surgical patients undergoing low-risk and high-risk inpatient surgery. Specifically, our goals were to characterize complication and FTR rates and to evaluate the association between the number of complications and FTR. Our hypothesis is that the rates and patterns of postoperative complications and FTR after pediatric surgery mirror those identified in the adult literature.