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14 Nursing Times 06.12.11 / Vol 107 No 48 / www.nursingtimes.

ailure to rescue (FTR) refers to a
death after a treatable complica-
tion. The rate of FTRs in surgical
patients derived from routine
administrative data is recognised as an
important indicator of patient safety by
the United States Agency for Healthcare
Research and Quality. It holds the promise
of being more sensitive to the quality of
care in a hospital than either conventional
mortality or complication rates (Silber et
al, 2007).
In this Policy+ we draw on ndings
from a recent report from the National
Nursing Research Unit to consider
whether the FTR rate can be used in Eng-
land (Jones et al, 2011).
What do FTR rates indicate?
Some deaths in hospital are inevitable.
Much of the difference in death rates
between hospitals has little to do with
differences in the quality of care that
people receive however, but is more
related to the degree of illness and co-
morbidity of patients who are receiving
treatment, together with their level of
vulnerability. Measures like the Hospital
Standardised Mortality Rate try to account
for this using statistical techniques,
but no statistical adjustment can ever be
For these reasons, FTR has often been
considered particularly sensitive to the
quality and quantity of nursing care that is
available to patients (Grifths et al, 2008).
How are FTR rates measured?
FTR rates used for both research purposes
and as quality indicators are typically
derived from hospital administrative data-
bases. However, their validity can be com-
promised if the coding of secondary diag-
noses (through which complications are
identied) is poor; this is because the indi-
cator relies on the identication of a group
of patients who experience particular
complications. Less-detailed coding of
diagnoses means less chance that compli-
cations have been recorded. Previously, it
has been concluded that English hospital
data were unsuitable for deriving FTR
measures, primarily because of low rates
of coding (McKee et al, 1999).
In our study we aimed to assess whether
the conclusions made about deriving FTR
rates for surgical patients from English
hospital data from 199697 still hold when
using more recent data (until March 2009),
and whether there was evidence that the
rates derived were indicative of quality.
As a response to concerns about low
rates of coding secondary diagnoses, we
used alternative approaches that have been
proposed, including:
Assuming that all surgical deaths are
FTR (Silver et al, 2007); and
Using extended hospital stays that fall
well outside the average range as an
(indirect) indicator of FTR (Rafferty et
al, 2007).
We used statistical techniques that
The rate of avoidable deaths among sur-
gical patients with treatable complications
another way of referring to FTR offers a
different way of exploring how a hospital
performs; this is one that relates to a spe-
cic group of patients and may offer some
For people undergoing surgery, the
chance of developing a complication, like
bleeding or pneumonia, is strongly related
to factors such as their age or an under-
lying condition. Although complications
are often a result of patient characteristics,
however, the ability of a hospital to suc-
cessfully treat a complication once it
occurs is strongly related to the quality of
care provided (Silber et al, 2007). The FTR
indicator is intended to show how well
hospitals perform once the complication
The potential signicance of the FTR
rate is reected in recent reports and
research, which emphasise the complexity
of responding to patients who are deterio-
rating and highlight potential points of
failure, including:
Not taking observations;
Not recording observations;
Not recognising early signs of
Not communicating observations
(Luettel et al, 2007).
In this article...
What failure to rescue (FTR) does and does not indicate
How to judge whether FTR measurements are reliable
Whether FTR rates can be derived from English hospital data
Nursing Practice
Failure to rescue
Can failure to rescue
be a key indicator of
patient safety?
A look at whether administrative data in English hospitals contain enough information
to reliably report failure to rescue rates and to what extent they afect patient safety
The latest evidence and policy review from the NNRU / Vol 107 No 48 / Nursing Times 06.12.11 15
Keywords: Failure to rescue/Patient

This article has been double-blind

peer reviewed
advantage for using this over the mortality-
based measures. As an indicator of hospital
performance, FTR is potentially linked to a
number of factors beyond the control of
the hospital, such as provision of commu-
nity services. In addition, the absence of
any association with the mortality-based
indicators suggests that the measure based
on the length of stay is not acting as a proxy
of FTR as originally conceived.
Further work is required to develop and val-
idate FTR as a quality indicator and develop
and test risk-adjustment models. NT
This Policy+ was produced in collaboration
with Professor Peter Grifths at the
University of Southampton, former director
of the National Nursing Research Unit
Silber JH et al (2007) Failure-to-Rescue:
comparing denitions to measure quality of care.
Medical Care; 45: 10, 918-925.
Jones S et al (2011) An Assessment of Failure to
Rescue Derived from Routine NHS data as a
Nursing Sensitive Patient Safety Indicator. London:
National Nursing Research Unit, Kings College
Luettel D et al (2007) Recognising and
Responding Appropriately to Early Signs of
Deterioration in Hospitalised Patients. London:
National Patient Safety Agency.
Grifths P et al (2008) State of the Art Metrics for
Nursing: A Rapid Appraisal. London: Kings College
McKee M et al (1999) Failure to rescue as a
measure of quality of hospital care: the
limitations of secondary diagnosis coding in
English hospital data. Journal of Public Health;
21: 4, 453-458.
Raferty AM et al (2007) Outcomes of variation in
hospital nurse stafng in English hospitals:
cross-sectional analysis of survey data and
discharge records. International Journal of Nursing
Studies; 44: 2, 175-1082.
correlated with the average number of
secondary diagnoses coded, which
suggests an absence of systematic bias
caused by coding practices;
Strong year-on-year correlation for FTR
rates in recent years, which suggests a
degree of stability consistent with the
rate reecting an underlying
characteristic of hospital performance;
A number of associations between the
FTR indicators and presumed markers
of quality, some of which have been
demonstrated in previous work in the
United States (Jones et al, 2011).
However, not all the relationships we
observed are clearly or plausibly indicative
of variations in quality. It seems likely that
there are confounding variables that were
not accounted for in our models. Any FTR
indicator would need to be adjusted for age
and other patient-level factors before
coming to a nal judgement.
Non-risk adjusted FTR rates cannot be
used to make comparisons between pro-
It is notable that previous work, which
showed that higher nurse stafng was
associated with lower levels of FTR, did not
consider medical stafng (Silber et al,
2007). Although we observed a similar
association when considering nursing in
isolation, the association disappeared
when we controlled for other factors.
Higher levels of clinically qualied staff
(doctors plus nurses) were associated with
lower levels of FTR, and a higher nurse
doctor ratio was associated with higher
rates of FTR.
Although our extended-stay FTR
measure performed well in some respects,
as there are no longer specic problems
with secondary coding, there is no clear
allowed us to determine associations
between FTR rates and a range of quality-
related organisational factors derived from
routine NHS data; these included stafng
variables such as the numbers of nurses
and doctors per bed, teaching status of the
hospital and nursing staff stability.
What do the English hospital data
Our ndings suggest that FTR indicators
can be derived from English hospital data
and that low levels of recording of sec-
ondary diagnoses are no longer a signi-
cant obstacle. We found:
FTR rates are not signicantly
There is clear potential to derive
mortality-based failure to rescue (FTR)
indicators for surgical patients from
routine administrative data in England
Our indicator, based on the United
States Agency for Healthcare Research
and Quality denition, is worthy of
further exploration as a potentially valid
safety measure
FTR indicators may ofer some
advantages over standardised mortality
measures (such as the Hospital
Standardised Mortality Rate) for
surgical patients and can, therefore, add
to the range of indicators of hospital
performance that are available
Unadjusted FTR rates cannot be used
to compare the quality of care between
FTR does not appear to be a
specically nurse-sensitive indicator


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