Defining failure to rescue in emergency general surgery on the Eve of Centers for Medicare and Medicaid Services adoption: A scoping review.

Abstract

Failure to rescue is an established surgical quality metric. The Centers for Medicare and Medicaid Services will replace Patient Safety Indicator-04 with a new failure-to-rescue measure in 2027. However, no standardized failure-to-rescue definition exists for emergency general surgery, and evidence supporting complication inclusion is lacking. We sought to examine whether failure-to-rescue definitions vary across emergency general surgery studies, how these definitions align with national frameworks, and characterize complication-mortality associations. A scoping review was conducted across 5 databases (2000-2025). Studies examining failure to rescue in adult emergency general surgery populations were included. Concordance between study-defined complications and established frameworks (Patient Safety Indicator-04, National Surgical Quality Improvement Program, and Centers for Medicare and Medicaid Services) was assessed. Odds ratios for complication-mortality associations were extracted. Among 23 studies, failure-to-rescue definitions included a mean of 12 complications (range 7-19), with 38 unique complications identified. Framework concordance was low: Patient Safety Indicator-04 47%, National Surgical Quality Improvement Program 43%, and Centers for Medicare and Medicaid Services 18%. Of Centers for Medicare and Medicaid Services failure-to-rescue complications, 45% have never been studied in emergency general surgery. Failure-to-rescue rates ranged 4.9%-21.4% and higher among geriatric cohorts (11.6%-29.9%). Complication odds ratios were rarely reported (14.5%); among those, acute respiratory distress syndrome (odds ratio, 6.7), disseminated intravascular coagulopathy (odds ratio, 4.9), sepsis (odds ratio, 1.4-7.6), and pneumonia (odds ratio, 1.9-8.7) demonstrated the strongest mortality associations, whereas deep venous thrombosis and surgical site infections showed inverse associations. Emergency general surgery failure to rescue suffers from heterogeneity, as complications determining failure-to-rescue definitions vary widely. Emergency general surgery-specific validation or exclusion from the Centers for Medicare and Medicaid Services 2027 measure warrants consideration.