Failure to rescue in acute liver failure: A multicenter cohort study

The concept of failure to rescue has been used to measure the quality of care for complications developed following surgery. The concept of failure to rescue has been poorly studied in patients with primary medical diseases, such as sepsis or acute liver failure (ALF). We performed a retrospective multicenter cohort study including consecutive patients with ALF within the United States ALF Study Group (USALFSG) prospective registry from 2010-2016. The failure to rescue rate for 12 medical complications in the registry was calculated as the mortality events up to 21 days after inclusion divided by the complication events registered on the first day after inclusion. The association between these complications and 21-day transplant-free mortality was studied. Among 665 patients with ALF, 478 (71.9%) were females, and the median (IQR) age was 42 (30-55) years. Acetaminophen intoxication was observed in 322 (48.4%) patients. Overall, 461 (69.3%) patients had at least one medical complication on the first day after inclusion (median [IQR] number of 1 [0-3]). The failure to rescue rate for the 12 complications was 32.8%. The complications with the higher failure-to-rescue rates were gastrointestinal bleed (63.6%), non-gastrointestinal bleed (53.9%), requirement for vasopressors (52.5%), and acute respiratory distress syndrome (48.1%). After adjusting for age, sex, etiology, and international normalized ratio, per each added complication present on day 1, the odds of 21-day transplant-free mortality increased by 38% (adjusted OR [95% CI] of 1.38 [1.24-1.54]; c-statistic [95% CI] of 0.77 [0.73-0.81]). In patients with ALF, the concept of failure to rescue highlights the need to improve prevention, early detection, and timely management of medical complications developing early in the hospital stay.