Mortality review

Brian Bjørn, M.D.International Forum on Quality Improvement in Health Care

Paris – April 9, 2014

Danish Society forPatient Safety

Overview

• Background and context– Why?– How ?

• IHI’s approach to mortality review– and how we tweaked it

• Danish experiences

Why measure mortality?

• Death is a definite and unique event• Deaths are recorded by law• Death rates are easily understood

– also by the public

• Traditional outcome measure in biomedical research

IHI: Move your dot

• Plot your dot• Examine your dot• Evaluate your dot• Understand your dot• Test changes

Plot your dot 1

2009

-01-

01

2009

-07-

01

2010

-01-

01

2010

-07-

01

2011

-01-

01

2011

-07-

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2012

-01-

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2012

-07-

01

2013

-01-

010

20

40

60

80

100

120

140 Hospital Standardized Mortality Ratio, by quarter

Plot your dot 2

No. of in-hospital deaths, by quarter, only deaths included in HSMR

Plot your dot 3

Jan-

11

Mar

-11

May

-11

Jul-1

1

Sep-1

1

Nov-1

1

Jan-

12

Mar

-12

May

-12

Jul-1

2

Sep-1

2

Nov-1

2

Jan-

13

Mar

-13

May

-13

Jul-1

3

Sep-1

3

Nov-1

3

Jan-

14

Mar

-14

02468

101214

No. of crash calls outside ICU, pr. month

Plot your dot

HSMR, raw mortality, crash call numbers

Examine your dot

Mortality review

Evaluate your dot

Mortality review

Understand your dot

Mortality review

Test changes

Model for Improvement

Mortality review

• Records from 50 consecutive deaths• Multidisciplinary team• Consensus process

ResourcesAvailability of palliative care

Mortality reductionQuality improvements

Box A

• Admission to ICU• Comfort care only

• Overuse of ICU beds?

Box B

• Admission to non-ICU beds• Comfort care only

• Inadequate hospice or other end-of-life care resources in the community?

Box C

• Admission to ICU• Active treatment

• Quality improvement and mortality reduction– VAP– CLABSI– etc.

Box D

• Admission to non-ICU beds• Active treatment

• Quality improvement and mortality reduction– Early Warning Score– Rapid response team– Sepsis bundle– Etc.

Danish experiences

• Limited benefit of using 2x2 matrix– Comfort care only in ICU bed a very rare event

• Desire to evaluate preventability– Consensus decision– Did the patient have to die in this shift?

Example: 14 preventable deaths

Theme Number

Hospital acquired pneumonia 3

Delayed treatment 3

Opioid overdose 2

EWS algorithm not followed 2

Delayed/wrong diagnosis 2

Anti-thrombotics not used 1

Unclear management plan 1

Hospital acquired pneumonia

• 76-years old• Admitted for episodic hyperglycemia. • Antibiotics are not prescribed until two days

after pneumonia is diagnosed. Patient discharged before first dose is administered. Readmission day after, dies unexpectedly

• Clearly preventable death due to hospital acquired pneumonia

Delayed treatment

• 80-years old• Transferred after long stay at another

hospital. Immunosuppressed due to ’prolonged’ corticosteroid treatment. Clinical signs of sepsis, antibiotics delayed by 8 hours.

• Preventability undetermined.

Plot your dot

Jan-

11

Mar

-11

May

-11

Jul-1

1

Sep-1

1

Nov-1

1

Jan-

12

Mar

-12

May

-12

Jul-1

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Sep-1

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Nov-1

2

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Mar

-13

May

-13

Jul-1

3

Sep-1

3

Nov-1

3

Jan-

14

Mar

-14

02468

101214

No. of crash calls outside ICU, pr. month

Evaluate/understand your dot

Oct-

10

Dec-1

0

Feb-1

1

Apr-1

1

Jun-

11

Aug-1

1

Oct-

11

Dec-1

1

Feb-1

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Apr-1

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12

Aug-1

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Oct-

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Dec-1

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Feb-1

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Apr-1

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13

Aug-1

3

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13

Dec-1

30

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100

Correct EWS observations, %, by month

Evaluate/understand your dotJa

n-12

Feb

-12

Mar

-12

Apr

-12

May

-12

Jun-

12Ju

l-12

Aug

-12

Sep

-12

Oct

-12

Nov

-12

Dec

-12

Jan-

13F

eb-1

3M

ar-1

3A

pr-1

3M

ay-1

3Ju

n-13

Jul-1

3A

ug-1

3S

ep-1

3O

ct-1

3N

ov-1

3D

ec-1

3Ja

n-14

Feb

-14

Mar

-14

0

20

40

60

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100

Observation days with correct action to EWS score, %, by month

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