Mortality review Brian Bjørn, M.D. International Forum on Quality Improvement in Health Care Paris...
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Transcript of Mortality review Brian Bjørn, M.D. International Forum on Quality Improvement in Health Care Paris...
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-
01
2012
-01-
01
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
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
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
2
Apr-1
2
Jun-
12
Aug-1
2
Oct-
12
Dec-1
2
Feb-1
3
Apr-1
3
Jun-
13
Aug-1
3
Oct-
13
Dec-1
30
20
40
60
80
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
80
100
Observation days with correct action to EWS score, %, by month
?