Staff at a California hospital found rapid mortality reviews conducted soon after a patient death resulted in the treatment team identifying opportunities to improve the patient’s care in more than 40% of the cases.1

The team conducting the rapid mortality reviews concluded this technique can offer advantages over the standard retrospective case reviews, provider surveys, and structured morbidity and mortality conferences.

The authors studied data from five years of patient deaths that occurred in the 24-bed medical ICU at the UCLA Medical Center.

Expanding Through Hospital

What started as a quality improvement effort in the ICU has now expanded because of the good results, says Kristin Schwab, MD, study co-author, co-director of the Post-ICU Recovery Clinic at UCLA, and medical director of UCLA Pulmonary Rehabilitation.

“It came about as part of our continual process to continue the care we provide in the ICU. We wanted to create a concrete and standardized process by which we could review all deaths and figure out how to improve care for people in the future,” Schwab says. “It’s now gone from our ICUs to other units in the hospital as well. Oncology is doing it with their patients, and it’s moving to every other area of the hospital.”

The project began in 2013 with patients who had died in the medical ICU in one week. By 2017, Schwab and colleagues were holding weekly meetings with the intention of reviewing every death on the unit. Over five years, the team reviewed 542 deaths, more than 80% of all deaths on the unit.

The weekly meetings are led by a facilitator drawn from a pool of quality-trained nurses and physicians who work to standardize the process. The facilitator is not someone who was involved in caring for the patient but reviews the patient’s chart before the meeting, held in a private conference room in the ICU.

The facilitator leads an interview with the care team. Questions include “Was the death potentially preventable?” and “Are there any aspects of care that could have been improved?”

Frank conversations are encouraged. These discussions begin broadly before narrowing to standard questions and then detailed queries specific to the case.

“We look at the deaths through the lens of process improvement. It’s important that it’s not meant to be punitive in any way,” Schwab says. “It is a standardized but relatively informal conversation with the entire care team. That includes the doctors, the nurses, and any consulting teams who were involved in the care.”

Action Items Identified

The facilitator enters a summary of the interview into a database the hospital quality leaders can review. They may identify action items and make recommendations.

Most other rapid mortality reviews last only 15 minutes, but Schwab says they often reveal meaningful information.

The rapid mortality reviews are not intended to catch anyone acting inappropriately but rather to identify potential areas of improvement. Schwab and colleagues determined only 7% of deaths were potentially preventable. However, in 40% of the cases, the treatment team concluded the patient’s care could have been better.

The facilitators saw room for improvement in a slightly higher percentage of cases, more than 50%. Action items were more likely to be identified when the patient received resuscitation after an in-hospital cardiac arrest or was not receiving comfort care.

Common quality improvement issues identified included medical errors, hospital-acquired infections, delays in care, communication, teamwork, advance care planning, and procedural complications. Lack of protocols, resource availability, and throughput also were cited at a system level.

More than 10% of the issues identified in the rapid mortality reviews led to changes within the unit, with 29 separate changes during the five years. In one case, the review led the hospital to create a standardized checklist for inbound patient transfers. In another, the hospital altered the electronic health record so that one-time orders were differentiated from continuing orders.

Different Than M&M

The hospital’s rapid mortality reviews differ from typical morbidity and mortality reviews in that they are held sooner after many patient deaths — every week, rather than monthly. The rapid mortality reviews also are conducted by the care team rather than an outside reviewer. “This is a discussion among the team that was on the ground actually providing care, and it’s a face-to-face interview. Often, there are surveys or chart abstractions used for mortality reviews. That is a very different approach,” Schwab says. “Without the face-to-face interview and the open-ended discussion, you end up missing a lot. This also benefits from including everyone who was involved — not just the doctors and nurses, but the ancillary staff as well.”

The information revealed in the rapid mortality reviews can be more useful than what might be gleaned from a monthly review.

“The recall bias can be so great if you wait weeks thereafter. The immediacy of it helps people with their recall and minimizing issues of memory,” Schwab says. During the COVID-19 pandemic, the rapid mortality reviews still are held in the ICU conference room, but they include a virtual option for team members who were not in the hospital that day.

Schwab encourages other hospitals to adopt the rapid mortality review, calling it a relatively easy process to implement that can significantly affect care quality.

“Finding a leader for this who can frame this from the quality improvement lens is really important. It also is important to establish a regular time when everyone involved knows this is going to happen every week,” Schwab says. “If you don’t have the capacity to review every death per week, we found that the most high-yield cases are those with a cardiac arrest and CPR, or patients not receiving comfort care. Focusing on those first and then expanding from that can be a good approach.”

Six percent of the deaths reviewed in the rapid mortality reviews were referred for further analysis in the morbidity & mortality conference. There are multiple avenues for cases to be referred to morbidity & mortality, so the rapid review represents one route for referral, Schwab says.

For cases that are referred, Schwab says there is direct communication between the rapid mortality review and morbidity & mortality teams to confirm the reason for referral. Case details from the rapid mortality review are conveyed to the other reviewers. 

REFERENCE

  1. Schwab KE, Simon W, Yamamoto M, et al. Rapid mortality review in the intensive care unit: An in-person, multidisciplinary improvement initiative. Am J Crit Care 2021;30:e32-e38.

SOURCE

  • Kristin Schwab, MD, Co-Director, Post-ICU Recovery Clinic; Medical Director, UCLA Pulmonary Rehabilitation, UCLA Medical Center. Phone: (310) 825-9111.