New Care Review Process Helps Cut Preventable Deaths
At a Los Angeles hospital, a new in-person multidisciplinary rapid mortality review (RMR) process successfully helped identification of critical patient care areas, according to a new study.
This novel approach assisted front-line healthcare workers in understanding key individual- and systems-level issues which increase mortality. The aim is to produce more effective, optimised patient care. Though efforts have been made since the Institute of Medicine’s 1999 report on preventable patient mortality, reducing the number of these deaths has been difficult, and in many cases, elusive.
The study looked at five years of the RMR process that reviewed patient deaths that took place in the 24-bed medical intensive care unit (ICU) at Ronald Reagan University of California Los Angeles (UCLA) Medical Center. Not only immediate concerns were picked up, but also valuable insights into preventable patient deaths.
“Our findings suggest that these short and timely in-person meetings can be a powerful tool for efforts to both improve quality and prevent mortality in the ICU,” said first author Kristin Schwab, MD. “Bringing members of the multidisciplinary care team together for regular face-to-face discussions provided a forum that revealed concerns and solicited tangible ideas for solutions.”
Retrospective case reviews, provider surveys, and structured morbidity and mortality conferences are common tactics, but unlikely to provide an efficient and practical means of reviewing all patient deaths. The RMR process started in 2013 as pilot, using data on a subset of patients who had died in the medical ICU during the week before. The subset gradually increased in size and by 2017, the team tried to review every death that occurred in the unit that week. Over the five-year period, the RMR team reviewed a total 542 deaths, over 80% of all those that occurred in the unit.
For each patient death, a facilitator led a semistructured interview with the care team after reviewing the patient’s chart, and added a brief report to a database. The quality team reviewed the data from each meeting, referring action items to the relevant department.
Only 7% of deaths were determined by the treatment team, RMR facilitator or both to be possibly preventable. However, in more than 40% of the deaths the treatment team thought care could have been improved, while the facilitator identified areas for improvement in over half the cases.
Cases in which the patient required resuscitation after an in-hospital cardiac arrest or those in which the patient did not get comfort care at the time of death were more likely to result in an action item.
Issues included concerns with communication or teamwork, advance care planning, care delays, medical errors, procedural complications and hospital-acquired infections. The systems-related action items were lack of protocols, resource availability and throughput. Among the action items, over 10% led to substantive systemic change, with 29 discrete changes occurring over the study period. Action items included making a standardised checklist for inbound patient transfers, and modifying the electronic health record to separate one-time orders from continuing orders.
Source: News-Medical.Net
Journal information: Schwab, K.E., et al. (2021) Rapid Mortality Review in the Intensive Care Unit: An In-Person, Multidisciplinary Improvement Initiative. American Journal of Critical Care. doi.org/10.4037/ajcc2021829.
