Abstract
Background: Healthcare quality improvements are one of the most important goals to reach a better and safer healthcare system. Reviewing in-hospital mortality data is useful to identify areas for improvement, and to monitor the impact of actions taken to avoid preventable cases, such as those related to healthcare associated infections (HAI).
Methods: In this paper, we present the experience of the Mortality Committee of Bambino Gesù Children Hospital (OPBG). OPBG has instituted a process of systematic revision of all in-hospital deaths conducted by a multidisciplinary team. The goal is to identify system-wide issues that could be improved to reduce in-hospital preventable deaths. In this way, the mortality review goes alongside all the other risk management activities for the continuous quality improvement and patient safety.
Results: In years 2008-2017, we performed a systematic analysis of 1148 inpatient deaths. In this time period, the overall mortality rate was 0.4%. Forty-seven deaths were caused due to infections, 10 of which involved patients with HAI transferred to OPBG from other facilities or patients with community- acquired infections. Six deaths related to HAI were followed by claims compensations. All these cases were not followed by compensation because the onset of HAI was considered an inevitable consequence of the underlying disease.
Conclusion: Introduction of the mortality review committee has proved to be a valid instrument to improve the quality of the care provided in a hospital, allowing early identification of care gaps that could lead to an increase in mortality rates.
Article Highlights Box: Reduction of preventable deaths is one of the most important goals to be achieved for any health-care system and to improve the quality of care.
• Several studies have shown that analysis of morbidity and mortality rate helps to detect any factors that can lead to an increase in in-hospital mortality rates.
• The review of in-hospital deaths allows to learn how to improve the quality and safety of care through identification of critical issues that lead to an increase in mortality ratio.
• In some medical areas, such as intensive care units or surgery, the implementation of the conference on mortality and morbidity is more useful for assessing procedures at high risk of errors.
• The implementation of existing databases with data deriving from the systematic review of medical records and in-hospital deaths appears to be desirable.
• Mortality Review Committees can represent a very useful tool for all the health facilities for the reduction of preventable deaths, such as those related to HAI.
Keywords: Healthcare quality, mortality committee, children hospital, mortality index, HAI, JCI accreditation.
Graphical Abstract
[1]
Aspden, P.; Corrigan, J.; Wolcott, J.; Erickson, S.M. Patient safety: Achieving a new standard for care; National Academies Press: Washington, DC, 2004.
[2]
Khon, L.; Corrigan, J.; Donaldson, M.S.
To err is human: Building
a safer health system; National Academies Press Washington DC,, 2000.
[3]
Hayward, R.A.; Hofer, T.P. Estimating hospital deaths due to medical errors. Preventability is in the eye of the reviewer. JAMA, 2001, 286(4), 415-420.
[4]
Gupta, M.; Fuchs, B.; Cutilli, C.; Cintolo, J.; Reinke, C.; Kean, C.; Fishman, N.; Sullivan, P.; Kelz, R.R. Preventable mortality: Does the perspective matter when determining preventability? J. Surg. Res., 2013, 184(1), 54-60.
[5]
Brennan, T.A.; Leape, L.L.; Laird, N.M.; Hebert, L.; Localio, A.R.; Lawthers, A.G.; Newhouse, J.P.; Weiler, P.C.; Hiatt, H.H. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N. Engl. J. Med., 1991, 324(6), 370-376.
[6]
Bamber, A.R.; Mifsud, W.; Wolfe, I.; Cass, H.; Pryce, J.; Malone, M.; Sebire, N.J. Potentially preventable infant and child deaths identified at autopsy: findings and implications. Forensic Sci. Med. Pathol., 2015, 11(3), 358-364.
[7]
Rutstein, D.D.; Berenberg, W.; Chalmers, T.C.; Child, C.G., III; Fishman, A.P.; Perrin, E.B. Measuring the quality of medical care. A clinical method. N. Engl. J. Med., 1976, 294(11), 582-588.
[8]
Morello, R.T.; Lowthian, J.A.; Barker, A.L.; McGinnes, R.; Dunt, D.; Brand, C. Strategies for improving patient safety culture in hospitals: a systematic review. BMJ Qual. Saf., 2013, 22, 11-18.
[9]
Oelke, N.D.; Suter, E.; Da Silva Lima, M.A.; Van Vliet-Brown, C. Indicators and measurement tools for health system integration: A knowledge synthesis protocol. Syst. Rev., 2015, 4, 99.
[10]
Shahian, D.M.; Iezzoni, L.I.; Meyer, G.S.; Kirle, L.; Normand, S.L. Hospital-wide mortality as a quality metric: Conceptual and methodological challenges. Am. J. Med. Qual., 2012, 27(2), 112-123.
[11]
Higginson, J.; Walters, R.; Fulop, N. Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety? BMJ Qual. Saf., 2012, 21(7), 576-585.
[12]
Kobewka, D.M.; van Walraven, C.; Turnbull, J.; Worthington, J.; Calder, L.; Forster, A. Quality gaps identified through mortality review. BMJ Qual. Saf., 2017, 26(2), 141-149.
[13]
Deshpande, J.K.; Throop, P.G.; Slayton, J.M. Standardization of case reviews (morbidity and mortality rounds) promotes patient safety. Pediatr. Clin. North Am., 2012, 59(6), 1307-1315.
[14]
Huddleston, J.; Diedrich, D.A.; Kinsey, G.C.; Enzler, M.J.; Manning, D.M. Learning from every death. J Patient Saf., 2014, 10(1), 6-12.
[15]
Lucier, D.; Folcarelli, P.; Totte, C.; Carbo, A.R.; Sokol-Hessner, L. Surveying care teams after in-hospital deaths to identify preventable harm and opportunities to improve advance care planning. Jt. Comm. J. Qual. Patient Saf., 2018, 44(2), 84-93.
[16]
National Quality Board. National Guidance on Learning from
Deaths - A Framework for NHS Trusts and NHS Foundation
Trusts on Identifying, Reporting, Investigating and Learning from
Deaths in Care. Available at: . https://www.england.nhs.uk/wp-content/uploads/2017/03/nqb-national-guidance-learning-from-deaths.pdf (accessed August 6, 2018).
[17]
Orlander, J.D.; Barber, T.W.; Fincke, B.G. The morbidity and mortality conference: The delicate nature of learning from error. Acad. Med., 2002, 77(10), 1001-1006.
[18]
James, J.T. Deaths from preventable adverse events originating in hospitals. BMJ Qual. Saf., 2017, 26, 692-693.
[19]
Sellier, E.; David-Tchouda, S.; Bal, G.; François, P. Morbidity and mortality conferences: Their place in quality assessments. Int. J. Health Care Qual. Assur., 2012, 25(3), 189-196.
[20]
Lecoanet, A.; Vidal-Trecan, G.; Prate, F.; Quaranta, J.F.; Sellier, E.; Guyomard, A.; Seigneurin, A.; François, P. Assessment of the contribution of morbidity and mortality conferences to quality and safety improvement: A survey of participants’ perceptions. BMC Health Serv. Res., 2016, 16, 176.
[21]
Szostek, J.H.; Wieland, M.L.; Loertscher, L.L.; Nelson, D.R.; Wittich, C.M.; McDonald, F.S.; Kolars, J.C.; Reed, D.A. A systems approach to morbidity and mortality conference. Am. J. Med., 2010, 123(7), 663-668.
[22]
Pierluissi, E.; Fischer, M.A.; Campbell, A.R.; Landefield, C.S. Discussion of medical errors in morbidity and mortality conferences. JAMA, 2003, 290(21), 2838-2842.
[23]
Lau, H.; Litman, K.C. Saving lives by studying deaths: Using standardized mortality reviews to improve inpatient safety. Jt. Comm. J. Qual. Patient Saf., 2011, 37(9), 400-408.
[24]
Royal College of Physicians. Acute care toolkit 11: Using data to
improve care. London Royal College of Physicians,, 2015.
[25]
Mcdonnell, C.; Laxer, R.M.; Roy, W.L. Redesigning a morbidity and mortality program in a university-affiliated pediatric anesthesia department. Jt. Comm. J. Qual. Patient Saf., 2010, 36(3), 117-125.
[26]
Umscheid, C.A.; Mitchell, M.D.; Doshi, J.A.; Agarwal, R.; Williams, K.; Brennan, P.J. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect. Control Hosp. Epidemiol., 2011, 32(2), 101-114.
[27]
Ranji, S.R.; Shetty, K.; Posley, K.A.; Lewis, R.; Sundaram, V.; Galvin, C.M.; Winston, L.G. Closing the quality gap: A critical
analysis of quality improvement strategies (vol. 6: prevention of
healthcare-associated infections). Rockville (MD): Agency for
Healthcare Research and Quality (US);, 2007. Report No.: 04(07)-
0051-6..
[28]
Stone, P.W.; Braccia, D.; Larson, E. Systematic review of economic analyses of health care-associated infections. Am. J. Infect. Control, 2005, 33(9), 501-509.
[29]
Raschka, S.; Dempster, L.; Bryce, E. Health economic evaluation of an infection prevention and control program: Are quality and patient safety programs worth the investment? Am. J. Infect. Control, 2013, 41(9), 773-777.
[30]
Scott, D.R. The direct medical costs of healthcare-associated infections
in US hospitals and the benefits of prevention. Available at: . https://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf (Accessed
July 15, 2018).
[31]
Agodi, A.; Auxilia, F.; Barchitta, M.; Brusaferro, S.; D’Alessandro, D.; Grillo, O.C.; Montagna, M.T.; Pasquarella, C.; Righi, E.; Tardivo, S.; Torregrossa, V.; Mura, I. GISIO-SITI. Trends, risk factors and outcomes of healthcare-associated infections within the Italian network SPIN-UTI. J. Hosp. Infect., 2013, 84(1), 52-58.
[32]
Eber, M.R.; Laxminarayan, R.; Perencevich, E.N.; Malani, A. Clinical and economic outcomes attributable to health care-associated sepsis and pneumonia. Arch. Intern. Med., 2010, 170(4), 347-353.
[33]
Stone, P.W. Economic burden of healthcare-associated infections: An American perspective. Expert Rev. Pharmacoecon. Outcomes Res., 2009, 9(5), 417-422.
[34]
Burgmann, H.; Hiesmayr, J.M.; Savey, A.; Bauer, P.; Metnitz, B.; Metnitz, P.G. Impact of nosocomial infections on clinical outcome and resource consumption in critically ill patients. Intensive Care Med., 2010, 36(9), 1597-1601.
[35]
Feudtner, C.; Christakis, D.A.; Zimmerman, F.J.; Muldoon, J.H.; Neff, J.M.; Koepsell, T.D. Characteristics of deaths occurring in children’s hospitals: Implications for supportive care services. Pediatrics, 2002, 109(5), 887-893.
[36]
Zegers, M.; De Bruijne, M.C.; Wagner, C.; Hoonhout, L.H.; Waaijman, R.; Smits, M.; Hout, F.A.; Zwaan, L.; Christiaans-Dingelhoff, I.; Timmermans, D.R.; Groenewegen, P.P.; van der Wal, G. Adverse events and potentially preventable deaths in Dutch hospitals: Results of a retrospective patient record review study. Qual. Saf. Health Care, 2009, 18(4), 297-302.
[37]
Hogan, H.; Healey, F.; Neale, G.; Thomson, R.; Vincent, C.; Black, N. Preventable deaths due to problem in care in English acute hospitals: A retrospective case record review study. BMJ Qual. Saf., 2012, 21(9), 737-745.
[38]
Institute for Healthcare Improvement. Move Your Dot--Measuring,
Evaluating and Reducing Hospital Mortality Rates. Cambridge,
MA: Institute for Healthcare Improvement, 2003.
[39]
Whittington, J.; Simmonds, T.; Jacobsen, D. Reducing hospital
mortality rates (Part 2). IHI Innovation Series white paper. Cambridge,
MA: Institute for Healthcare Improvement,, 2005.
[40]
Kristensen, S.; Mainz, J.; Bartels, P. The ESQH-office for quality
indicators. Establishing a set of patient safety indicators. Safety
improvement for patients in Europe (SImPatIE),. 2007.
[41]
Frigola-Capell, E.; Pareja-Rossell, C. Montse Gens-Barber.; Oliva-Oliva, G.; Alava-Cano, F.; Wensing, M.; Davins-Miralles, J. Quality indicators for patient safety in primary care. A review and Delphi-survey by the Linneaus collaboration on patient safety in primary care. Eur. J. Gen. Pract., 2015, 21(Suppl. 1), 31-34.
[42]
Jarman, B.; Gault, S.; Alves, B.; Hider, A.; Dolan, S.; Cook, A.; Hurwitz, B.; Iezzoni, L.I. Explaining differences in English hospital death rates using routinely collected data. BMJ, 1999, 318(7197), 1515-1520.
[43]
Van der Laan, J.; de Bruin, A.; Penning, C.; van den Akker, J. HSMR 2016: Methodological report. https://www.hsmr.nl/wp-content/uploads/2016/01/2015hsmrmethodologicalreport2014.pdf (Accessed June 12, 2018).
[44]
Jarman, B.; Pieter, D.; Van Der Veen, A.A.; Kool, R.B.; Aylin, P.; Bottle, A.; Westert, G.P.; Jones, S. The hospital standardized mortality ratio: A powerful tool for Dutch hospitals to assess their quality of care? Qual. Saf. Health Care, 2010, 19(1), 9-13.
[45]
Van Gestel, Y.R.; Lemmens, V.E.; Lingsma, H.F.; de Hingh, I.H.; Rutten, H.J.; Coebergh, J.W. The hospital standardized mortality ratio fallacy: A narrative review. Med. Care, 2012, 50(8), 662-667.
[46]
Goldfarb, M.G.; Coffey, R.M. Case mix differences between teaching and non-teaching hospitals. Inquiry, 1987, 24, 68-84.
[47]
Brien, S.E.; Ghali, W.A. Public reporting of the hospital standardized mortality ratio (HSMR): Implications for the Canadian approach to safety and quality in health care. Open Med., 2008, 2(3), e70-e73.
[48]
The Health and Social Care Information Centre. Indicator Specification:
Summary Hospital-level Mortality Indicator, 2017.Available
at: . https://digital.nhs.uk/data-and-information/publications/ clinical-indicators/shmi/current. (Accessed: July 25, 2018).
[49]
Freemantle, N.; Richardson, M.; Wood, J.; Ray, D.; Khosla, S.; Sun, P.; Pagano, D. Can we update the Summary Hospital Mortality Index (SHMI) to make a useful measure of the quality of hospital care? An observational study. BMJ Open, 2013, 3(1)e002018
[50]
Patrick, S.W.; Schumacher, R.E.; Davis, M.M. Methods of mortality risk adjustment in the NICU: A 20-year review. Pediatrics, 2013, 131(1), S68-S74.
[51]
Friedman, J.N.; Pinard, M.S.; Laxer, R.M. The morbidity and mortality conference in university-affiliated pediatric departments in Canada. J. Pediatr., 2005, 146(1), 1-2.
[52]
Rachel, M.M.; Stewart, M.W. Establishing a mortality review process. J. Nurs. Care Qual., 2009, 24(3), 211-222.
[53]
Barbieri, J.S.; Fuchs, B.D.; Fishman, N.; Cutilli, C.C.; Umscheid, C.A.; Kean, C.; Koshy, S.; Sullivan, P.G.; Brennan, P.J.; Kelz, R.R. The Mortality Review Committee: A novel and scalable approach
to reducing inpatient mortality. Jt. Comm. J. Qual. Patient Saf., 2013, 39(9), 387-395.
[54]
Clarke, D.L.; Furlong, H.; Laing, G.L.; Aldous, C.; Thomson, S.R. Using a structured morbidity and mortality meeting to understand the contribution of human error to adverse surgical events in a South African regional hospital. S. Afr. J. Surg., 2013, 51(4), 121-126.
[55]
Heidelberg, L. Surgical mortality review reduces preventable deaths and patient safety indicators.; (PSIs). Intern. Med. Rev. , 2017, 3(8), 1-13.
[56]
Frey, B.; Doell, C.; Klauwer, D.; Cannizzaro, V.; Bernet, V.; Maguire, C.; Brotschi, B. The Morbidity and Mortality Conference in pediatric intensive care as a means for improving patient safety. Pediatr. Crit. Care Med., 2016, 17(1), 67-72.
[57]
Seiler, R.W. Principles of the morbidity and mortality conference. Acta Neurochir. , 2001, 78, 125-126.
[58]
Ciofi Degli Atti, M.L.; Cuttini, M.; Ravà, L.; Ceradini, J.; Paolini, V.; Ciliento, G.; Pomponi, M.; Raponi, M. Trend of healthcare-associated infections in children: Annual prevalence surveys in a research hospital in Italy, 2007-2010. J. Hosp. Infect., 2012, 80(1), 6-12.
[59]
Rutledge-Taylor, K.; Matlow, A.; Gravel, D.; Embree, J.; Le Saux, N.; Johnston, L.; Suh, K.; Embil, J.; Henderson, E.; John, M.; Roth, V.; Wong, A.; Shurgold, J.; Taylor, G. Canadian nosocomial infection surveillance program a point prevalence survey of health care-associated infections in Canadian pediatric inpatients. Am. J. Infect. Control, 2012, 40(6), 491-496.
[60]
Kinnula, S.; Buettcher, M.; Tapiainen, T.; Renko, M.; Vepsäläinen, K.; Lantto, R.; Heininger, U.; Uhari, M. Hospital associated infections in children: A prospective post-discharge follow-up survey in three different paediatric hospitals. J. Hosp. Infect., 2012, 80(1), 17-24.
[61]
Zingg, W.; Hopkins, S.; Gayet-Ageron, A.; Holmes, A.; Sharland, M.; Suetens, C. Health-care-associated infections in neonates, children, and adolescents: An analysis of paediatric data from the European Centre for disease prevention and control point-prevalence survey. Lancet Infect. Dis., 2017, 17(4), 381-391.
[62]
Olivier, C.; Kunneke, H.; O’Connell, N.; Von Delft, E.; Wates, M.; Dramowski, A. Healthcare-associated infections in paediatric and neonatal wards: A point prevalence survey at four South African hospitals. S. Afr. Med. J., 2018, 108(5), 418-422.
[63]
Thursky, K.; Lingaratnam, S.; Jayarajan, J.; Haeusler, G.M.; The, B.; Tew, M.; Venn, G.; Hiong, A.; Brown, C.; Leung, V.; Worth, L.J.; Dalziel, K.; Slavin, M.A. Implementation of a whole of hospital sepsis clinical pathway in a cancer hospital: Impact on sepsis management, outcomes and costs. BMJ Open Qual., 2018, 7(3)e000355
[64]
Shorr, A.F.; Micek, S.T.; Jackson, W. L Jr.; Kollef, M.H. Economic implications of an evidence-based sepsis protocol: Can we improve outcomes and lower costs? Crit. Care Med., 2007, 35(5), 1257-1262.
[65]
Ranji, S.R.; Shetty, K.; Posley, K.A.; Lewis, R.; Sundaram, V.; Galvin, C.M.; Winston, L.G. Prevention of healthcare-associated
infections. Agency Healthcare Res. Qual,, 2007.AHRQ Publication
No. 04(07)-0051-6..
[66]
Zimlichman, E.; Henderson, D.; Tamir, O.; Franz, C.; Song, P.; Yamin, C.K.; Keohane, C.; Denham, C.R.; Bates, D.W. Health
care-associated infections: A meta-analysis of costs and financial
impact on the US health care system. JAMA Intern. Med., 2013, 173(22), 2039-2046.
[67]
Shahian, D.M.; Wolf, R.E.; Iezzoni, L.I.; Kirle, L.; Normand, S.L. Variability in the measurement of hospital-wide mortality rates. N. Engl. J. Med., 2010, 363(26), 2530-2539.
[68]
Lilford, R.; Pronovost, P. Using hospital mortality rates to judge hospital performance: A bad idea that just won’t go away. BMJ, 2010, 340, c2016.
[69]
Rabizadeh, S.; Gower, W.A.; Payton, K.; Miller, K.; Vera, K.; Serwint, J.R. Restructuring the morbidity and mortality conference in a department of pediatrics to serve as a vehicle for system changes. Clin. Pediatr, 2012, 51(11), 1079-1086.
[70]
Cifra, C.L.; Bembea, M.M.; Fackler, J.C.; Miller, M.R. Transforming the morbidity and mortality conference to promote safety and quality in a PICU. Pediatr. Crit. Care Med., 2016, 17(1), 58-66.
[71]
Giesbrecht, V.; Au, S. Morbidity and mortality conferences: A narrative review of strategies to prioritize quality improvement. Jt. Comm. J. Qual. Patient Saf., 2016, 42(11), 516-527.
[72]
Bechtold, M.; Scott, S.; Dellsperger, K.C.; Hall, L.W.; Nelson, K.; Cox, K.R. Educational quality improvement report: Outcomes from a revised morbidity and mortality format that emphasized patient safety. Postgrad. Med. J., 2008, 84(990), 211-216.
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