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Mortality review

Danish Society for Patient Safety. Mortality review. Brian Bjørn, M.D. International Forum on Quality Improvement in Health Care Paris – April 9, 2014. Overview. Background and context Why ? How ? IHI’s approach to mortality review and how we tweaked it Danish experiences.

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Mortality review

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  1. Danish Society for Patient Safety Mortality review Brian Bjørn, M.D. International Forum on QualityImprovement in Health Care Paris – April 9, 2014

  2. Overview • Background and context • Why? • How ? • IHI’s approach to mortalityreview • and howwetweaked it • Danish experiences

  3. Why measure mortality? • Death is a definite and unique event • Deathsarerecorded by law • Death rates areeasilyunderstood • also by the public • Traditionaloutcome measure in biomedical research

  4. IHI: Moveyourdot Plot yourdot Examineyourdot Evaluateyourdot Understand yourdot Test changes

  5. Plot yourdot 1 Hospital StandardizedMortality Ratio, by quarter

  6. Plot yourdot 2 No. of in-hospital deaths, by quarter, onlydeathsincluded in HSMR

  7. Plot yourdot 3

  8. Mortalityreview Records from 50 consecutivedeaths Multidisciplinary team Consensusprocess

  9. Resources Availability of palliative care Mortalityreduction Qualityimprovements

  10. Box A Admission to ICU Comfortcareonly Overuse of ICU beds?

  11. Box B Admission to non-ICU beds Comfortcareonly Inadequate hospice or other end-of-lifecareresources in the community?

  12. Box C • Admission to ICU • Active treatment • Qualityimprovement and mortalityreduction • VAP • CLABSI • etc.

  13. Box D • Admission to non-ICU beds • Active treatment • Qualityimprovement and mortalityreduction • EarlyWarning Score • Rapid response team • Sepsis bundle • Etc.

  14. Danish experiences • Limited benefit of using 2x2 matrix • Comfortcareonly in ICU bed a very rare event • Desire to evaluatepreventability • Consensus decision • Did the patient have to die in thisshift?

  15. Example: 14 preventabledeaths

  16. Hospital acquiredpneumonia 76-years old Admitted for episodichyperglycemia. Antibioticsare not prescribeduntiltwodaysafterpneumonia is diagnosed. Patient dischargedbeforefirstdose is administered. Readmissiondayafter, dies unexpectedly Clearlypreventabledeath due to hospital acquiredpneumonia

  17. Delayedtreatment 80-years old Transferred after long stay at another hospital. Immunosuppressed due to ’prolonged’ corticosteroidtreatment. Clinicalsigns of sepsis, antibioticsdelayed by 8 hours. Preventabilityundetermined.

  18. Plot yourdot

  19. Evaluate/understand yourdot

  20. Evaluate/understand yourdot

  21. ?

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