1. The importance for palliative care
Mortality Reviews
The importance for palliative care
Gemma Lewis, Palliative Medicine ST5
Irene Logan, Macmillan CNS YGC
Dr Brian Tehan, Cons Anaesthetist
Catherine Roberts, Quality Improvement Manager

2. Overview What are mortality reviews? Who/when/how?
What is their purpose?
What can palliative care glean from mortality reviews?

3. Mortality Reviews
Compulsory for all hospitals to review all deaths (CMO May 2010). No guidance as to how these reviews should be done!

4. Measures used Conventional approaches to quantifying adverse events:
Voluntary Incident Reporting
Record Reviews
Observational databases
The Global Trigger Tool was devised by the IHI
This was based on the principle of Triggers

5. Why use trigger tools?
Trigger Tools focus on identifying harm as opposed to errors.
By focusing on events experienced by patients it can help shift the culture from individual blame for errors.
This can facilitate system redesign.

6. Global Trigger Tool Approach
Provides a tool for a systematic case note review
Provides a long term outcome measure
Reviews for triggers then assess for harm
Triggers are in ‘modules’

7. Monthly Global Trigger Tool Review
20 sets of case notes reviewed per month
Each acute hospital in Wales
Random sample of live discharges and deaths (mostly live discharges within sample)
YGC commenced early 2005
Clear inclusion/exclusion criteria
Mandatory measure supplied to WG via Annual Quality Framework (AQF) reporting
CORPORATE 20 SETS CASENOTES PER MONTH (mostly live discharges)
Complication of treatment/procedure
Readmission to hospital within 30 days
Patient fall
Abrupt drop in Hb
CORPORATE MORTALITY REVIEW
Cardiac arrest (usually assoc. with early warning systems)
Pressure ulcer
OTHER (new trigger)
Lack of early warning score or response

8. Mortality Review Process YGC
Patient case notes are completed by clinical staff following death.
Mortality Review Process YGC
Patient case notes are completed by clinical staff following death.
Coding manager (or nominated individual) obtains a weekly list of all in-patient deaths
List is randomised
Retrieval of notes for designated meeting via Coding Manager
Notes reviewed individually by group with discussion (as many as can be reviewed in order of randomised list). Meeting to last 90 minutes, same day/time each week.
Last 10 minutes of meeting:
Group discussion re potential concerns/referrals/identified events
Group identify general positive and negative process issues within the review
Any particular concerns to be translated into patient stories in order to support themes emerging
Issues identified for potential clinical audit to be shared with CPG clinical audit leads
Summary review sheet completed
Completed review forms scanned into relevant audit software package (FORMIC) by nominated individual and then into excel programmes (set up specifically for the review)
EVENT SEVERITY
Category E contributed to or resulted in temporary harm to the patient & required intervention.
Category F contributed to or resulted in temporary harm to patients & required initial or prolonged hospitalisation.
Category G contributed or resulted in permanent patient harm.
Category H required intervention to sustain life
Category I contributed to the patient’s death
Notes returned to filing
Quality Improvement
Top themes will inform local improvement projects and provide short term process and outcome measures.
Long term outcome measure – Mortality Adverse Event Rate
Reporting
Reporting and communicating outcomes from the review is yet to be confirmed
Reporting of individual quality improvement projects prompted via the review will be as per existing agreement.

9. What about palliative care?

10. Switching to Terminal Care

11. Changing to terminal care and use of the Care Pathway

12. Deaths per ward

13. Focus Wards

14. 43% recognised as terminal on ICP
Use of the Care Pathway
407 deaths in total
27% of these on ICP
43% recognised as terminal on ICP

15. Use of DNA-CPR form

16. Work in Progress...
Identified wards which need general palliative care education and promotion of care pathway as gold standard for end of life care.
Focus on palliative care in dementia
Working with care of the elderly teams
Working with AMU

17. Work in Progress... Auditing DNA-CPR use throughout Betsicadwaladr
Regional audit 2011/12

18. Work in Progress... Patients admitted from NH Fairly common
Often have co-morbid conditions
Admission not always appropriate
Ties in with care of the elderly/dementia
Educational role for NH staff and GPs as well as advanced care planning for such patients

19. What next for Mortality Reviews?
Outcomes - Ensuring we learn!
Further develop standards – e.g. links with AQF?
Clinical engagement/ Team recruitment
Patient stories of particular concerns identified
Spread across HB
Link with local reporting/complaints/audit
Avoid duplication
Reporting of process results/outcomes
How we deal with serious concerns

20. Thank you for listening.
Any Questions?