1. How Structured Mortality Reviews Can Improve Quality of Care
Anne Pullyblank
Colorectal Surgeon North Bristol NHS Trust
Clinical director WEAHSN
@APullyblank

2. When good data goes bad

3. What to do? Check the data! One trauma case
One patient inadvertently marked as dead

4. Ask This Man for Insight!
O/E ratios
Confidence intervals ?normal variation
More detailed information

5. Case Review Medical student SSC Sepsis Patients with high P-POSSUM
Structured mortality review
Global Trigger Tool

6. National Mortality Case Record Review Programme

7. Mortality Review Context
The National Mortality Case Record Review Programme is in place to assist all acute hospitals in England and Scotland to review deaths and safety & quality of care
The national programme supports hospitals in the use of an evidence-based review method called Structured Judgement Review [SJR]
SJR provides both quantitative and qualitative information on care that goes well, or not so well

8. National Structured Mortality Review
Trusts in the WEAHSN are part of the national pilot
WEAHSN has created the first Mortality Review Collaborative bringing together 6 trusts from within the region and 2 from outside the West of England
Involvement from the Medical Examiners Pilot being delivered in Gloucestershire
Replaces global trigger tool

9. The purpose of Structured Judgement Review
The review system can be used for individual cases [e.g. ‘M&M’] and for groups of cases
The information allows units or organisations to ask ‘why’ questions about things that happen, to enable learning and action where required
Results show good care as well as poor care (and good care is much more frequent)
Like all mortality review programmes, the support of a robust governance process is required

10. What is special about the SJR method?
It examines both interventions and holistic care
Reviewers give written explicit judgements on safety and quality of phases of care (the structure)
Reviewers give overall care and phase of care scores to accompany judgements scores are
It is an internal review process usually based on one reviewer’s judgement, with an second stage review where there is cause for concern at first review

11. Phases of care Admission and Initial care – first 24 hours approx.
Care during a procedure
Perioperative/procedure care
On-going care up to end of life or discharge of the patient (may cover a prolonged period)
End of Life care or Discharge care
Overall care

12. The 1-5 phase of care score
1 Very poor care 2 Poor care 3 Adequate care 4 Good care 5 Excellent care

13. What should a judgement comment look like?
Needs to be explicit
Score needs to reflect the comment
You can have a good comment but still have a bad score for the whole phase of care

14. What should a judgement comment look like?
For example:
There was some evidence of good management by overnight team with prompt review and intervention (a ‘good’ comment though phase judged 2)
Overall, a fundamental failure to recognise the severity of this patient’s respiratory failure (2)

15. Assessment of problems in healthcare
In this section reviewers comment on whether specific types of problems were identified and if so, whether harm was caused e.g. – no, or if yes, please identify problem type(s) from selected list and indicate whether any led to harm
The are 8 problem categories eg:
Problem related to treatment and management plan?
Did the problem lead to harm?
No [ ] Probably [ ] Yes [ ]
Adapted from PRISM 2 study documents, with permission 2016

16. Using the review results
Care scores – use these to identify patterns in phases or aspects of care for further exploration
Judgement commentaries – draw out the themes, eg ‘Early senior planning in complex cases means care goes well’
Contrast good and poor assessments within the themes – why does practice variation happen?

17. An example of review themes
Contrasts occurred in areas such as:
Opportunities taken and missed
EWS score recognition
Senior review and case review timing
Recognition of change
DNACPR management
Documentation
Fluid management

18. Adaptions for ELC Have added sepsis screening
Components of care bundle
Applying to emergency laparotomy deaths

19. Phase of care: Each page contains....
Please record your explicit judgements about the quality of care the patient received and whether it was in accordance with current good practice (for example, your professional standards or your professional perspective). If there is any other information that you think is important or relevant that you wish to comment on then please do so.
Please rate the care received by the patient during this phase:
Very poor Excellent
(Please circle only one score).

20. Phase of care: Admission and initial management (approximately the first 24 hours)
Full care to be reviewed, but the following should be specifically considered and answered in this box:
What was the time of first review by Consultant Surgeon
Was there follow up NEWScores calculated? (Or a recognition of deterioration/illness?)
Timely recognition of Sepsis (if applicable)
Was the Sepsis 6 carried out?
Were antibiotics administered?

21. Phase of care: Ongoing care
Full care to be reviewed, but the following should be specifically considered and answered in this box. The previous box relates to the first 24hrs of care – this is ongoing care past 24hrs:
Was there follow up NEWScores calculated? (Or a recognition of deterioration/illness?)
Timely recognition of Sepsis (if applicable)
Was the Sepsis 6 carried out?
Were antibiotics administered?

22. Phase of care: Care during a procedure
Full care to be reviewed, but the following should be specifically considered and answered in this box:
Was a Lactate calculated and recorded?
What was the Pre Op P-POSSUM score?
What was the patient’s time to theatre – planned and actual?
Was there a Consultant Surgeon in theatre?
Was there a Consultant Anesthetist in theatre?
What was the ASA Score?
Did the patient undergoing cardiac output monitoring?

23. Phase of care: Perioperative care
Full care to be reviewed, but the following should be specifically considered and answered in this box:
Did the patient go to ITU post Op?
If no which ward did they go to?
Was there a care of the elderly review? (mark N/A where not appropriate)

24. Phase of care: End of Life/Discharge
Please record your explicit judgements……
Full care to be reviewed, but the following should be specifically considered and answered in this box:

25. What we Found… Sepsis not well managed
Medical admissions more likely to die
Higher pre-op P-POSSUM and also higher ASA

26. Response… Sepsis not well managed
Sepsis screening tool in surgical proforma
Medical admissions more likely to die
Higher pre-op P-POSSUM and also higher ASA
Wider review
Education of medics/ED
Information on intranet/JD handbook

27. Why you should not panic
Data might be wrong
Locked vs unlocked data
Small numbers
Natural variation
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