Preventable mortality evaluation in the ICU

L Marjon Dijkema, Willem Dieperink, Matijs van Meurs, Jan G Zijlstra, L Marjon Dijkema, Willem Dieperink, Matijs van Meurs, Jan G Zijlstra

Abstract

Mortality is the most widely measured outcome parameter. Improvement of this outcome parameter in critical care is nowadays expected not to come from new technologies or treatment, but from delivering the right care at the right moment in a safe way. The measurement of mortality as an outcome parameter confronts us with a problem in providing follow-up to the results. Especially when proven structure and process interventions are applied already, the cause of a suboptimal performance cannot be deduced easily. One possibility is to evaluate the causes of death and to judge preventability. In this article we explore the opportunities and difficulties of a tool to evaluate preventable mortality in the ICU.

References

    1. Kohn L, Corrigan JM, Donaldson MS, Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
    1. Donabedian A. Evaluating the quality of medical care. 1966. Milbank Q. 2005;16:691–729. doi: 10.1111/j.1468-0009.2005.00397.x.
    1. Pronovost PJ, Goeschel CA, Marsteller JA, Sexton JB, Pham JC, Berenholtz SM. Framework for patient safety research and improvement. Circulation. 2009;16:330–337. doi: 10.1161/CIRCULATIONAHA.107.729848.
    1. Brennan TA, Gawande A, Thomas E, Studdert D. Accidental deaths, saved lives, and improved quality. N Engl J Med. 2005;16:1405–1409. doi: 10.1056/NEJMsb051157.
    1. Curtis JR, Cook DJ, Wall RJ, Angus DC, Bion J, Kacmarek R, Kane-Gill SL, Kirchhoff KT, Levy M, Mitchell PH, Moreno R, Pronovost P, Puntillo K. Intensive care unit quality improvement: a 'how-to' guide for the interdisciplinary team. Crit Care Med. 2006;16:211–218. doi: 10.1097/.
    1. Moreno RP, Rhodes A, Donchin Y. Patient safety in intensive care medicine: the Declaration of Vienna. Intensive Care Med. 2009;16:1667–1672. doi: 10.1007/s00134-009-1621-2.
    1. Gajic O, Afessa B. Physician staffing models and patient safety in the ICU. Chest. 2009;16:1038–1044. doi: 10.1378/chest.08-1544.
    1. Bouadma L, Deslandes E, Lolom I, Le Corre B, Mourvillier B, Regnier B, Porcher R, Wolff M, Lucet J. Long-term impact of a multifaceted prevention program on ventilator-associated pneumonia in a medical intensive care unit. Clin Infect Dis. 2010;16:1115–1122. doi: 10.1086/656737.
    1. Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Med. 2008;16:17–60. doi: 10.1007/s00134-007-0934-2.
    1. de Vos M, Graafmans W, Keesman E, Westert G, van der Voort PH. Quality measurement at intensive care units: which indicators should we use? J Crit Care. 2007;16:267–274. doi: 10.1016/j.jcrc.2007.01.002.
    1. Dubois RW, Brook RH. Preventable deaths: who, how often, and why? Ann Intern Med. 1988;16:582–589.
    1. Chiara O, Cimbanassi S, Pitidis A, Vesconi S. Preventable trauma deaths: from panel review to population based-studies. World J Emerg Surg. 2006;16:12. doi: 10.1186/1749-7922-1-12.
    1. Pronovost PJ, Colantuoni E. Measuring preventable harm: helping science keep pace with policy. JAMA. 2009;16:1273–1275. doi: 10.1001/jama.2009.388.
    1. Vincent JL, Parquier JN, Preiser JC, Brimioulle S, Kahn RJ. Terminal events in the intensive care unit: review of 258 fatal cases in one year. Crit Care Med. 1989;16:530–533. doi: 10.1097/00003246-198906000-00009.
    1. Polderman KH, Thijs LG, Girbes AR. Interobserver variability in the use of APACHE II scores [letter] Lancet. 1999;16:380.
    1. Vincent JL, Moreno R. Clinical review: scoring systems in the critically ill. Crit Care. 2010;16:207.
    1. Dijkema LM, Dieperink W, Heesink A, Zijlstra JG. Evaluating (potential) preventable mortality in an adult ICU [abstract] Intensive Care Med. 2011;16:S137.
    1. Guru V, Tu JV, Etchells E, Anderson GM, Naylor CD, Novick RJ, Feindel CM, Rubens FD, Teoh K, Mathur A, Hamilton A, Bonneau D, Cutrara C, Austin PC, Fremes SE. Relationship between preventability of death after coronary artery bypass graft surgery and all-cause risk-adjusted mortality rates. Circulation. 2008;16:2969–2976. doi: 10.1161/CIRCULATIONAHA.107.722249.
    1. Ben Tovim DI. Hospital mortality ratios. Death is final: getting the balance right. BMJ. 2010;16:c2741. doi: 10.1136/bmj.c2741.
    1. Rosenberg AL, Hofer TP, Strachan C, Watts CM, Hayward RA. Accepting critically ill transfer patients: adverse effect on a referral center's outcome and benchmark measures. Ann Intern Med. 2003;16:882–890.
    1. De Vlieger GY, Mahieu EM, Meersseman W. Clinical review: What is the role for autopsy in the ICU? Crit Care. 2010;16:221. doi: 10.1186/cc8925.
    1. Girbes AR, Zijlstra JG. Is routine autopsy in the intensive care unit viable? Crit Care. 2010;16:425. doi: 10.1186/cc9069.
    1. Ksouri H, Balanant PY, Tadie JM, Heraud G, Abboud I, Lerolle N, Novara A, Fagon JY, Faisy C. Impact of morbidity and mortality conferences on analysis of mortality and critical events in intensive care practice. Am J Crit Care. 2010;16:135–145. doi: 10.4037/ajcc2010590.
    1. Org G, Timsit JF, Soufir L, Tafflet M, Adrie C, Philippart F, Zahar JR, Clec'h C, Garrouste-Orgeas M, Jamali S, Dumenil AS, Azoulay E, Carlet J. Impact of adverse events on outcomes in intensive care unit patients. Crit Care Med. 2008;16:2041–2047. doi: 10.1097/CCM.0b013e31817b879c.
    1. Frey B, Schwappach D. Critical incident monitoring in paediatric and adult critical care: from reporting to improved patient outcomes? Curr Opin Crit Care. 2010;16:649–653. doi: 10.1097/MCC.0b013e32834044d8.
    1. Sari AB, Sheldon TA, Cracknell A, Turnbull A. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. BMJ. 2007;16:79. doi: 10.1136/.
    1. Resar RK, Rozich JD, Simmonds T, Haraden CR. A trigger tool to identify adverse events in the intensive care unit. Jt Comm J Qual Patient Saf. 2006;16:585–590.
    1. Rothschild JM, Landrigan CP, Cronin JW, Kaushal R, Lockley SW, Burdick E, Stone PH, Lilly CM, Katz JT, Czeisler CA, Bates DW. The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005;16:1694–1700. doi: 10.1097/.
    1. Cales RH, Trunkey DD. Preventable trauma deaths. A review of trauma care systems development. JAMA. 1985;16:1059–1063. doi: 10.1001/jama.1985.03360080071032.
    1. MacKenzie EJ. Review of evidence regarding trauma system effectiveness resulting from panel studies. J Trauma. 1999;16:S34–S41. doi: 10.1097/00005373-199909001-00008.
    1. Stelfox HT, Straus SE, Nathens A, Bobranska-Artiuch B. Evidence for quality indicators to evaluate adult trauma care: a systematic review 4. Crit Care Med. 2011;16:846–859. doi: 10.1097/CCM.0b013e31820a859a.
    1. Saltzherr TP, Wendt KW, Nieboer P, Nijsten MW, Valk JP, Luitse JS, Ponsen KJ, Goslings JC. Preventability of trauma deaths in a Dutch Level-1 trauma centre. Injury. 2011;16:870–873. doi: 10.1016/j.injury.2010.04.007.
    1. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;16:370–376. doi: 10.1056/NEJM199102073240604.
    1. Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, Etchells E, Ghali WA, Hebert P, Majumdar SR, O'Beirne M, Palacios-Derflingher L, Reid RJ, Sheps S, Tamblyn R. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004;16:1678–1686. doi: 10.1503/cmaj.1040498.
    1. Zegers M, de Bruijne MC, Wagner C, Hoonhout LH, Waaijman R, Smits M, Hout FA, Zwaan L, Christiaans-Dingelhoff I, Timmermans DR, Groenewegen PP, 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;16:297–302. doi: 10.1136/qshc.2007.025924.
    1. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality in Australian Health Care Study. Med J Aust. 1995;16:458–471.
    1. Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer. JAMA. 2001;16:415–420. doi: 10.1001/jama.286.4.415.
    1. Thomas EJ, Lipsitz SR, Studdert DM, Brennan TA. The reliability of medical record review for estimating adverse event rates. Ann Intern Med. 2002;16:812–816.
    1. Hofer TP, Hayward RA. Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis. Ann Intern Med. 2002;16:327–333.
    1. Hutchinson A, Coster JE, Cooper KL, McIntosh A, Walters SJ, Bath PA, Pearson M, Rantell K, Campbell MJ, Nicholl J, Irwin P. Assessing quality of care from hospital case notes: comparison of reliability of two methods. Qual Saf Health Care. 2010;16:e2. doi: 10.1136/qshc.2010.040352.
    1. Zegers M, de Bruijne MC, Wagner C, Groenewegen PP, van der Wal G, de Vet HC. The inter-rater agreement of retrospective assessments of adverse events does not improve with two reviewers per patient record. J Clin Epidemiol. 2010;16:94–102. doi: 10.1016/j.jclinepi.2009.03.004.
    1. Hofer TP, Bernstein SJ, DeMonner S, Hayward RA. Discussion between reviewers does not improve reliability of peer review of hospital quality. Med Care. 2000;16:152–161. doi: 10.1097/00005650-200002000-00005.
    1. Christianson MK, Sutcliffe KM, Miller MA, Iwashyna TJ. Becoming a high reliability organization. Crit Care. 2011;16:314. doi: 10.1186/cc10360.
    1. Reader TW, Cuthbertson BH. Teamwork and team training in the ICU: where do the similarities with aviation end? Crit Care. 2011;16:313. doi: 10.1186/cc10353.
    1. Welters ID, Gibson J, Mogk M, Wenstone R. Major sources of critical incidents in intensive care. Crit Care. 2011;16:R232. doi: 10.1186/cc10474.

Source: PubMed

3
Prenumerera