In-person rapid mortality review process sparked improvements in patient care

An in-person multidisciplinary rapid mortality review (RMR) process helped identify specific areas to improve patient care at a Los Angeles hospital, according to a study published in American Journal of Critical Care (AJCC).

The novel approach helped front-line clinicians understand both individual- and systems-level issues that contribute to mortality, with the ultimate aim of optimizing the delivery of patient care.

"Rapid Mortality Review in the Intensive Care Unit: an In-Person Multidisciplinary Improvement Initiative" explores the data generated from five years of reviewing patient deaths that occurred in the 24-bed medical intensive care unit (ICU) at Ronald Reagan University of California Los Angeles (UCLA) Medical Center.

The analysis found that the RMR process not only identified immediate concerns related to patient care but also yielded valuable insights on potentially preventable patient deaths and areas for hospital improvement initiatives.

First author Kristin Schwab, MD, is a pulmonologist and critical care physician at UCLA Health and a clinical instructor in the Division of Pulmonary and Critical Care Medicine, Department of Medicine, at UCLA's David Geffen School of Medicine.

Our findings suggest that these short and timely in-person meetings can be a powerful tool for efforts to both improve quality and prevent mortality in the ICU. Bringing members of the multidisciplinary care team together for regular face-to-face discussions provided a forum that revealed concerns and solicited tangible ideas for solutions."

Kristin Schwab, MD, First Author

Retrospective case reviews, provider surveys, and structured morbidity and mortality conferences can be useful tools for discussions about safety and quality issues, but these common tactics are unlikely to provide an efficient and practical means of reviewing all patient deaths.

The RMR process began as a pilot in 2013, with a subset of patients who had died in the medical ICU during the prior week. The subset gradually grew and by 2017, the team was attempting, during the weekly meetings, to review every death that occurred in the unit. During the five-year period, the RMR team reviewed 542 deaths, which was more than 80% of all deaths that occurred in the unit.

For each patient death, a facilitator reviewed the patient's chart prior to the meeting to prepare to lead a semistructured interview with the care team. Questions included, "Was the death potentially preventable?" and "Are there any aspects of care that could have been improved?" followed by additional open-ended questions.

Following the meeting, the facilitator recorded a summary of the discussion into a database. The quality team reviewed the data from each meeting and referred any action items to the appropriate department.

Only 7% of deaths were deemed potentially preventable, as determined by the treatment team, RMR facilitator or both. However, the treatment team believed that care could have been improved in more than 40% of the deaths, while the facilitator identified areas for improvement in more than half of the cases.

Cases in which the patient required resuscitation after an in-hospital cardiac arrest or those in which the patient was not receiving comfort care at the time of death were associated with a higher likelihood of generating an action item.

Issues included concerns with communication or teamwork, advance care planning, delays in care, medical errors, procedural complications and hospital-acquired infections. Systems-related action items addressed lack of protocols, resource availability and throughput.

Among the identified action items, more than one in 10 led to tangible systemic change, with 29 discrete changes occurring during the study period.

Examples of completed action items include creating a standardized checklist for inbound patient transfers and changing the electronic health record to separate one-time orders from continuing orders.