(42 - Saturday) Creating a Process to Improve the Timeliness and Characterization of Mortalities in Hospitalized Patients with Congenital Heart Disease and to Identify and Implement Countermeasures

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Abstract:

Introduction:
Mortality events can present important opportunities for improvement in healthcare delivery. Analysis of such events offers insight into deficiencies of hospital systems. However, traditional mortality reviews are confined to static reviews and conferences that are often temporally distant from the event. Such delayed reviews are prone to recall bias and limited scope. This may contribute to challenges in identifying improvement opportunities and to delays in implementing critical countermeasures.

Aim:
A structured, interdisciplinary, rapid-review process was designed to evaluate mortality events in real time ( < 2 weeks) among hospitalized patients with congenital heart disease.

Methods:
An interdisciplinary committee was developed including representatives from medical, surgical, nursing leadership and hospital quality/safety leadership. A novel mortality rating system was designed to characterize surgical mortalities by patient risk factors and surgical complexity utilizing the STS STAT system. Medical mortalities were characterized by the risk of mortality upon admission and the degree of predicted recoverability. These ratings were iteratively reviewed by all stakeholders and definitions agreed upon (Table 1). The objective of the process was to review every mortality events within 2 weeks of its occurrence. For each review, attendance of stakeholders, number of improvement opportunities identified, and the specific improvement areas were tracked. Over time, patterns in mortality events have been tracked to allow further insight into institutional trends.

Results:
Between December, 2021 and June, 2022, a total of 17 mortality events were reviewed. No mortality event went without evaluation. Average time from mortality occurrence to review was 9 days, including 1 event in which the review was delayed to accommodate the standard serious safety event review process of the institution. Among key stakeholders (n=21), attendance averaged 17 members. Of events reviewed, 100% identified at least one opportunity for systems improvement and on average 2 opportunities were identified per review. 10/17 events were retrospectively deemed to have a pre-operative / pre-admission risk of mortality greater than 40%.

Conclusions:
Rapid, systems-based review of mortality events has the potential to focus institutional improvement efforts in a timely fashion. We found that a rapid review process with interdisciplinary perspectives has identified systems improvement opportunities with every review and facilitated coordination of subsequent improvement efforts. This process is ongoing and its impact on center-specific mortality rates will be assessed.