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e-Autopsy: Kaiser Hospitals Dig In to Data to Assess Mortality

Cheryl Clark, for HealthLeaders Media, February 24, 2011

There's been work on preventing ventilator pneumonias and preventing pressure ulcers. But aspiration pneumonia is something that's fairly common in all hospitals, but there just hasn't been a good way to study it," Kanter  says.

So far, the teams are looking at three conditions that deceased patients had when they presented to the hospital before their deaths, even if that condition was not the direct cause of their death: ruptured aortic aneurysm, Clostridium difficile infections, and aspiration pneumonia, which is especially likely in patients with stroke.

Charts are sent to several sets of reviewers who are asked to independently evaluate the patient's care. Sometimes the reviewers agree about what might have influenced the patient's trajectory, and sometimes they don't.

Litman says the teams are looking at a number of possible safety improvements, "for example whether patients at risk for aspiration pneumonia can be identified before they aspirate by using a checklist for high risk problems, like stroke or swallow problems that can make aspiration more likely, whether getting a 'swallow evaluation' by a speech therapist for high risk patients may be helpful, (and) if changing the way they are fed can help, for example by one of several different methods to prevent aspiration in patients with tube feedings."

Now, after studying aspiration pneumonia, physicians might issue a nothing by mouth order or NPO until the patient's ability to swallow could be assessed.

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