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

You've heard the macabre joke that hospitals and doctors "bury their mistakes." Well, here's an interesting twist: At Kaiser Permanente hospitals in Southern California, doctors are doing precisely the opposite. They're rolling back time in the death process – exhuming their unknown mistakes so to speak – to see what, if anything, they can learn in order to save similar patients the next time around.

But they're not doing it the old way through invasive autopsies. Those are expensive, increasingly unpopular with families, forbidden by some religions, and often don't reveal that much about errors in the process of hospital care.

Kaiser's hybrid manual and electronic mortality review uses storytelling and specialists' scrutiny to study medical charts of patients who died in the hospital. The process builds a precise timeline of what happened. The goal is to prevent death and/or improve end-of-life care by looking for places to improve—from ambulatory settings prior to admission to the inpatient bedside.

"Mistakes happen in every hospital. But in the past, there hasn't been a good way to look at trends for people who are dying, trends for people who are (experiencing) harm," says Kerry Litman, MD, Kaiser's director of physician quality and a leader in this effort. Kaiser, with a large sample of deaths among their 3.2 million Southern California enrollees, presents a unique opportunity to aggregate trends, he says.

During a session, "Saving More Lives by Studying Death," at a December Institute for Healthcare Improvement forum in Orlando, Litman joined Helen Lau, RN regional director of hospital performance quality and risk management, and Michael Kanter, MD, medical director of quality and clinical analysis to tell their story.

They began by showing a slide illustrating the course of one sample patient:  

80+ patient with dizziness was found to have severe carotid stenosis on Doppler. The results were not reported to the physician, who ‘found’ it during a health maintenance visit eight months later and ordered a vascular surgery consult.

Two weeks later, while being evaluated for a carotid endarterectomy, the patient suffered a major stroke with dysphagia (difficulty swallowing) and was admitted to the hospital. A swallow evaluation was ordered, but oral feeding also started. Swallow evaluation was completed two days later and found high risk for aspiration. However during this time, patient had already developed aspiration pneumonia, from which they [sic] died.

Traditional quality programs might not have identified these problems to allow improvements. Would yours?

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.

Lau adds that Kaiser brings in non-physician and non-nurse providers for a more disciplinary approach to inform the process. Speech therapists, nutritionists are part of the mix.

The hospital system also is experimenting with elevating the head of the bed in patients who are identified as high risk of aspiration pneumonia. This strategy is now used with ventilator-associated pneumonia patients, but is not well known for patients with aspiration pneumonia, Litman says.

So far, they've done a "deep dive" with e-Autopsy strategies on 150 deceased patients who met the criteria since 2009 in 12 Kaiser hospitals, Kanter says.

Litman, Lau, and Kanter, however, still aren't ready to talk in detail about any solutions they may have found, because they're not yet sure what they know.

"We're sort of in a learning cycle of trying different interventions and then measuring, to see whether that actually helps the patients in any way, and if it does we would continue that and expand it throughout our system," Kanter said. "And if it doesn't we'd try something else. We're in the middle of doing what we call rapid improvement of planning an intervention, and implementing it on a small scale."

And they emphasize that Kaiser already has a death rate that is far below the national average. In fact, in recent years they have reduced that rate from 80% to 60%, based on the Hospital Standardized Mortality Ratio index.

But this is about being the best they can be, and helping others find tools to improve care, they say.

Diane Jacobsen, who directs the Institute for Healthcare Improvement's Improving Flow Through Acute Care Settings and Reducing Mortality Rates (HSMR) project, says hospitals have long performed mortality reviews. But what's exciting about projects like Kaiser's e-Autopsy is "what we can learn from the death record. Rather than 'did someone do something wrong, or make a bad judgment,' it's a broader and more open discussion – what are the opportunities for learning?

"Perhaps we find out things that would not have resulted in a different outcome, but they might identify areas where we can improve," Jacobsen said. "Was the patient deteriorating earlier in the case? Could we have responded earlier? Hindsight is always 20-20, but in the midst of the patient coming in, sometimes there are subtle signs and symptoms...that in retrospect, could have been acted on a little earlier."

In the Clostridium difficile project, Litman, Lau, and Kanter are looking at colitis diarrhea, and whether inappropriate antibiotics might have been used. "Although the study did not find a problem with this, it shows e-Autopsy is a new way to look for ways to improve and serve as a 'double check' that good care is being given," Litman said.

So far, there's been so many potential hints of how to improve care, the team plans to expand to other conditions such as gastrointestinal bleeds in patients taking anticoagulant medication, patients with sepsis who recently had an outpatient visit and patients who undergo code blues, including those patients who survive.

I asked Litman if, when he explains e-autopsy to other health providers, does he often hear the joke about hospitals and doctors burying their mistakes?