Nurse-led Morbidity and Mortality Case Conferences Enhance Early Detection of Deteriorating Patient

Abstract Description

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Authors (including presenting author) :

Leung MT(1), Lau WY(1), Lee SK(1), Lun PY(1), Ng YK(1), Cheung KY(1), Chan WC(1)

Affiliation :

(1) Department of Surgery, North District Hospital

Introduction :

Surgical Outcomes Monitoring and Improvement Program (SOMIP) in 2016/2017 showed the 30-day crude mortality rate of elective ultra-major and major surgical operations was 0.3% while the 30-day crude mortality rate of emergency surgical operations was 5.0%. North District Hospital was one of the outliers in the 30-day crude mortality rate of emergency surgery. Morbidity and Mortality Case Conferences is the practice of medicine to review the cases for further improvement. But it is not a usual practice in nursing. To tackle the problem, Nurse-led Morbidity and Mortality (M&M) Conferences was introduced to analyze the adverse outcomes in patient care and strive for improvement.

Objectives :

Nurse-led Morbidity and Mortality (M&M) Case Conferences aim to analyze cases with post-operative 30-day mortality on regular basis. Adverse outcomes associated with shortcomings are identified to prevent repetition.

Methodology :

Patient with post-operative 30-day mortality from July 2017 to June 2018 were identified by using Clinical Data Analysis and Reporting System (CDARS). The medical records of the captioned patients were retrieved and have a detailed analysis on the contributing factors. Case sharing sessions with alert of high risk area and recommendations are given to nursing staff.

Result & Outcome :

25 episodes of morbidity and mortality cases were recorded. 8 cases were identified with areas for improvement. 3 cases were recommended to have prompt escalation of call. It was noted that when patients’ condition did not improve after the houseman’s treatment order, only houseman was informed instead of medical officer. Another 4 cases were recommended to have a prompt assessment when patients’ conditions deteriorate. Case sharing sessions to the frontline colleagues that highlight the area for improvement in patient care were delivered. Evaluation of cases was done from July to October 2018. Only one case related to prompt escalation of call was identified and all the cases had prompt assessment when patient’s condition deteriorates. Nurse-led Morbidity and Mortality Case Conferences is a good opportunity for learning and reflection. It enables colleagues to revisit the errors and prevent repetition. The result shows it is effective in enhancing the quality of detection of deteriorating patient and the subsequent follow up actions.