February spotlight: Patient Safety — Significant reduction in mortality ratios across MLH

By Denise M. Murphy, RN, MPH, CIC, FAAN, Vice President, Quality and Patient Safety


Over the last year, MLH has seen a 53% reduction in mortality ratios.  It is our desire to share the achievement with the medical staff with an explanation of how improvements were made and what has to be done to sustain top decile performance in mortality.



In Fall, 2012, we realized that MLH had a higher than average mortality ratio (observed/expected) as compared to our peer group in the Council of Teaching Hospitals database . Our 2012 performance (0.91 ratio) compared to the COTH median performance (0.85) was not acceptable.   We engaged with Premier, Inc., our measurement partners, to identify best practices in mortality reduction, and drilled down into data that helped explain the causes for our higher than expected ratios.



Three areas were identified for improvement efforts:

1)    Early identification, resuscitation and maintenance of patients with severe sepsis, the #1 clinical reason for what we deemed to be “preventable” deaths.

2)    Evaluation and consultation for patients who met criteria for appropriate use of palliative care and hospice services (which, if criteria met, would remove patients receiving end of live support care from our pool of “unexpected” deaths)

3)    Improvement in clinical documentation to more accurately reflect severity of illness and risk of mortality (which results in coding that determines whether patients are categorized as an expected or unexpected death)



Open this link to see graphics demonstrating the decrease in mortality ratios at each campus.


A “Surviving Sepsis” campaign was launched with early focus on patients presenting to the Emergency Dept needing rapid testing, fluid resuscitation, antibiotics and stabilization for handoff to the HMS/ICU teams for maintenance. Raising awareness through education and creating standardized clinical protocols, alerts and communication was the standard approach at every campus.


Appropriate and timely use of palliative care and hospice has increased at every campus through widespread education about services and criteria necessary for hospice designation.  Dedicated palliative care RNs collaborating with certified palliative care physicians has led to a more appropriate level of care for patients and their families.


The clinical documentation improvement (CDI) initiative began in July with physician education and addition of CDI Specialists who communicate closely with physicians about use of CMS-accepted language that accurately documents severity of illness and risk of mortality.



–          Keep Sepsis high on the radar so that timely identification and intervention can continue for this high risk population.

–          Watch for the “surviving sepsis” campaign to move beyond ED patients to hospitalized inpatients demonstrating early signs of sepsis.  Rapid response teams will be expanding their role – more to come about this work in early February.

–          Advanced life planning discussions and crucial conversations about goals for end of life care is the best thing we can do for patients and families under our care…the earlier the better.  Palliative care physicians and nurses have experience and tools that can assist you in your approach to these tough but crucial discussions.

–          Please get to know CDI Specialists at your hospital.  These are experienced nurses with coding skills that are trained to review medical records and send “queries” to physicians when they see opportunities to refine documentation according to CMS guidelines.  Please answer these queries and work together to better reflect the severity of a patient’s condition or risk of mortality.

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