Morbidity and mortality conferences are vital to promote systemwide improvement, said Professor Hans Flaatten, speaking at the European Society of Intensive Care Medicine (ESICM) congress in Barcelona this month. In France, the UK and the U.S. morbidity and mortality conferences are compulsory, but there are important reasons for all intensivists to hold them. ICU services can learn from serious adverse events, as many are unique and are better analysed by detailed workthrough of the case with the relevant stakeholders present.

When to Have Morbidity and Mortality Conferences

ICUs must be system ready to create the opportunity to learn from serious events in the unit. It is probably best to have fixed time points throughout the year rather than on demand, e.g. once every fortnight, or on the 3rd day of the month. There is no need to be afraid that you do not have anything to discuss, emphasised Flaatten. The meeting needs 30-60 minutes for one or more cases to discuss.

Who to Invite

Morbidity and Mortality conferences should be open to all relevant stakeholders. However, some stakeholders will need to be invited, e.g. surgeons, referring physicians. 1-2 participants need to know the case well, so that they can explain the event. The case should be presented by one of these people, but she/he does not have to chair the session or initiate the discussions.

How to Run it

Recently the approach has become more open. The key is to document discussions and implement recommendations.

Traditional approach
Recent approach
Focus on education and individual learningFocus on system performance and quality improvement
Closed room discussionsLess focus on the individuals
Little/ no documentationDocumented discussion, part of department procedures
Physicians onlyAll staff invited

Flaatten recommended a paper about how one hospital (Monroe Carell, Jr. Children’s Hospital at Vanderbilt) transformed its practice, turning its morbidity and mortality conference into an instrument for systemwide improvement.

SBAR (Situation - Background/ Assessment & Analysis - Recommendation & Review) is a framework for the conference. The situation requires the problem to be stated, e.g. the procedure of the operation or statement of the adverse outcome. The background includes clinical information, such as patient history, indications and interventions, lab reports and imaging studies, procedures details, hospital course, recognition and management of any complications. Assessment and analysis includes error and root cause analysis to evaluate what happened and why. Error analysis includes the description of the sequence of events that led to the adverse outcome. Root cause analysis is the description of the fundamental cause(s) of the adverse outcome in relation to human errors (e.g. error in diagnosis, technique, judgement, communication), systems errors (e.g. error(s)/ problems in care system/ organisation, such as poor supervision, low staffing, inadequate coordination of care etc.) or patient-related factors (e.g. patient disease or non-compliance). Review of the literature is important to see how ICUs can align with evidence-based practice. Recommendations are the proposed actions to prevent further similar problems.

Flaatten put it that morbidity and mortality conferences could be combined with quality assurance conferences. He cited a paper by Schwarz and colleagues in BMJ Quality & Safety which implemented a systems-oriented morbidity and mortality conference in remote rural Nepal for quality improvement.

Asked about selecting cases for discussion, Flaatten acknowledged that not all cases can be discussed. He suggested looking at the case profile to see if there were specific problems that needed highlighted. Prof. Julian Bion noted that at his institution everyone, including nurses and trainees, was able to nominate a case for discussion. However, arguments can be made for random review and complete review of cases, as there is a risk of bias if you do selected reviews.

Claire Pillar
Managing Editor, ICU Management

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ICU, ESICM 2014, Morbidity and mortality Morbidity and mortality conferences are vital to promote systemwide improvement, said Professor Hans Flaatten, speaking at the European Society of Intensiv...