545 - Implementation of structured mortality reviews in the Neonatal Intensive Care Unit

Publication Number: 545.5221

Lindsay Ellsworth, University of Michigan Medical School, Chelsea, MI, United States; Meera Meerkov, Trinity Health, Ann Arbor, MI, United States; Katherine E. Bates, University of Michigan Medical School, Ann Arbor, MI, United States; Rebecca Vartanian, University of Michigan Medical School, Ann Arbor, MI, United States

Background: Our children’s hospital convened a work group to develop a standardized mortality review and notification system to ensure that all pediatric inpatient deaths were reviewed. Prior to this effort, there was no formal mortality review process established in the Neonatal Intensive Care Unit (NICU).

Objective: To develop a reliable process for mortality review in the NICU that 1) ensures every mortality is reviewed by a multidisciplinary committee, 2) identifies opportunities for system and process improvement, and 3) leads the implementation of change.

Design/Methods: Through iterative process improvement, a multidisciplinary mortality review committee (MMS) consisting of physicians, trainees, advanced practice providers, nurses, clinical nurse specialist, nurse supervisors, risk management, and social work was developed. The MMS members are notified of mortalities via a hospital-based notification system. Each mortality undergoes a structured comprehensive case review based on the Ottawa M&M Model. Feedback from providers and bedside staff is elicited and incorporated into reviews. The monthly MMS meetings then review each case, identify areas for improvement, and determine next steps for further reviews and action items (Figure 1).

Results: 158 mortalities occurred in the NICU between February 2021 and September 2024 with 100% of cases reviewed by the MMS, averaging 3.6 (±2.2) cases per month (range 0-9 cases). Predominant etiologies of mortalities included neonatal loss after a trial of therapy or planned palliative care, complications related to congenital anomalies or prematurity, and sepsis (Figure 2). After MMS review, cases were routed to: NICU patient safety conference (22, 13.9%), unit-based educational conferences (19, 12.0%), infection prevention team (12, 7.5%), multi-disciplinary team debriefings (9, 5.7%), and hospital-level patient safety review (6, 3.8%). A total of 36 unique action plans were developed including new clinical practice guidelines on the use of 2.0-mm endotracheal tubes and early high frequency jet ventilation, revision of small baby positioning and skin care practices, purchasing of new airway equipment, new subspecialty communication workflows, and the creation of a NICU specific sepsis team.

Conclusion(s): A structured mortality review model in the NICU with multidisciplinary input on 100% of mortalities led to actionable change with policy improvements on a local level. This process has shown applicability as a model for our hospital-wide system to ensure that practice-based learning and change implementation occurs following each mortality.

Figure 1. NICU Mortality Committee Workflow and Notification Process


Figure 2. Breakdown of NICU Mortality Review Cases
Abbreviations: Neonatal Intensive Care Unit (NICU), Intrauterine Growth Restriction (IUGR), Persistent Pulmonary Hypertension of the Newborn (PPHN), Necrotizing Enterocolitis (NEC).