1685: Implementation of a Multimodal Standardized Mortality Review Process in a High-Acuity Medical Icu

Introduction: Mortality reviews are essential for identifying opportunities for improvement (OFI) in the care of critically ill patients. Current models include universal case review, automated provider notification, and committee discussion. Each has limitations: high effort with variable yield, inconsistent provider response, or insufficient case capture, respectively. We developed and implemented a structured, multimodal process aimed at effective and efficient review of a high volume of mortalities to identify OFI. Methods: Our standardized Mortality Committee review process, implemented in 2024, identified cases for review through mechanisms: 1) Real-time (within 24 hours) case review via daily interdisciplinary ICU huddle, 2) Standardized email follow-up to discharging provider, 3) Select “red flag” review triggers. Results: In 2024, 145 out of 491 (29.5%) mortalities were reviewed by our interdisciplinary mortality review committee. 55 cases (11.2%) were selected by being labelled as an unexpected mortality or as having potential opportunities for improvement (OFI) though the daily ICU huddle review. 90 cases (18.3%) were selected based on “red-flag” triggers. Standardized committee review identified OFIs in 81 cases (55.9%). The phases of care where OFIs occurred were ICU (35.2%, 51/145), Medical-Surgical unit (15.2%, 22/145), Emergency room (4.1%, 6/145), Hospital-to-Hospital transfers (11%, 16/145), and “other” (2.8%, 4/145). OFIs were categorized as assessment/diagnosis (21.4%, 31/145), communication (15.2%, 22/145), documentation (22.8%, 33/145), medication administration (4.8%, 7/145), end of life care (23.5%, 34/145), and “other” (12.4%, 18/145). 67 cases (46.2%) had more than one phase of care or OFI noted. Conclusions: Our multimodal review process combines several previously described approaches to mortality review with a novel, daily case review that enabled efficient, high-yield case screening and review in a high-volume, high-acuity ICU setting. Integration into daily workflows, use of standardized follow-up mechanisms, and structured interdisciplinary review allowed for timely identification of OFIs, supporting both system-level change, interdisciplinary engagement, and shared accountability.