Cape Breton doctors, province search for cause of high hospital death rate

Nova Scotia's health authority and a group of local doctors are both doing separate reviews to figure out why so many people are dying unexpectedly in Cape Breton Regional Municipality hospitals.

The death rate in CBRM hospitals has been the highest in the country three years in a row and was well above the national average for two years before that.

Dr. Ward Patrick, senior director of critical care with the health authority, said officials have tried to standardize improvements across the province on the assumption that numbers would get better everywhere.

As a result, the provincial hospital standardized mortality ratio (HSMR) has steadily come down over the last few years.

The Cape Breton rate dipped briefly two years ago, but shot back up in new numbers released last month by the Canadian Institute for Health Information (CIHI).

"We had assumed that we had finally hit the tipping point for Cape Breton and that they were starting to show the same improvement as the rest of the province was seeing and that changed in December," Patrick said. "We said we can't assume that anymore. We now need to have a look and see if there's something different."

The health authority says most unexpected hospital deaths are from chronic obstructive pulmonary disease (COPD), heart failure and sepsis.

It says one of the reasons for the high numbers in CBRM hospitals is that numbers from four hospitals are being combined and reported as one, which skews the data.

Officials also say there are errors in the data they send to CIHI.

They say administrative staff sometimes improperly code charts by including palliative cases with data about expected deaths, and doctors sometimes fail to write a discharge summary, which makes it harder for staff to code properly.

Patrick said officials have started meeting with a medical advisory committee to identify solutions to some of the data problems.

A review two years ago found about two per cent of charts were improperly coded, and Patrick said seven per cent of charts last year did not have a discharge summary.

'A very difficult nut to crack,' says health official

Even though palliative cases have previously been identified as skewing the data, the errors have continued, he said.

"It's been a very difficult nut to crack for us, because up to now, when we go back and look at it, there are a lot of charts that would be excluded, or should be excluded, based on the palliative care status of the patient.

"We know that we have to look at this and try and make improvements. The frustrating part for us has been the things that we've been doing up to now have been working throughout the province as a whole. The one piece that's been more resistant has been Cape Breton health-care complex."

Patrick said the health authority has formed several teams to look specifically at the three main causes of unexpected death in Cape Breton.

What the health authority is doing

The province has also:

• Recommended improvements that were delayed by COVID-19.
• Implemented an antimicrobial stewardship program for common infections.
• Updated standard orders for sepsis and COPD.
• Begun a review on sepsis identification in wards outside the emergency department.
• Provided refresher training for coding staff.
• Started investigating the effect of transfers from one hospital to another within CBRM.

Dr. Margaret Fraser, a family physician who works out of the Cape Breton Regional Hospital in Sydney, said a group of local doctors is starting an independent review of the numbers.

She said medical staff are concerned because reporting on the hospital deaths is frightening people and keeping them from getting care.

Fraser said people need to know the hospitals have good quality staff who care and are looking for ways to improve.

"Is there an issue in the Cape Breton Regional Hospital?" she said. "Probably, but we need to look at that closer and find out where the quality improvement needs to be done.

"Although the health authority has done quality reviews in the past, I don't think there has been sufficient attention given to this specific group of hospitals."

Fraser said local doctors want to look at issues beyond the data CIHI uses.

She said factors like poverty and obesity can affect whether patients seek health care in a timely manner.

"We really are very early on in what we're doing," she said.

According to CIHI, an HSMR of 100 roughly represents the average expected number of deaths at any given hospital.

'This is a real improvement,' says Patrick

Five years ago, the provincial number was 115. It rose two years later to 129, but the last annual report shows it is back down to 107.

Patrick said new six-month data since then show the provincial mortality ratio has come down to match the national average and the numbers in Cape Breton have significantly improved.

He said the partial numbers place the provincial and national averages at 101, while the mortality ratio in CBRM hospitals is down from 143 to 119.

Even though there may be fewer people in hospital because of the COVID-19 pandemic, any effect on the data in Cape Breton has an equal effect on the data provincially and nationally, said Patrick.

"I actually believe in spite of COVID, this is a real improvement," he said.

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