Lessons learned by the Saskatoon Health Region about hospital deaths

Watch above: A study released at the end of 2014 reported the number of deaths at St. Paul’s Hospital is higher than the national average. Meaghan Craig has more from the Saskatoon Health Region on what changes have been made.

SASKATOON – It’s been more than seven months since the Canadian Institute for Health Information (CIHI) raised the alarm about the number of patient deaths occurring at St. Paul’s Hospital in Saskatoon. The 2013-2014 data released by CIHI showed that 57 per cent of hospitals had seen decreases in the number of patients dying in hospital over the course of five years.

Data complied represented 80 per cent of all deaths in a hospital setting excluded patients listed as palliative care patients.

Out of 83 Canadian hospitals monitored, St. Paul’s was the only one that was above the national average for hospital deaths.

READ MORE: Deaths at St. Paul’s Hospital higher than national average

“You really need to know that you can be safe in several places, one is your home and two is the hospital,” said Dr. George Pylypchuk, head of medicine for the Saskatoon Health Region.

In order to ensure this, that would mean both Pylypchuk and the chief of surgery needed to understand what was happening at St. Paul’s first and foremost then how to deal with it.

“The first part of the plan was basically was to look at our deaths and exactly what was happening in our whole region.”

The 108 consecutive deaths that occurred in region over a three month time period were analyzed, using three levels of investigation.

“When we did the review of 108 consecutive patients that died within our system we found that a lot of the individuals that required palliative care actually were admitted to acute care hospitals and they died within the acute care hospitals.” said Dr. Ivar Mendez, head of the department of surgery.

A large portion of the individuals were elderly with chronic diseases or complex health concerns like cancer.

Still, 45 charts out of the 108 would proceed to a second review flagged by the two department heads if there were concerns regarding the case.

Why these deaths occurred came down to three things: a failure to plan and communicate as well as a failure to rescue, in words could something have been done differently to prevent the patient’s death like a different medication or surgical procedure.

“We are looking at processes, we have plans on how we’re going to be continue looking at moralities and morbidities. We have this new 90-day ‘hoshin’ that’s being developed starting Sept. 1, this is a huge piece of work to ensure that people are kept safe,” said Pylypchuk.

Health officials also say in the future they will be reviewing deaths on a real-time basis as opposed to retrospectively and every death that occurs in the region will be reviewed.