a b s t r a c t

Background: Morbidity and Mortality (M&M) rounds are peer review conferences during which cases with adverse outcomes and difficult management decisions are presented. Their primary objective is to learn from complications and errors, modify behavior and judgment based on previous experiences, and prevent repetition of errors leading to complications. The objective of this study was to determine if M&M conferences can reduce repetitive error making demonstrated by a shift of the incidence of cases presented at M&M by chief complaint (CC) and experience of attendings.

Methods: All M&M cases from 1/1/2014-12/31/2017 derived from an urban, tertiary referral Emergency Department were reviewed and grouped into 12 different CC categories and by attending years of experience (1-4, 5-9 and 10+). Number and percent of M&M cases by CC and years of attending experience were calculated by year and a chi-squared analysis was performed.

Results: 350 M&M cases were presented over the four-year study period. There was a significant difference between CC categories from year-to-year (p b 0.001). Attendings with 1-4 years of experience had the majority of cases (46.3%), while those with 5-9 years had the fewest total cases (15.1%, p b 0.001).

Conclusions: There was a persistent significant difference across CC categories of M&M cases from year-to-year, with down-trending and up-trending of specific CCs suggesting that M&M presentation may prevent repetitive errors. Newer attendings show increased rates of M&M cases relative to more experienced attendings. There may be a distinctive educational benefit of participation at M&M for attendings with fewer than five years of clinical experience.

(C) 2019

Introduction

Morbidity and Mortality (M&M) rounds are traditional, recurring, peer review conferences during which cases with adverse outcomes and difficult management decisions are presented. These rounds are commonly held in large healthcare institutions by medical and surgical services. Their primary objective is to learn from complications and errors, to modify behavior and judgment based on previous experiences, and to prevent repetition of errors leading to complications. While M&Ms are ubiquitous throughout multiple departments and institutions, they can differ in their format and main focus [1-3]. While surgical M&Ms are typically held weekly and focus more on adverse events, internal medicine rounds may be held monthly

? Poster presented at Society for Academic Emergency Medicine New England Regional Meeting, March 27, 2019.

* Corresponding author.

E-mail address: [email protected] (J.J. Lewis).

and discuss system-based events or more medically interesting cases [4, 5].

Given the variety in structure, timing and overall discussion at various departmental M&Ms, it is not surprising that there is significant heterogeneity in the research of the educational effects of participation in M&M and there is limited data on educational effectiveness [1,2,6-8]. The majority of educational studies investigating the effectiveness of M&M presentations as a teaching tool are comprised of descriptive design studies with participant satisfaction outcomes rather than objective results [6,9]. Other studies have described self-reported knowledge after participation in M&M rounds rather than competence-based results [6]. The use of a standardized presentation format has shown enhanced knowledge acquisition as determined by pre- and post-implementation questionnaires [10]. However, this assessment is limited by its questionnaire format rather than true clinical practice and future clinical outcomes. Likewise, adoption of a standardized framework (CanMEDS) to fully emphasize and articulate specific educational competencies has shown improved identification of quality care issues and may assist learners to translate the educational

https://doi.org/10.1016/j.ajem.2019.09.015

0735-6757/(C) 2019

training objectives into clinical practice, but does not evaluate the impact on future M&M cases or error [11].

Thus, it is unclear if there is a difference year-to-year in the chief complaints (CC) of Emergency Medicine (EM) M&M cases or if cases vary by attending experience. The objective of this study was to determine if there is a difference among M&M chief complaints from year-to-year to see if M&Ms modify behavior and systems to prevent repetitive errors arising from specific types of complaints. Additionally, we sought to determine if there is an effect in the rate of attending physician M&M case presentations based on years of clinical experience and its educational effect.

Methods

Study design and setting

We reviewed all M&M cases from 1/1/2014-12/31/2017 at an academic tertiary care center which is home to a three-year academic EM residency program with N55,000 annual patient visits. M&M rounds are held weekly throughout the year and run as a one-hour conference led by the chief residents. Two to three cases are presented per M&M conference. Cases are typically referred from the Quality assurance Committee for presentation at M&M (with all cases with significant morbidity, unexplained mortality or with dramatic and Unusual presentations referred for presentation), although attendings and residents can voluntarily refer concerning individual cases for consideration of presentation. The QA Committee at our institution is comprised of attending physicians and meets monthly to review cases. The members of the committee rotate periodically so that ultimately each attending should rotate though the committee. All attendings in our department partake in the initial QA review of cases weekly. M&M case presentations consist of a sequential, time-stamped, clinical course presented by the resident who cared for the patient, while questions and subsequent discussion are prompted by audience members who are blinded to the patient’s outcome. The attending involved in the cases is present and contributes to the discussion. All Emergency Department staff who are not working clinically are expected to attend.

Outcome measures

As our primary outcome, we looked at differences among M&M CCs from year-to-year. Secondarily, we sought to determine if there was an effect on the rate of individual attending physician M&M case presentations secondary to the M&M’s educational benefits based on the number of years of attending clinical experience post residency.

M&M cases over this four-year period were reviewed by two of the study authors and were grouped into 12 different CC categories: Abdominal, Blunt Trauma, Cardiac, Central Nervous System, Urologic and Gynecologic, Hematologic (which included metabolic and infectious CCs), Hemorrhagic, Musculoskeletal, Penetrating Trauma, Psychiatric, Respiratory and Toxicology based on initial triage presentation, not final diagnosis. To assess the impact of attending level of experience, cases were also grouped by attending year of post- residency graduation: 1-4, 5-9 and 10+ years. New clinical fellows were included in the 1-4 years of experience group.

Primary data processing

Number and percent of M&M cases by CC and years of attending experience were calculated by year and a chi-squared analysis was performed. P b 0.05 was considered to indicate statistical significance.

Results

There were 350 M&M cases presented over the study period. There was a significant difference between CC categories from year-to-year

(p b 0.001), with cardiac (15.4%), neurologic (15.4%), hematologic

(14.0%), respiratory (12.3%) and blunt trauma (13.7%) representing the overall majority of cases. There was a downtrend in neurologic (18.1% to 12.2%) and toxicology cases (12.5% to 2.0%) and an uptrend

in cardiac (6.9% to 24.5%) and hematologic cases (13.9% to 21.4%) over the study period (Table 1). Attendings with 1-4 years of experience had the majority of cases (46.3%), while those with 5-9 years had the fewest total cases (15.1%, p b 0.001). There was an increase in proportion of cases cared for by attendings with 1-4 years of experience from 31.9% to 46.9%, while those with 5-9 years decreased from 20.8% to 12.2% (p b 0.001) (Table 2). The median number of cases per attending during the study period was 5 (IQR 2-8, range 1-19). The number of attendings per group was evenly distributed yearly and over the study period, with 1-4 years representing 29.4%, 5-9 years representing 32.4% and 10+ years representing 38.2%.

Discussion

To our knowledge, this is the first study attempting to look at year- to-year trends of EM M&M presentations. There was a persistent significant difference across CC categories of M&M cases from year-to- year. There were upward and downward trends in the number of M&M cases by specific CC by year. Newer attendings faced increased rates of M&M cases relative to more experienced attendings. We believe there is likely to be an educational and experience related effect to presenting at M&M.

M&Ms are assumed to be an essential part of all continuing medical education for faculty and important clinical teaching rounds for residents; however, demonstrating the educational effectiveness has proven difficult [6,12]. While previous studies have shown subjective improvement in satisfaction and self-reported participant knowledge [6], this is the first study investigating the year-to-year trends of M&M cases. There was a persistent significant difference in CC categories presented from year-to-year and a significant difference in attending presentations based on years of experience. While increased clinical experience is a likely contributing factor, having cases presented at M&M, we believe, is an unmatched vehicle providing valuable educational experience to help avoid future errors. Interestingly, there seems to be an increase in cases after 10+ years of experience. This may be related to a decrease in the number of M&M presentations by those attendings during their previous five years of clinical practice. Alternatively, it is possible that attendings with 10 or more years of experience are more comfortable referring their own cases for discussion at M&M. Since there was no ability to track which presented cases were self-referred versus those referred directly from QA, it was not possible to determine this impact.

While there was a persistent significant difference across CC categories from year-to-year, we did not see a significant change in number of cases per each specific CC from year-to-year. There were upward and downward trends, specifically cardiac and hematologic cases increasing and neurologic and toxicology cases decreasing over the study period and the percentage of total cases for each specific CC varied from year-to-year. However, on a year-to-year basis, the difference in number of cases for each specific CC was more difficult to ascertain. This may have been a result of a relatively low number of each specific CC per year, thus limiting the ability to detect a significant difference. Additionally, given that certain CC categories persistently represented the majority of cases, it is possible that higher risk presentations are related to those CC.

However, it is possible that there are other contributing factors to continued similar CC M&M presentations. There is a yearly transition of faculty, as well as new clinical fellows joining the group each year. This transition also likely contributes to the higher number of M&M cases presented by less experienced attendings as there are very few senior attendings who did not spend multiple years at our institution during the study period. Additionally, there is a yearly transition of

Table 1

Percent of Emergency Medicine M&M cases by chief complaint on a year-to-year basis. Overall p b 0.001.

		Year				Total
		2014	2015	2016	2017
Abdominal	Count	8	3	9	3	23
	% within year	11.1%	3.5%	9.5%	3.1%	6.6%
Blunt Trauma	Count	8	15	12	13	48
	% within year	11.1%	17.6%	12.6%	13.3%	13.7%
Cardiac	Count	5	16	9	24	54
	% within year	6.9%	18.8%	9.5%	24.5%	15.4%
Central Nervous System	Count	13	15	14	12	54
	% within year	18.1%	17.6%	14.7%	12.2%	15.4%
Urologic and Gynecologic	Count	6	1	0	4	11
	% within year	8.3%	1.2%	0.0%	4.1%	3.1%
Hematologic	Count	10	10	8	21	49
	% within year	13.9%	11.8%	8.4%	21.4%	14.0%
Hemorrhagic	Count	1	6	4	4	15
	% within year	1.4%	7.1%	4.2%	4.1%	4.3%
Musculoskeletal	Count	3	3	4	6	16
	% within year	4.2%	3.5%	4.2%	6.1%	4.6%
Penetrating Trauma	Count	1	3	6	2	12
	% within year	1.4%	3.5%	6.3%	2.0%	3.4%
Psychiatric	Count	1	1	4	0	6
	% within year	1.4%	1.2%	4.2%	0.0%	1.7%
Respiratory	Count	7	10	19	7	43
	% within year	9.7%	11.8%	20.0%	7.1%	12.3%
Toxicology	Count	9	2	6	2	19
	% within year	12.5%	2.4%	6.3%	2.0%	5.4%
Total	Count	72	85	95	98	350

Table 2

Percent of Emergency Medicine M&M cases by attending level of experience on a year-to-year basis. Overall p b 0.001.

			Year				Total
			2014	2015	2016	2017
Experience in years	1-4	Count	23	51	42	46	162
		% within year	31.9%	60.0%	44.2%	46.9%	46.3%
	10+	Count	34	26	35	40	135
		% within year	47.2%	30.6%	36.8%	40.8%	38.6%
	5-9	Count	15	8	18	12	53
		% within year	20.8%	9.4%	18.9%	12.2%	15.1%
Total		Count	72	85	95	98	350
		% within year	100.0%	100.0%	100.0%	100.0%	100.0%

new residents in our academic program and inexperience of the trainees may contribute to more errors despite attending supervision. Prior studies have suggested there is a trend in under-reporting of errors by residents to their attendings [13]. This may bar early intervention even in cases of minor error leading to further complications with adverse outcomes, ultimately resulting in case presentation at M&M. Hutter et al also showed that there is under- reporting of both in-hospital and post-discharge complications and deaths at traditional M&M conferences when compared to data from a Quality Improvement program, which may impact M&M participants’ understanding of the error component [14]. Alternatively, there is typically a focus on major complications rather than minor complications at M&M [15]. Inclusion of minor complications, in that study, improved faculty and residents‘ perceptions on M&M as a means to improve clinical care [15]. Perhaps our department’s focus on more egregious errors for the majority of cases may diminish the overall understanding and goal for the M&M discussion.

The question remains as to the optimal method of improving the

educational outcomes of participation in the M&M conference. Our department’s approach to M&M is somewhat unique in that the team who cared for the case being presented is identified and discusses their decision-making. This approach is rarely used in EM M&M conferences, yet one of the most important features of M&M conference is the admission of error as a way to develop intellectual honesty, accept that all physicians err, and learn to improve rather than have loss of

confidence following a bad outcome. A consistent structure to M&M rounds is essential [9,11,16-20]. Our M&Ms follow a standardized and consistent structure in presentation; however, there is likely room for improvement. Audience interruption during patient history or clinical course can detract from the overall presentation [20]. While this can lead to interesting discussion, perhaps the ideal format would have the history and clinical course presented in full, prior to audience questions. The counter argument to this approach, however, is that is that this would preclude a granular analysis of the decision making and quality of the data collection based on checking if the appropriate actions were taken in a timely manner. Kwok et al notes a need for summarizing and disseminating key points after the conference as participants may not accurately recall the salient points of discussion [17]. This would be a simple intervention for which the presenting chief resident could circulate a summarizing document of the presented cases, including a succinct description of the adverse event, suggestions for improvement and links to pertinent articles. At our institution, we have recently implemented a monthly “overtime” discussion during which the chief resident and attendings are able to further discuss cases with the residents with a more education driven focus. Further studies on the impact of this more informal educational guided discussion post M&M may prove beneficial.

Additionally, our M&M conference is not recorded or available via teleconference. This limits the overall attendance and may impact the overall educational mission and future errors. At our institution, at

least three academic faculty members work clinically during M&M. Tele-video-conferencing (TVC) may provide a solution [21]. TVC for M&M rounds has been found to have no significant difference in learning and was preferable to commuting to the academic center solely for participation at M&M [21]. While it is expected that all faculty and residents attend M&M if they are not on vacation or working clinically, the reality is that attendance is impacted by travel time and the availability of TVC would likely increase attendance and learning. There are obvious concerns with patient privacy; however, if this was offered only on a closed-circuit system with no ability to record, these concerns may be allayed.

This is the first study which we know of to look at a more objective outcome measure of educational effectiveness of EM M&M rounds. Further studies are needed to fully determine the educational effect of presentation at M&M rounds. Future investigation into specific educational interventions like the monthly “overtime”, effect on year- to-year error rates per CC as determined by the QA Committee or even resource utilization by attendings after M&M presentation may be beneficial in fully determining the educational effect of M&M presentations.

Limitations

As a single-center study the generalizability of our data is limited. While there were 350 M&M cases in total presented over study period, the highest total number of cases for any CC over the four years was 54. Likewise, within each CC there was a relatively lower number of cases per year, which may further limit the ability to determine a statistically significant difference on a year-to-year basis. With regards to attending trends, given that there are over 40 faculty in our department, there is a relatively low number of cases reviewed per each individual attending, which limits the ability to detect a difference between CC by attending presentation. Moreover, there is yearly turnover of approximately 10% of the faculty due to clinical fellow transitions and therefore new attendings were included in the 1-4 year experience group on a yearly basis. There is also selection bias in the cases by the QA Committee. Though the criteria for M&M referral are uniform, with all cases with significant morbidity, unexplained mortality or with dramatic and unusual presentation deemed appropriate for M&M, it is possible some cases were not presented because the presenting chief resident felt that the outcome was expected. Additionally, while cases are typically referred by the QA Committee, the ability for cases to be voluntarily flagged for presentation may skew the results. There is no tracking of M&M case referrals to determine how many cases were self-referred versus those referred directly from the QA Committee. Additionally, we did not track individual attendees at each M&M round to determine future impact. Lastly, while the cases were grouped into CC categories by two of the study authors, who reviewed all cases and agreed on classification, there may be bias in the grouping of specific cases into each specific CC category.

Conclusions

There was a persistent significant difference across CC categories from year-to-year, with downward and upward trends in the number of cases per each specific CC. Newer attendings show increased rates

of M&M cases relative to more experienced attendings, though this effect begins to wane after more than 10 years. There is likely a genuine educational benefit in presenting cases at M&M for attendings with less clinical experience.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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