How ICU Intubated Patient Deaths are Analyzed for the Root Cause

When it comes to analyzing ICU deaths, particularly those of intubated patients, the process is no different from the analysis of any other patient's death. Most of the time, it is quite straightforward. A ventilator is primarily a life-sustaining piece of equipment that provides temporary support while the underlying problem is addressed. It is rare for a death to occur where the ventilator is the unknown factor.

The relationship between sedation and ventilator settings is not as direct as one might think. Sedation levels are primarily determined by the patient's level of agitation rather than the specific settings of the ventilator. Wean trials are the only scenario where there might be a slight adjustment in sedation levels to assess the patient's readiness to come off the ventilator. However, sedation is not a factor in setting the ventilator's parameters. The ventilator is configured to meet the patient's oxygenation and ventilation needs, not the level of sedation.

Morbidity and Mortality Meetings in ICU

Each ICU has a specific process for reflecting on and learning from patient deaths. In our ICU, we conduct a monthly Morbidity and Mortality meeting where all deaths are analyzed, discussed, and reflected upon. If there are any common learning points, they are taken back to improve patient care and outcomes.

Root Cause Analysis in Hospital Deaths

Dr. Jay's answer is correct. Very few deaths in the hospital, whether in the ICU or otherwise, are thoroughly analyzed for the root cause. The number of autopsies conducted specifically for this purpose is extremely limited. Often, the exact root cause is of little importance, and both the medical professionals and the patient's families are not interested in subjecting the deceased to such an investigation.

The Mismatch Between Ventilator Settings and Sedation

The concept of a "mismatch" between ventilator settings and patient sedation is somewhat vague, and its relationship to the cause of death is uncertain. The ventilator is set to meet the patient's oxygenation and ventilation needs, not based on the level of sedation. Conversely, the level of sedation is determined by the patient's agitation, not by the ventilator settings. This means there is rarely a direct mismatch between the two.

It is entirely possible for a patient on a ventilator to not be adequately sedated, but this situation is not related to a mismatch in ventilator settings. Instead, it is a mismatch between the medical team's care and the patient's needs for sedation. Such a scenario is the result of a lack of compassion or understanding between the medical staff and the patient's specific needs.

Based on my experience of thirty years in the ICU, I have never encountered a situation where a so-called mismatch between ventilator settings and patient sedation was a factor in the cause of death. Medical professionals aim to balance the needs of the patient, but the primary purpose of a ventilator is to maintain life until the underlying condition can be addressed.