Aim: Measure the number of deaths not related to expected end of life and not related to pre-hospital care.

Cases: Total of patients discharges dead (variable “discharge decision” = 5), among eligible population.

Eligible population: All stays in acute somatic care units excepted from:

  • Stays assigned to Swiss statistics codes M500, M900, M950, M990, if the average length of stay exceed 10 days;
  • Stays with a zero length of stay (only among stays aggregated according to SwissDRGs rules);
  • Newborn deaths on first day (even if no diagnostic is coded).

Patients receiving preventive or curative major procedures or a planned chemotherapy (Z-mC) are included in the eligible population.

All other stays are included, except if they correspond to patients that are probably living their last months of life (i.e. expected end of life) or to patients requiring resuscitation at admission (i.e. related to pre-hospital care). These two last exclusion criteria are detailed below.

Expected end of life exclusion criteria: Patients are excluded if they have at least three metastatic neoplasms (C78*, C790-C798) or they have a total score of at least three points, depending on severe and evolutive chronic conditions (metastasis, malignant neoplasms, malnutrition, immunodeficiency, dependence, extremely low birth weight, dementia, chronic kidney disease-stage 5, hepatorenal syndrome, more than 80 years old). Patients receiving palliative care are also excluded (ICD-10 Z515, CHOP 938A and 938B).

Resuscitation at admission criteria: Patients are excluded if they died less than 5 days after their admission and suffer from one of the following conditions: cerebral and head trauma, effect of electric current, cardiac arrest, ventricular fibrillation and flutter, respiratory arrest, anencephaly, stroke, ruptured aneurysm, myocardial infarct. If they survived at least 5 days, they are however eligible.

Finally, the eligible population is subdivided into three subpopulations:
– potential therapeutic relentlessness if stays correspond to end of life and to a therapy with curative aim
– resuscitation : if the patient has survived more than 4 days
– security : all other patients

Click here for more details: eligible population.

Output files: Results are given by hospital and site in Death.xlsx file. There are detailed by hospital stay in Eligible_death.txt. Stays excluded from eligible population are provided in the Exclusions_Deaths.txt file.

Interpretation: Premature deaths correspond to deaths, which might be prevented with best quality of care in an ideal world. We can thus analyze mortality by distinguishing what relates to the safety of care, attemps to save difficult situations (resuscitation) and what relates to possible therapeutic relentlessness. In the latter case (relentlessness), if the mortality rate is lower than expected for similar situations, intervening was correct. Patients requiring potentially resuscitation cases are often specific to university hospitals; here too, if the observed rate < expected one, it means that the hospital is efficient. The question of safety is interpreted in the same way. The risk adjustment model is specific for each subpopulation.

Strength of the indicator: The review of premature deaths often shows a dramatic sequence of complication and treatment attempts failing to save the lives. A certain non-compressible threshold of such adverse events is difficult to avoid (the expected rate expresses this inescapable risk of medicine). If the observed rate is lower than expected, the hospital is probably secure. On the contrary, if it the latter is higher than the former, SQLape indicator has more chance to detect avoidable issue than usual measures of death rates, which might be impacted by end of life or palliative care.

Limitations: Experience has shown that high rates of premature deaths might be correlated with aggressive surgery among patients ending their lives, thus prolonging the life of these patients beyond the exclusion threshold. Therefore, a high premature death rate might indicate a propensity of the hospital to conduct such life-prolonging therapy, and not only an issue of hospital security. Such aggressive procedures are sometimes justified by the fact that the patient will have some good days ahead.  In such cases, it would thus be interesting to consider the quality of life after the operations to assess the appropriateness of such interventions.