- Email: [email protected]
Surgical Quality Assessment
OCTOBER 199I , VOL 54, NO 4
AORN JOURNAL
Surgica1 Quality Assessment A SIMPLIFIED ~PROACH Deanna L. DeLong, RN
W
hen I became the surgical department’s quality assessment (QA) committee chairperson at St Luke’s Hospital, Kansas City, Mo, the coordinator of surgical services gave me an assortment of papers and unfinished projects and a quick reminder to attend the monthly interdepartmental committee meetings. In an attempt to organize the committee, I read everything available on QA. I found little information, and most of it was vague, poorly organized, and not applicable to the OR. I then found the Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) 1991 Accreditation Manual for Hospitals, which provided the information I needed to create a department QA plan.’ A QA plan states the department’s structure, responsibilities, and scope of care, and defines QA terms. It also specifies the QA committee members’ responsibilities. The department’s “Philosophy” and “Objectives” statements were other good information sources. This information was helpful in writing the “Scope of Care” as well as the QA plan. An example of a “Scope of Care” statement, which is based on the statement used at St Luke’s, follows: Surgical services stafl members provide perioperative care to all surgical patients except those undergoing cardiac surgery. We provide preoperative care including admitting outpatients, intraoperative care, and postoperative care including transferring patients to the postanesthesia care unit. A n optimal O R staff
includes 90 full-time employees comprised of registered nurses, technicians, secretaries, orderlies, and aides. Surgical services provides emergency services 24 hours p e r day, seven days p e r week. Scheduled cases are accepted Monday through Friday, f r o m 8 AM to 5 PM. There is a surgical team on duty at all times, and there is a backup team on call. After formalizing the “Scope of Care,” I made a list of the department’s responsibilities, including clinical activities involving high patient volume, high patient risk, and problem areas for the staff. I put this information in a
Deanna L. DeLong, R N , B S , is the sta,ffing/scheduling coordinator and the quality assurance chairperson in surgical services at St Luke’s Hospital, Kansas City, M o . She earned her nursing diploma from St Luke’s Hospital School of Nursing, Kansas City, Mo, and her bachelor of science degree in health arts from the College of St Francis, Joliet, 111. 831
OCTOBER 199I , VOL 54, NO 4
AORN JOURNAL
St. Lukc's Hospital o f Kansas City QUALITY ASSURANCE REPORT
Dcpartmcnt:
Scctlon:
IMPORTANT ASPECT OF CARE:
Clinical Indicator: T.F.E.
Why is this Indicator clinically significant?
Indicator Source: Data Source: Frequency data is collected:
4onitor Duration (dares): )aka collected by: Frequency compared to T.F.E.: Frequencydata is tabulated:
Individual responsible for data comparison: Sample definition & size (ie., mndonz, sequenrid, dni&,100%, erc.) explain:
INITIALEVALUATION (dare)
Total auditcd:
70Compliance:
Results &Findings:
Needs Evaluation? (YcslNo)
Ifyes. identify action plan:
Follow-up Datc:
Aclion plan discusscd and/or rcvicwcd by t h e dcparrmeni hcad Person responsible to implcmcnt action: na m
Date action to bc takcn:
(dnie): title QA-46 (11/89)
Fig 1. Single-page reporting form (fronr, buck on opposite page) used at St Luke's Hospital, Kansas 832
OCTOBER I99 I, VOL 54, NO 4
AORN JOURNAL
Rcsulis Sc Findings:
Problcm rcsolved
or
0 Nccds coniinucd cvaluaiion
IdentiCy action plan:(Only ifcontinued evnktinrion ir indicnred)
Follow-up Date: Action plan discussed and/or reviewed by the department head Person responsible to implement action:
(dnre):
nume
title
Date action to be taken:
*
PdFOLLOW-UP(dnre) Results & Findings:
0 Problem resolved
Total audited
or
% Compliancc:
0 Needs continued evaluaiion
Identify action plan and send to IQAC Steering:(Only ifconrimed evnlunrion is indicnred)
Follow-up Datc: Action plan discussed and/or revicwed by the depariment h a d Person responsible to implement action:
(dnre): title
name
Date action to be taken:
IQAC Representative
Dcpartmcni Coordinator name
date
name
date
Administration
name
date
name
date
Physician Dirccior
City, Mo. (Reprinted with permission from St Luke's Hospital, Kansas City, Mo) 833
OCTOBER 1991, VOL 54, NO 4
AORN JOURNAL
Quality assessment problems can arise from miscommunication, insufficient orientation, or simple carelessness. chart under the heading “Aspects of Care.’‘ These departmental functions, or aspects of care, are further delineated by statements called “indicators” that describe measurable care processes. structures, clinical events, complications, or outcomes. These are areas considered most important for monitoring and evaluation. They denote specific criteria that need to be studied, thus defining problem areas within the department and providing the focus for data collection. I cross-referenced the J C A H O “Standards for Surgical and Anesthesia Services” ( S A ) a n d AORN “Standards of Administrative Nursing Practice: OR” on the “Aspects of Care” chart as a quick reference to applicable standards and guidelines. This crossreference also provides valuable support during JCAHO visits. Examples of indicators, along with the cross-referencing, for the aspect of care entitled “Employee Licensure and Clinical Competence” follow. There are mechanisms to ensure that each practitioner provides only those services for which he or she has been determined competent (SA 1.2.1. AORN Standard 111). There are mechanisms to ensure that a plan of continuing education is available for all individuals who provide surgical services (SA 1.3.3.4,AORN Standard IX). The staffing for the provision of surgical and anesthesia services is related to the scope and complexity of the services offered (SA I .8, AORN Standard VIII). 1 also developed a timeline for accomplishing data collection, data interpretation, evaluation. and follow-up implementation. The timeline chart is a quick, easy way to follow the progress of various studies. After selecting the indicator for study, which may be an existing problem area. the committee members review the department’s current
‘
834
standards and develop a questionnaire to accurately determine whether the behavior under study complies with the set standards. The questionnaire requires “yeslno” answers to all questions. Some sample statements for a traffic control study include: “doors to O R remain closed except during movement of personnel or equipment.” or “appropriate signs indicate traffic and dress control.” The committee members select a time frame, a sample size and the method of data collection for the study and decide who will collect, tabulate, and compare the data to the threshold for evaluation (TFE). The TFE is the pre-established cutoff point which, if met or exceeded, signals a problem. Most sources agree that 85% is the minimum acceptable threshold, meaning that 85% of ongoing practices must comply with department standards. In other words, if 15% of studied practices do not comply with set standards, a problem exists, and an investigation is necessary. Problems can arise from miscommunication, insufficient orientation, or simple carelessness. Once the problem source is identified, the committee members decide on corrective action and assign responsibility for implementation. After corrective action has taken place, the committee members repeat the study to check for improvement. If resolution does not occur after the corrective action, the committee refers the problem to the interdepartmental QA committee (IQAC). The IQAC decides whether evaluation criteria are realistic, whether the TFE is too high, or whether departmental policy needs to be redesigned.
Reporting System
I
prefer a reporting system that requires only one form (Fig 1). Having a single sheet per study eliminates confusion and helps pre-
AORN JOURNAL
OCTOBER 1991,VOL54, N O 4
vent lost or misplaced information when several studies occur simultaneously. All data are in one place and are easy to reference. I organize the entire system in one notebook, with supplemental projects and cooperative studies included. I often include graphs and charts for increased understanding.
Staff Communication
0
ne of the best ways to enhance communication is a QA bulletin board. I use the bulletin board to communicate compliance, teach new concepts, make improvements, and point out potential problems. To illustrate ideas and make the boards more interesting, I sometimes use computer generated charts and graphs, or pictures clipped from journals, catalogs, and newspapers. Theme ideas come from current studies, reported problems, and journal articles. I change the board frequently to keep it fresh, concise, and current, and I frequently use snaphots to illustrate points. For one series, we photographed staged breaks in technique and posted them with the heading, “What’s wrong with this picture?” The response was amazing. Everyone participated and was very interested. The QA bulletin board is a big success.
Recommendations
T
he department QA plan should be revised yearly to reflect policy updates and changes. Quality assessment results and activities should be posted on the bulletin board and printed in hospital publications. People retain more information for longer periods of time if they both see and hear it. For a successful QA program, the entire staff must cooperate fully and understand all aspects of QA, including its purposes, goals, and terminology. I developed a referral form specifically to get staff members involved. The referral form serves as a “suggestion” sheet for the staff members and gives the members space to describe the problem, its location, the suspected cause, and suggested actions. With the referral
form available, if a staff member notices a problem, he or she can report it and can remain anonymous if he or she so desires. The committee chairperson researches each reported problem and presents it at the QA committee meeting. The committee members discuss each report and decide what action will be taken. The committee sends the person who reported the problem a written memo denoting actions taken, progress achieved, or resolution. The minutes, which include copies of all communication, are sent to management for review. To keep the staff members informed, the committee members report QA activities and results at all staff meetings.
Summary
T
he current approach to QA primarily involves taking action when problems are discovered and designing a documentation system that records the deliverance of quality care. Involving the entire staff helps eliminate problems before they occur. By keeping abreast of current problems and soliciting input from staff members, the QA at our hospital has improved dramatically. The cross-referencing of JCAHO and AORN standards on the assessment form and the single-sheet reporting form expedite the evaluation process and simplify record keeping. The bulletin board increases staff members’ understanding of QA and boosts morale and participation. A sound and effective QA program does not require reorganizing an entire department, nor should it invoke negative connotations. Developing an effective QA program merely requires rethinking current processes, The program must meet the department’s specific needs, and although many departments concentrate on documentation, auditing charts does not give a complete picture of the quality of care delivered. The QA committee must employ a variety of data collection methods on multiple indicators to ensure an accurate representation of the care delivered, and they must not overlook any issues that directly affect patient outcomes. 835
AORN JOURNAL
Notes 1. Joint Commission on Accreditation of Healthcare Organizations, I Y Y I Accreditcition Manuc// , f o r Hospitrz/s (Oakbrook Terrace. Ill: Joint Commission
on Accreditation of Healthcare Organizations. 1990) 11.5-111. 2. Joint Commission on Accreditation of Healthcare Organizations, lY91 Acc,reditatiori Manual f . r Hospitals, SA 1.1.1. 770: “Standards of administrative nursing practice: OR“ in AORN Staridards mid Recoinniended Prac~ticc~~ fiir Periopercitiixr Nitrsirzg, Standard 111 (Denver: Association of Operating Room Nurw\. Inc. 1091) II:4-2. 3. Joint Commission on Accreditation of Health-
OCTOBER 1991, VOL 54, NO 4
care Organizations, 1991 Accreditation Manual f o r Hospirals, SA 1.3.3.4, 270; “Standards of administrative nursing practice: OR,” Standard IX, II:4-4. 3. Joint Commission on Accreditation of Healthcare Organizations, 1991 Accreditation Manual f o r Hospitals, SA I .8, 27.5; “Standards of administrative nurcing practice: OR,“ Standard VIII, II:4-2. Suggested reading Joint Commission on Accreditation of Healthcare Organizations, Guide to Q u a l i t y Assurance (Chicago: Joint Commission on Accreditation of Healthcare Organizations, 1988).
Measles Virus Under Investigation Recent outbreaks of measles among collegeage people and some infants have prompted studies to determine if the measles virus has changed. The measles vaccine was first licensed in 1963, and experts are questioning if it is less effective against a possibly stronger virus. Cases in infants led to questions about whether the vaccine’s effectiveness varies among different races or ethnic groups, according to an article in the April 22/29. 1991, issue of Americmw Medicvil Neii..v. The Centers for Disease Control, Atlanta, is conducting a project to determine whether the measles virus has become more virulent, requiring a new vaccine. The investigators are looking at measles outbreaks in college students who should have been vaccinated as children. Hints to a more virulent virus include a higher death rate, more complications such as encephalitis. and a higher vaccine failure rate in children. The vaccine‘s usual failure rate is 5% to IOc/r. but in some areas. one third of the measles cases are children. suggesting a stronger virus. Measles outbreaks among Native American infants in Arizona have led experts to question whether the effectiveness of the vaccine varies i n different racial or ethnic groups. Forty percent of tho\e cases were in infants less than one year old. when maternal immunity was 836
thought to protect them. All mothers had been vaccinated. Before the vaccine became available, the annual number of measles cases in the United States approached 500,000. Experts estimate that the vaccine has prevented 74.5 million cases. Only 1,500 cases of measles were reported in 1983, and the disease was thought to be nearly eradicated. By 1990, the number of reported cases had increased to 26,526 with 97 deaths, according to the article.
AORN JOURNAL
Surgica1 Quality Assessment A SIMPLIFIED ~PROACH Deanna L. DeLong, RN
W
hen I became the surgical department’s quality assessment (QA) committee chairperson at St Luke’s Hospital, Kansas City, Mo, the coordinator of surgical services gave me an assortment of papers and unfinished projects and a quick reminder to attend the monthly interdepartmental committee meetings. In an attempt to organize the committee, I read everything available on QA. I found little information, and most of it was vague, poorly organized, and not applicable to the OR. I then found the Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) 1991 Accreditation Manual for Hospitals, which provided the information I needed to create a department QA plan.’ A QA plan states the department’s structure, responsibilities, and scope of care, and defines QA terms. It also specifies the QA committee members’ responsibilities. The department’s “Philosophy” and “Objectives” statements were other good information sources. This information was helpful in writing the “Scope of Care” as well as the QA plan. An example of a “Scope of Care” statement, which is based on the statement used at St Luke’s, follows: Surgical services stafl members provide perioperative care to all surgical patients except those undergoing cardiac surgery. We provide preoperative care including admitting outpatients, intraoperative care, and postoperative care including transferring patients to the postanesthesia care unit. A n optimal O R staff
includes 90 full-time employees comprised of registered nurses, technicians, secretaries, orderlies, and aides. Surgical services provides emergency services 24 hours p e r day, seven days p e r week. Scheduled cases are accepted Monday through Friday, f r o m 8 AM to 5 PM. There is a surgical team on duty at all times, and there is a backup team on call. After formalizing the “Scope of Care,” I made a list of the department’s responsibilities, including clinical activities involving high patient volume, high patient risk, and problem areas for the staff. I put this information in a
Deanna L. DeLong, R N , B S , is the sta,ffing/scheduling coordinator and the quality assurance chairperson in surgical services at St Luke’s Hospital, Kansas City, M o . She earned her nursing diploma from St Luke’s Hospital School of Nursing, Kansas City, Mo, and her bachelor of science degree in health arts from the College of St Francis, Joliet, 111. 831
OCTOBER 199I , VOL 54, NO 4
AORN JOURNAL
St. Lukc's Hospital o f Kansas City QUALITY ASSURANCE REPORT
Dcpartmcnt:
Scctlon:
IMPORTANT ASPECT OF CARE:
Clinical Indicator: T.F.E.
Why is this Indicator clinically significant?
Indicator Source: Data Source: Frequency data is collected:
4onitor Duration (dares): )aka collected by: Frequency compared to T.F.E.: Frequencydata is tabulated:
Individual responsible for data comparison: Sample definition & size (ie., mndonz, sequenrid, dni&,100%, erc.) explain:
INITIALEVALUATION (dare)
Total auditcd:
70Compliance:
Results &Findings:
Needs Evaluation? (YcslNo)
Ifyes. identify action plan:
Follow-up Datc:
Aclion plan discusscd and/or rcvicwcd by t h e dcparrmeni hcad Person responsible to implcmcnt action: na m
Date action to bc takcn:
(dnie): title QA-46 (11/89)
Fig 1. Single-page reporting form (fronr, buck on opposite page) used at St Luke's Hospital, Kansas 832
OCTOBER I99 I, VOL 54, NO 4
AORN JOURNAL
Rcsulis Sc Findings:
Problcm rcsolved
or
0 Nccds coniinucd cvaluaiion
IdentiCy action plan:(Only ifcontinued evnktinrion ir indicnred)
Follow-up Date: Action plan discussed and/or reviewed by the department head Person responsible to implement action:
(dnre):
nume
title
Date action to be taken:
*
PdFOLLOW-UP(dnre) Results & Findings:
0 Problem resolved
Total audited
or
% Compliancc:
0 Needs continued evaluaiion
Identify action plan and send to IQAC Steering:(Only ifconrimed evnlunrion is indicnred)
Follow-up Datc: Action plan discussed and/or revicwed by the depariment h a d Person responsible to implement action:
(dnre): title
name
Date action to be taken:
IQAC Representative
Dcpartmcni Coordinator name
date
name
date
Administration
name
date
name
date
Physician Dirccior
City, Mo. (Reprinted with permission from St Luke's Hospital, Kansas City, Mo) 833
OCTOBER 1991, VOL 54, NO 4
AORN JOURNAL
Quality assessment problems can arise from miscommunication, insufficient orientation, or simple carelessness. chart under the heading “Aspects of Care.’‘ These departmental functions, or aspects of care, are further delineated by statements called “indicators” that describe measurable care processes. structures, clinical events, complications, or outcomes. These are areas considered most important for monitoring and evaluation. They denote specific criteria that need to be studied, thus defining problem areas within the department and providing the focus for data collection. I cross-referenced the J C A H O “Standards for Surgical and Anesthesia Services” ( S A ) a n d AORN “Standards of Administrative Nursing Practice: OR” on the “Aspects of Care” chart as a quick reference to applicable standards and guidelines. This crossreference also provides valuable support during JCAHO visits. Examples of indicators, along with the cross-referencing, for the aspect of care entitled “Employee Licensure and Clinical Competence” follow. There are mechanisms to ensure that each practitioner provides only those services for which he or she has been determined competent (SA 1.2.1. AORN Standard 111). There are mechanisms to ensure that a plan of continuing education is available for all individuals who provide surgical services (SA 1.3.3.4,AORN Standard IX). The staffing for the provision of surgical and anesthesia services is related to the scope and complexity of the services offered (SA I .8, AORN Standard VIII). 1 also developed a timeline for accomplishing data collection, data interpretation, evaluation. and follow-up implementation. The timeline chart is a quick, easy way to follow the progress of various studies. After selecting the indicator for study, which may be an existing problem area. the committee members review the department’s current
‘
834
standards and develop a questionnaire to accurately determine whether the behavior under study complies with the set standards. The questionnaire requires “yeslno” answers to all questions. Some sample statements for a traffic control study include: “doors to O R remain closed except during movement of personnel or equipment.” or “appropriate signs indicate traffic and dress control.” The committee members select a time frame, a sample size and the method of data collection for the study and decide who will collect, tabulate, and compare the data to the threshold for evaluation (TFE). The TFE is the pre-established cutoff point which, if met or exceeded, signals a problem. Most sources agree that 85% is the minimum acceptable threshold, meaning that 85% of ongoing practices must comply with department standards. In other words, if 15% of studied practices do not comply with set standards, a problem exists, and an investigation is necessary. Problems can arise from miscommunication, insufficient orientation, or simple carelessness. Once the problem source is identified, the committee members decide on corrective action and assign responsibility for implementation. After corrective action has taken place, the committee members repeat the study to check for improvement. If resolution does not occur after the corrective action, the committee refers the problem to the interdepartmental QA committee (IQAC). The IQAC decides whether evaluation criteria are realistic, whether the TFE is too high, or whether departmental policy needs to be redesigned.
Reporting System
I
prefer a reporting system that requires only one form (Fig 1). Having a single sheet per study eliminates confusion and helps pre-
AORN JOURNAL
OCTOBER 1991,VOL54, N O 4
vent lost or misplaced information when several studies occur simultaneously. All data are in one place and are easy to reference. I organize the entire system in one notebook, with supplemental projects and cooperative studies included. I often include graphs and charts for increased understanding.
Staff Communication
0
ne of the best ways to enhance communication is a QA bulletin board. I use the bulletin board to communicate compliance, teach new concepts, make improvements, and point out potential problems. To illustrate ideas and make the boards more interesting, I sometimes use computer generated charts and graphs, or pictures clipped from journals, catalogs, and newspapers. Theme ideas come from current studies, reported problems, and journal articles. I change the board frequently to keep it fresh, concise, and current, and I frequently use snaphots to illustrate points. For one series, we photographed staged breaks in technique and posted them with the heading, “What’s wrong with this picture?” The response was amazing. Everyone participated and was very interested. The QA bulletin board is a big success.
Recommendations
T
he department QA plan should be revised yearly to reflect policy updates and changes. Quality assessment results and activities should be posted on the bulletin board and printed in hospital publications. People retain more information for longer periods of time if they both see and hear it. For a successful QA program, the entire staff must cooperate fully and understand all aspects of QA, including its purposes, goals, and terminology. I developed a referral form specifically to get staff members involved. The referral form serves as a “suggestion” sheet for the staff members and gives the members space to describe the problem, its location, the suspected cause, and suggested actions. With the referral
form available, if a staff member notices a problem, he or she can report it and can remain anonymous if he or she so desires. The committee chairperson researches each reported problem and presents it at the QA committee meeting. The committee members discuss each report and decide what action will be taken. The committee sends the person who reported the problem a written memo denoting actions taken, progress achieved, or resolution. The minutes, which include copies of all communication, are sent to management for review. To keep the staff members informed, the committee members report QA activities and results at all staff meetings.
Summary
T
he current approach to QA primarily involves taking action when problems are discovered and designing a documentation system that records the deliverance of quality care. Involving the entire staff helps eliminate problems before they occur. By keeping abreast of current problems and soliciting input from staff members, the QA at our hospital has improved dramatically. The cross-referencing of JCAHO and AORN standards on the assessment form and the single-sheet reporting form expedite the evaluation process and simplify record keeping. The bulletin board increases staff members’ understanding of QA and boosts morale and participation. A sound and effective QA program does not require reorganizing an entire department, nor should it invoke negative connotations. Developing an effective QA program merely requires rethinking current processes, The program must meet the department’s specific needs, and although many departments concentrate on documentation, auditing charts does not give a complete picture of the quality of care delivered. The QA committee must employ a variety of data collection methods on multiple indicators to ensure an accurate representation of the care delivered, and they must not overlook any issues that directly affect patient outcomes. 835
AORN JOURNAL
Notes 1. Joint Commission on Accreditation of Healthcare Organizations, I Y Y I Accreditcition Manuc// , f o r Hospitrz/s (Oakbrook Terrace. Ill: Joint Commission
on Accreditation of Healthcare Organizations. 1990) 11.5-111. 2. Joint Commission on Accreditation of Healthcare Organizations, lY91 Acc,reditatiori Manual f . r Hospitals, SA 1.1.1. 770: “Standards of administrative nursing practice: OR“ in AORN Staridards mid Recoinniended Prac~ticc~~ fiir Periopercitiixr Nitrsirzg, Standard 111 (Denver: Association of Operating Room Nurw\. Inc. 1091) II:4-2. 3. Joint Commission on Accreditation of Health-
OCTOBER 1991, VOL 54, NO 4
care Organizations, 1991 Accreditation Manual f o r Hospirals, SA 1.3.3.4, 270; “Standards of administrative nursing practice: OR,” Standard IX, II:4-4. 3. Joint Commission on Accreditation of Healthcare Organizations, 1991 Accreditation Manual f o r Hospitals, SA I .8, 27.5; “Standards of administrative nurcing practice: OR,“ Standard VIII, II:4-2. Suggested reading Joint Commission on Accreditation of Healthcare Organizations, Guide to Q u a l i t y Assurance (Chicago: Joint Commission on Accreditation of Healthcare Organizations, 1988).
Measles Virus Under Investigation Recent outbreaks of measles among collegeage people and some infants have prompted studies to determine if the measles virus has changed. The measles vaccine was first licensed in 1963, and experts are questioning if it is less effective against a possibly stronger virus. Cases in infants led to questions about whether the vaccine’s effectiveness varies among different races or ethnic groups, according to an article in the April 22/29. 1991, issue of Americmw Medicvil Neii..v. The Centers for Disease Control, Atlanta, is conducting a project to determine whether the measles virus has become more virulent, requiring a new vaccine. The investigators are looking at measles outbreaks in college students who should have been vaccinated as children. Hints to a more virulent virus include a higher death rate, more complications such as encephalitis. and a higher vaccine failure rate in children. The vaccine‘s usual failure rate is 5% to IOc/r. but in some areas. one third of the measles cases are children. suggesting a stronger virus. Measles outbreaks among Native American infants in Arizona have led experts to question whether the effectiveness of the vaccine varies i n different racial or ethnic groups. Forty percent of tho\e cases were in infants less than one year old. when maternal immunity was 836
thought to protect them. All mothers had been vaccinated. Before the vaccine became available, the annual number of measles cases in the United States approached 500,000. Experts estimate that the vaccine has prevented 74.5 million cases. Only 1,500 cases of measles were reported in 1983, and the disease was thought to be nearly eradicated. By 1990, the number of reported cases had increased to 26,526 with 97 deaths, according to the article.