GTT from manual to automated processes & - From patient injuries as a management tool to a clinical relevant tool Jan Terje Henriksen Nordland Hospital Trust
Agenda Why ASJ/GTT What is GTT & ASJ/NCAF? How does NCAF work? Organization at Nordland Hospital Trust in relation to GTTASJ/NCAF development ASJ/NCAF & improvement work Challeges and opportunities
Why spend time on developing ASJ/NCAF? Documenting patient injuries systematically Time saving from searching to verifying/falsifying Electronic documentation from paper to systematic archive Quality assurance of communication similar over time and between teams Unified method in journal searches although not unified verifying/falsifying Great point of departure for further development in relation to improvement work
Why GTT? Only 5 to 20% of patient injuries that is documented in journals is discovered by health personal's voluntary reporting in incident reporting systems (Classen et al, 2011). Up to 94 % of patient harm that can be documented in a random selection of journals is discovered using GTT (Sharek et al, 2011) Journal searches with GTT is not precise enough to compare results between hospitals/health trusts, but consistent enough to measure results for specific units over GTT is a measure of results, and says nothing about cause-effect, yet..!
Definition used by the Norwegian patient safety programme Patient safety Protection against unnecessary harm as a consequence of health care services or lack of health care services
Definition of harm in the Global trigger tool method "Accidental physical injury which has occurred as a result of medical treatment or which the treatment has contributed to, which requires further monitoring, treatment or hospitalization or which has a fatal outcome."». Regardless if injury was preventable or not! -Seen from a patient perspective
Use of GTT Injuries to the GTT is what the clinical environment often perceive as expected complications and it happens". See the event from the patient's point of view: Would you be satisfied if this happened to you? If the answer is NO, it is an injury.
Global Trigger Tool (GTT) facts Tool for retrospective survey of patient injury, developed in the US by IHI (Griffin and Resare 2009) Method searching for 44 (NLSH)/57 predefined triggers in randomly selected patient journals Some of the triggers are the starting point for patient injuries In the event of a finding of patient injuries, these are classified by type and severity GTT was introduced as a method in the national patient safety campaign of 2011 - all health trusts in Norway must analyze minimum 240 admissions/journals per year At Nordland Hospital Trust we analyze 1,680 admissions / year, spread over to 7 teams, from 2014 1920 admissions / year spread over to 8 teams (including Pediatrick GTT).
Skadetyper 1. Allergic 2. Bleeding 3. Fall injury 4. Fracture 5. Urinary tract infection 6. CVK infection 7. Lower respiratory tract infection 8. Postoperative wound infection 9. Respiratory associated pneumonia 10. Other infection 11. Reoperation 12. Postoperative bleeding/hematoma 13. Postoperative respiratory complication 14. Organ injury 15. Confused at operation 16. Other surgical complication 17. Drug injury 18. Medical technical damage 19. Postpartum/obstetrics damage 20. Thrombosis/embolism 21. Pressure ulcer 22. Exacerbation of Chronic Illness 23. Other injuries
Structure of GTT- analysis Findings of harm Findings of triggers Structured journal analysis 1. Analysis of randomly selected journals 2. In some you find predefined triggers 3. Some triggers are followed by patient injuries 4. Mapping and classification of severity and type
Classification Category A: Condition or even that could cause error Category B: A Fault was discovered before patient was harmed Category C: Patient exposed to fault with no harm Category D: Patient exposed to fault and required observation or action to confirm that patient was not harmed Harm does not reach patient Category E: No permanent harm that required treatment Category F: Category G: No permanent harm that lead to prolonged hospitalization Prolonged harm permanent consequence Category H: Life saving treatment initiated Category I: Patient dies Harm reaches patient NCC MERP (The national coordinating Council for Medication Errors Reporting and Prevention) Index for Catergoizing Errors
Results for Nordland Hospital Trust Share of patient injuries per 1000 bed days Share of patient injuries per 100 stays Share of stays with minimum one injury
Results for Nordland Hospital Trust General categories without possibility of drilling Further development of ASJ/NCAF can provide the opportunity of drilling
Results for Nordland Hospital Trust Prevalence measurement are more in-depth - Few measures with low significance level - Permanent change or random variation
FIRST PAGE FOR NCAF NCAF
NCAF VALIDATING INJURIES
NCAF STRUCTURED TRIGGERS
NCAF UNSTRUCTURED TRIGGER
TRIGGERS & «HIT-PROBABILITY» NCAF VS ASJ/ATA FP means false positive NCAF hit, but not ASJ FN means false negative NCAF no hit, but ASJ hit U unstructured S structured
GTT ORGANIZATION IN NORDLAND HOSPITAL TRUST 8 GTT team (2 nurses og 1 doctor) Lofoten, Vesterålen and Bodø (kir, ort, med, kk, hbev, ped-klinikkene have team members) 1920 stays is analyzed per year = approx. 7% of all bed-days in 2012 Time consumption: 1 day/month per nurse, 2 hrs/month per doctor Section for patient safety : Internal training of new examiners Produce and review procedures for the trust Two reglar GTT seminars (spring & fall) for the GTT teams Quality assurance of deviating trends Yearly comprehensive report with results for the trust and the various locations and clinics/departments Results and analysis are presented to board and trust management twice a year
In the beginning there was... Board report 42/2010
ASJ/NCAF cooperation accross structure Nordland Hospital Trust overall structure ASJ/ NCAF + HN RHF HN IKT SAS Institute
ASJ/NCAF development requires effort from a lot of persons Patient Coordination/training & analysis & presentation Regional Competence- Serv. Pat.safety Practical use& feedback GTT team GTT team Development/ testing Doctors Developers Prosject management/ Regional coordination
GTT team: 2 specialist nurses 1 doctor possibly 1 administrative support person (from quality unit) Administrative support person Upload results in Extranet Produces graphs and presents results twice a year plus yearly report Nurses Examines journals (10 journals every 14 days, 240 per year per team) Maximum 20 minutts per stay Independently Compares Sends results to doctor Doctor Meet nurses once a month and examines joint results and findings of patient injuries
Knowledgebased development 1 PhD on GTT method and selection 1 PhD on oncology and unwanted events and on knowledge on further development of the GTT method more possibilities of drilling within categories More interest by clinicians? More dependent on an automated solution?
ASJ/NCAF is a tool for continuous improvement GTT ASJ/NCAF Analysis/results Fewer patient injuries
Communication - how is results shared? Reports to board and management group Newsletters Electronic boards Intranet Internet Media Social media
Challenges & opportunities Stable GTT teams Into work schedule Stable solution Dashboard and results as temperature measurement? Use of results in improvement work (UVI) Stronger connection between results and improvement method/pdsa circle will require more frequent data Further development of NCAF and archetype based journal in DIPS journal will improve hit rate on triggers and hence more frequent data Make results widely accessible use electronic web portal Registration of results in extranet new and more automated solution? Algorithm with pattern recognition for unstructured and structured data will increase hit rate possible to scan all journals continuously for injuries/unwanted events hopefully not an unrealistic dream Started to compare the most severe injuries (G, H, I) towards our incident reporting system
Reaching the top requires commitment, patience & staying power! - NCAF Spreading solution to other trusts in the North, but far from complete!