Welcome to the APAC Global Trigger Tool Session Dr Carol Haraden IHI Gillian Robb CMDHB Carol Haraden Introductions Gillian Robb
Outline for this session Introduction to the Global Trigger Tool What is the Global Trigger Tool Using the Global Trigger Tool Examples / Case studies of improvement initiatives First Do No Harm
Patient Harm Common Median incidence of in hospital adverse events: 9.2% Median percentage of preventability: 43.5% Lethal: 7.4% (de Vries st al 2008) Costly In NZ: $10,000 per patient Cost of preventable adverse events was estimated at around $590 million 30% of public hospital expenditure goes toward treating preventable events (Brown et al 2002) Do we have the full picture about patient harm in our DHBs? How many harmed? What are the most common harms? What are the common issues? Where do they occur? Are we successfully improving patient safety?
Window on patient harm Voluntary Reporting Internal Incident reporting system Serious & Sentinel Event Morbidity & Mortality Meetings Metrics Routine data Surveillance systems Audits External ACC treatment injury claims Inquests HDC investigations Patient Administration System Coding data Patients Patient complaints Patient surveys Focus groups Qualitative Global Trigger Tool Harms per 1000 patient days Harms per 100 admissions % patients Quantitative harmed Increase the volume of data Broaden the perspective
What is the GTT 9 Background Computerized triggers for ADE identification and concurrent intervention David Classen (1990) ADE review identifying 14 triggers accounting for majority of ADE s David Classen (1994) Adverse drug event trigger tool developed for the IHI Idealized Design of the Medication System (1999) ICU Adverse event trigger tool, IHI Idealized Design ICU (2002) Global Trigger Tool testing and spread to US and international hospitals (2004)
Why Use Trigger Tools? Traditional reporting of errors, incidents, or events does not reliably occur in the best of cultures in healthcare Voluntary methods underestimate events and concentrate on what is interpreted as being preventable Easily identifies events without complex technology Can be integrated into a good sampling methodology Global Trigger Tool Modules Cares (General) Critical Care Medication Surgery L&D ED
C1 C2 C3 C4 C5 C6 C7 C8 C9 C10 C11 C12 C13 C14 C15 Cares Module Triggers Transfusion or use of blood products Any Code or arrest Dialysis Positive blood culture X-Ray or Doppler studies for emboli Abrupt drop of greater than 25% in Hg or Hemtocrit Patient fall Decubiti Readmission within 30 days Restraint use Infection of any kind In hospital Stroke Transfer to higher level of care Any procedure complication Other E Category of Harm NCCMERP Index Temporary harm, intervention required F Temporary harm, initial or prolonged hospitalization G Permanent patient harm H Life sustaining intervention required I Contributing to Death
Global Trigger Tool Examples Readmit within 30 days with recurrence of abscess right hip. Readmit next day w/ileus s/p exp lap for tumor. Stopped lasix-acute renal failure. Readmitted in 30 days for wound revision due to incisional seroma. Readmit related with wound infection. Volume Depletion with altered mental status caused by Lasix -resulted in hospital admission. ARF due to nephrotoxicity due to combination of ACE and NSAIDS taken at home. Ischemic colitis had rt hemicolectomy. New onset CP=MI. Unresponsive, coded. Decreased loc & sats on Morphine PCA. Rec'd Narcan. Global Trigger Tool Using the GTT
Outline Getting Started Chart review process Data entry & analysis Reporting Next steps GTT in NZ Getting Started: People Organisational commitment to patient safety Executive Sponsor Steering group to support the process Programme lead / Coordinator Reviewers
Roles & responsibilities Role Responsibility Time commitment Per month Executive Sponsor Steering Committee Championthe GTT; provide resources ; remove roadblocks Endorse & promote GTT; engage support and participation; supportprogramme lead. 1 hour per month 1 hour per month Programme Lead Coordination of programme & process, oversees data entry, data analysis & reporting 8-10 days per month (0.4 FTE) Review team Completes chart reviews within specified timeframes & meets with team doctor 12-15 hours month (includes meetings) Physicians Authenticates findings of the reviewers 3-4 hours per month Getting Started: Resources Dedicated space Secure Access to computers Process for managing charts Training & support for reviewers Initial Training Ongoing training and refreshers Data collection tool Database Excel spreadsheet Dedicated database
Chart Review Process
Chart review process 20 minute limit Discharge summary Laboratory results Medication chart & administration record Operative record Nursing notes Physician progress notes If time permits, any other areas of the record (such as History & Physical, Consult notes, or Emergency Department notes). The GTT is not designed to identify all harms, but by using the recommended IHI systematic process, sufficient harms are identified to provide useful information for the organisation Flags for harm Filtering process Modules in GTT Cares Medication Laboratory Surgery Intensive Care Emergency Care Triggers
Harm Categories Harm Category E F G H I Description Temporary harm to the patient and required intervention Temporary harm to the patient and required initial or prolonged hospitalisation Permanent patient harm Intervention required to sustain life. Patient death National Coordinating Council for Medication Error Reporting and Prevention Index Managing the data: Data collection tool
Florida Hospital AE sub-categories Events related to: Medication Laboratory Patient Care Hospital Acquired infection Surgery & Other procedures Intensive Care When harm occurred Code In Pt Definition AE occurred during this hospital admission Adm 1 Adm 2 AE present on admission, occurred within 30 days of this admission. AE present on admission, occurred between 30 days and 12 months of this admission. Adm 3 AE present on admission, occurred greater than 1 year of this admission. Re- Admit AE present on admission, related to prior discharge, occurred within 30 days of admission.
Where harm occurred Code In Pt Definition EC, ICU, Theatre, Ward X, AT&R etc (during this admission) Adm 1 Adm 2 Adm 3 Re- Admit Ward X (prior admission at CMDHB), Another DHB, Private Hospital, Aged Care Facility, Primary Care Provider, At Home etc Ward X (prior admission at CMDHB), Another DHB, Private Hospital, Aged Care Facility, Primary Care Provider, At Home etc Ward X (prior admission at CMDHB), Another DHB, Private Hospital, Aged Care Facility, Primary Care Provider, At Home etc Ward X (prior admission at CMDHB), Another DHB, Private Hospital, Aged Care Facility, Primary Care Provider, At Home Managing the data: Database
Reporting: Metrics Adverse events per 1000 patient days Adverse events per 100 patient admissions Percent admissions with an adverse event. Events by Categories of harm
Results 2011-2012 Records Reviewed 339 Total events: 152 Events/1,000 bed days: 64.34 Events/100 admissions: 44.84 Percent Patients harmed: 34.22 Event categories: E: 81 (53.29 %) F: 65 (42.76 %) G: 2 (1.32 %) H: 3 (1.32 %) I: 1 (0.66 %)
Harm Category E F G H I Description Temporary harm to the patient and required intervention Temporary harm to the patient and required initial or prolonged hospitalisation Permanent patient harm Intervention required to sustain life. Patient death
Frontline clinicians Reporting: Who Executive Team Board Purpose of GTT Reporting: What Key results (Metrics + Context) Examples of harms in each category What you are doing about it
Next Steps: Drilling down Focus on harms not triggers Start simply Inpatient / non-inpatient Events by sub-categories Common medications Drill deeper Events related to sub-classifications Further record reviews enriched sample Next Steps: Drilling Down Sub-Category Adverse Events Severity N=152 E F G H J Medication/IV Fluids 104 55 46 2 1 Hospital Acquired Infection 17 7 10 Surgery or Other Procedure 6 4 1 1 Patient Care 7 4 3 Other 18 11 5 2
Medication Related Events Total Harms 152 % Medication Related (n = 104) 68% Inpatient Events (n=67) 64% Events present on admission occurring within 30 days: (n= 22) Events associated with a re-admission (n=15) 21% 15% Percent 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Frequency of Medication Related Events 100.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Events
Medications Implicated Event No Events (%) Primary Drug Involved Secondary Drug involved Constipatio n 24 (23%) Morphine (37.5%) Oxycodone (21% ) Bleeding 20 (19%) Nausea & Vomiting 12 (11.5% ) Aspirin (45%) Enoxaparin (20%) Warfarin (20%) Morphine (58%) Oxycodone (8%) Improvement Plan: Focus on prescribing of opiates Establish a team Do a more in depth analysis Demographics (age, gender, ethnicity) Case weights Length of stay Service area Process / system issues Variation in prescribing
GTT in NZ Brief History Current DHBs doing GTT HQSC Support Future Harm and Error 46
Adverse Events Harm and Error HARM Harm is the focus of discussion Looks at all unintended results Measurement is clear and direct Nothing is theoretically unpreventable ERROR Errors and humans are the focus of discussion Tends to focus on those outcomes felt to be related to error Measurement relies on self-reporting Many AEs seen as unpreventable Accepting the Harm Burden Adverse Event and Errors Error definition bears upon concept of preventability and human mistake Adverse event describes harm to the patient regardless of error and is often system-based Relationship between errors and adverse events: Adverse Events Errors Mortality
Finding the triggers exercise Example of a trigger: Transfer to higher level of care Endoscopy Post procedure somnolent and hypotensive (BP 80) transferred to ICU Placed on Bi-Pap Received standard Demerol and Versed for procedure Given Romazicon; stayed in unit 12 hours.
Exercise 51 Question #1 A patient on chronic anticoagulation has a INR of 8.2. Does that represent an adverse event? 1 - Yes 2 - No
Analysis of a Trigger (INR 8.2) In itself, the abnormal INR is not an adverse event The appropriate portion of the chart must be reviewed to determine if an adverse event has occurred Large retroperitoneal bleed has been diagnosed The event has caused a prolongation of the hospitalization and has been classified as a category? Question #2 Given the previous description of an event and the categories, how would you categorize the event? 1 - E 2 - F 3 - G 4 - H 5 - I
Question #3 Given the previous description of an event and the categories, how would you categorize the event? 1 - E 2 - F 3 - G 4 - H 5 - I Question #4 Given your understanding of the hospital you work in, guess as to your adverse event rate? 1 - Significantly less than 100 events/1000 patient days 2 - Slightly less than 100 events/1000 patient days 3 - About the average, 100 events/1000 patient days 4 - More than 100 events/1000 patient days
Experience with the GTT 57 Exemplar Hospital Validation Review Hospital A Hospital B Hospital C Events/1000 patient days Events/100 admissions % of admissions with an event 79 90 85 83 49 37 48 45 35% 28% 32% 32%
Additional GTT Reviews Plus Exemplar Hospitals Events/1000 Days 3 Exemplar Hospitals (900Charts) 40 Bed rural Hospital (300 Charts 10 Hospital Research Project (240 charts) 7 Hospital System (3000 Charts) 83 90 NA 119 86 Multi-state Tertiary System (2000 charts) Events/100 admissions 45 40 37 41 38 Admissions with adverse events 32% 30% 30% 29% 30%