“Warming” to the use of the Global Trigger Tool

Session G5

March 9, 2012

Objectives

• Gain basic understanding of Trigger Tool methodology

• Learn how Trigger Tool data is used to support Patient Safety

• Gain knowledge of the capability of the VCH/PHC electronic database

Trigger Tool Methodology

Global Trigger Tool

• Developed by the IHI

• Reliable and valid tool that measures harm related to or from the delivery of care

• Takes focus off of what is considered to be preventable

“Triggers are defined as occurrences, prompts, signals, or flags found on review of the medical record that “trigger” further investigation to determine the presence or absence of a adverse drug event.”

Rozich JD, Haraden CR, Resar RK. Adverse drug event trigger tool: a practical methodology for measuring medication related harm. Qual Saf Health Care. 2003;12 (3):194 –200

Harm Defined

IHI Global Trigger Tool:unintended physical injury resulting from or

contributed to by medical care that requires additional monitoring, treatment or hospitalization, or that results in death.

Griffin FA, Resar RK. IHI Global Trigger Tool for Measuring Adverse Events, 2nd edition, IHI Innovation Series white paper.

Cambridge, Massachusetts: Institute for Healthcare Improvement; 2009. (Available on www.IHI.org)

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 frequently concentrate on what is interpreted as being preventable

• Easily identifies events without requiring complex technology

Event detection in validation site

n %

Confirmed events detected 171 100

IHI Global Trigger Tool 160 93.6

Utah-Missouri abstract code tool 72 42.1

AHRQ PSI tool 10 5.8

Voluntary incident reporting 0 0

2008 IHI National Forum on Quality Improvement in Health Care,

Fran Griffin, Dr. David Classen, Lee Adler, Jamie Campbell, Margie McKeever

How do you decide who to marry?

No person really decides before they grow up who they're going to marry. God decides it all way before, and you get to find out later who you're stuck with. - Kristen, age 10

Methodology

Step 1: Random selection of records.

Step 2: Chart review using a list of “triggers” that have been tested over time

Step 3: Determine if the positive trigger is an indicator of an adverse event.

Step 4: Categorize the adverse events into categories of harm

Considerations

• 75% of all events will be picked up by both reviewers (the G, H and I events)

• 25% of events will be picked up by one reviewer or the other (E and F)

• Definitions of harm become more standard with two reviewers

Modules

• Care

• Surgical

• Medication• Intensive Care

• Perinatal

• Emergency

Cares Module TriggersC1 Transfusion or use of blood products

C2 Code/arrest/rapid response team

C3 Acute dialysis

C4 Positive blood culture

C5 X-ray or Doppler studies for emboli or DVT

C6 Decrease of greater than 25% in hematocrit or hemoglobin

C7 Patient fall

C8 Pressure ulcers

C9 Readmission within 30 days

C10 Restraint use

C11 Healthcare associated infection

C12 In-hospital stroke

C13 Transfer to higher level of care

C14 Any procedure complication

C15 Other

Category of Harm (from NCC MERP Index)

E Temporary harm, intervention required

F Temporary harm, initial or prolonged

hospitalization

G Permanent patient harm

H Life sustaining intervention required

I Contributing to death

Indicators from GTT

1. # Adverse events/ 1,000 patient days

2. # Adverse events/100 patient admissions

3. % Admissions with at least one Adverse event

0

50

100

150

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250

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Calendar Month

SPH #ofAdverseEvents/ 100Admissions MSJ #ofAdverseEvents/ 100AdmissionsMSJ avg SPH avg

# of adverse events per 100 admissions

Datasource: GTT

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Calendar Month

SPH #ofAdverseEvents/ 1000PtsDays MSJ #ofAdverseEvents/ 1000PtsDaysMSJ avg SPH avg

# of adverse events per 1000 patient days

Datasource:GTT

0%

10%

20%

30%

40%

50%

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2006-10

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Calendar Month

Global trigger tool audit: % of patients with an adverse event [PHC]

PHC ratio CL LCL UCLData Source:GTT

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1

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Calendar Month

% p

atie

nts

wit

h a

t le

ast

on

e ad

vers

e ev

ent

SPHratio avg MSJratio avgDatasource: GTT database

Global trigger tool audit: % of patients with at least one adverse event [PHC]

Implementation of newcatheter care guidel i ne

CDMR; Ini tia tion of accreditati on preparations

MSJ Medici netransformation begins(completed May, 2009)

Start of TCAB atMSJ

Introduction ofwhite boards

New ini tia l assessment/screens and trigger tools/

new care pl an (Jul -Sep)

Introduction of practice

coaches for accreditation

52

46

1712 11 9 8 8 7

5 5 5 3 2 1 1 1 10%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0

10

20

30

40

50

60

Any operative complication

Healthcare-associated infection

Any procedure complication

Other -

medication related

Clostridium difficile positive stool

Other -

care related

Pressure ulcers

Over sedation/hypotension

Benadryl (Diphenhydramine) use

Abrupt medication stop

Antiemetic use

Patient fall

Instrumented delivery

Transfusion or use of blood products

Rising BUN or Serum Creatinine greather than 2 times baseline

3rd-or 4th

-degree lacerations

Narcan (Naloxone ) use

Intubation/Reintubation/BiPap in Post Anesthesia Care Unit

…

Cumulative %

Frequency

Adverse Events Observed Using Global Trigger ToolJanuary to December, 2011 [PHC]

3.74.6

1.6 0.8 0.7

5.0

0.3 0.2 0.3 0.30.0

1.0

2.0

3.0

4.0

5.0

6.0Healthcare

-associated infection

Any operative complication

Any procedure complication

Clostridium difficile positive stool

Over-

sedation/hypotension

Monthly rate

Adverse Events Observed Using Global Trigger Tool for PHC and PHC medicine units

PHC (January to Novemenber)11/12 PHC medicine(June to Novemenber)11/12

0.0

1.0

2.0

3.0

4.0

5.0

Healthcare-associated

infection

Medication related-Other

Antiemetic use

Glucose less than 50mg/dl

Benadryl (Diphenhydramine) use

Monthly rate

Adverse Events Observed for PHC medicine units

(June to Novemenber)11/12

How can a stranger tell if two people are married?

You might have to guess, based on whether they seem to be yelling at the same kids. - Derrick, age 8

24

Trigger Tools around the world

NHS

• Pediatric, Acute, and Primary care

• Even have a portal, plus videos, tools,etc.

http://www.institute.nhs.uk/safer_care/safer_care/trigger_tool_portal.html

25

Examples of other Trigger Tools

• Adverse drug events

• NICU• ICU

• Acute hospital

• Outpatient

• Pediatric• Oncology

• Primary Care (UK)

26

Baylor (North Texas)- 8 acute sites

Adverse events:

•68.1 per 1000 patient days

•50.8 per 100 encounters•39.8% of admissions were found to have at least one 1 AE

27

Of all AEs identified

• 61.2% were hospital-acquired

• 10.1% of which were H or I (near death or death)

28

U.S.

• IHI and Premier; developed a new ADE trigger tool based on Classen’s work.

• Trialed it in 86 hospitals across US• 2837 charts reviewed

– Rozich et al

29

Some Triggers

• Nalaxone

• Flumenazil

• Vitamin K • INR greater than 6

• Abrupt medication stop

• Transfer to higher level of care

30

Findings

• Only 5 of 274 adverse drug events were reported in their incident reporting system

• Average 2.94 events per 1000 doses• Most frequent was antiemetic

• Most valuable trigger was ‘abrupt medication stop

31

CPSI

• Developing a pediatric trigger tool

32

How do you make a marriage work?

Tell your wife that she looks pretty, even if she looks like a dump truck.

- Ricky, age 10

Multiple indicators

• Need a variety of measures to monitor activity

• One methodology is not enough e.g. reporting vs. chart review vs. survey

• Gives more complete picture

• Provides direction and priority for action.

Trigger Tool data for Patient Safety

VCH/PHC Quality/Patient Safety Indicators

1. Hospital Standardized Mortality Ratio (HSMR)

2. Adverse Event Rates (using the GTT)

3. Safety Culture Survey (staff and patient)

4. In-hospital fractures

5. Pharmacy Indicators (e.g. Medication reconciliation, unsafe abbreviations, illegible handwriting audits)

6. Infection Control Surveillance Data (e.g.. MRSA, VRE, CDAD, HH audits)

Trigger Tool Practical Use

• Establishes within an institution a baseline of harm

• Resources can be focused effectively• Affect of interventions can be followed

when adverse event rate is measured over time

Support for Patient Safety

Harm

• Concentrates less on people more on systems

• Looks at all unintended results

• Makes measurement easier

• Concentrates on harm and those errors that cause harm IHI.org

Errors

• Errors are the focus of discussion and solutions

• Tends to focus only on those results felt to be related to error, ignores other events

• Requires judgment

• Human found responsible for most of the errors

VCH/PHC Database

VCH: % of AE Breakdown by Category FY2010-11

4 All Other Adverse Events5%

3C-Care Mgt Medication Related Events

9%3A-Allergic Reactions5%

2D-Care Mgt Procedure Related Complications

11%

2C-Routine Invasive Procedural Complications

8%

2B-Interventional/ Diagnostic Complications

4%2A-Intra/ Post Surgical

Complications32%

1C-Care Mgt Related Infections

13%

1B-Procedural Infections10%

1A-Surgical/ Operative Infections

3%

VCH % of Adverse Event by Severity FY 2010-11

040

44

52

000

55

45

000

60

40

090

61

30

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

E- Temp. Harm & Req'dan Intervention

F- Temp. Harm & Req'dan Intervention orProlonged Hosp.

G- Permanent Harm H- Req'd anIntervention to

Sustain Life

I- Death

Q1 Q2 Q3 Q4

Nosocomial BSI: Percent Contribution by Primary Source (VGH)

0

5

10

15

20

25

30

2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 (Q1)

Fiscal Year

%

Urine CVC Respiratory Soft Tissue Surgical Site Gastrointestinal Vascular No primary source Other source

43

Overall cost-benefit analysis

Cost Evaluation

•UTI is the most common HAI at VCH with 18,900 cases over the last 4 years

44

Overall cost-benefit analysisCost Evaluation

•Cost drivers UTI, bacteremias and VRE are the main cost drivers and responsible for almost 70% of costs concerning HAIs

Summary

• Gain basic understanding of Trigger Tool methodology

• Learn how Trigger Tool data is used to support Patient Safety

• Gain knowledge of the capability of the VCH/PHC database

Questions?