Anne Matlow MD FRCPC Hospital for Sick Children, Toronto for CAPHC’s Trigger Tool Design Group
-
Upload
sawyer-herrera -
Category
Documents
-
view
21 -
download
1
description
Transcript of Anne Matlow MD FRCPC Hospital for Sick Children, Toronto for CAPHC’s Trigger Tool Design Group
Anne Matlow MD FRCPC
Hospital for Sick Children, Toronto
for CAPHC’s Trigger Tool Design Group
The Canadian Paediatric Trigger Tool
OBJECTIVES
• To discuss the rationale and current methods available for detection of adverse events, focusing on trigger tool methodology
• To review the history behind the development of the Canadian Pediatric Trigger Tool (CPTT)
• To review the results to date, and future directions
Rationale for detection of adverse events
Rationale for detection of adverse events
“To measure is to know” Archimedes
- how you are doing
- how you compare to others
“You can’t improve what you can’t measure”Act Plan
Study Do
What is an Adverse Event?
What is an Adverse Event?
….. “an injury that is caused by medical management rather than underlying disease and that prolongs hospitalization, produces a disability at discharge, or both” Brennan, Leape
….. “an unintended injury or complication which results in disability, death or prolonged hospital stay and is caused by health care management”. Wilson, Baker
….. “unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalization, or that results in death”. IHI
What is an Adverse Event?Harm caused by medical management
….. “an injury that is caused by medical management rather than underlying disease and that prolongs hospitalization, produces a disability at discharge, or both”
….. “an unintended injury or complication which results in disability, death or prolonged hospital stay and is caused by health care management”.
….. “unintended physical injury resulting from or contributed to by medical care that requires additional
monitoring, treatment or hospitalization, or that results in death”.
What is an Adverse Event?Disability
….. an injury that is caused by medical management rather than underlying disease and that prolongs hospitalization, produces a disability at discharge, or both
….. an unintended injury or complication which results in disability, death or prolonged hospital stay and is caused by health care management.
….. unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalization, or that results in death.
NCC MERP Classification for AEs
• Category E Contributed to or resulted in temporary harm to the patient and required intervention
• Category F Contributed to or resulted in temporary harm to the patients and required initial or prolonged hospitalization
• Category G Contributed to or resulted in permanent patient harm
• Category H Required intervention to sustain life• Category I Contributed to or resulted in the
patient’s death
Detecting Adverse Events
Method AE/1000 admissions
Incident Reports (2-8%) 5Retrospective Chart Review 30Stimulated Voluntary Reports 30Automated Flags 55*Daily chart review 85Automated Flags and Daily review 130*
*triggers= screening tool Original slide courtesy of Dr Philip Hebert
Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review BMJ 2007;334:79
• 324 patient safety incidents were identified in 230/1006 admissions (22.9%; 95% confidence interval 20.3% to 25.5%).
• 270 (83%) patient safety incidents were identified by case note review (TT) only,
• 21 (7%) by the routine reporting system only, and 33 (10%) by both methods. – TT 12x more sensitive than routine
reporting system
Estimating Adverse Event Rates with Triggers
Country N Year # Trigger Positive
Incidence of AE
Canada 3,745 2000 1527 (40.7%) 7.5%
USA (U&C)
USA (NY)
14,700
30,195
1992
1984
2868 (19.5%)
7817 (26.0%)
2.9%
3.7%
Australia 14,179 1992 6210 (43.7%) 16.6%
UK 1,014 1999 405 (40.5%) 10.8%
N Z 1,326 1998 4197 (62.0%) 12.9%
Use of triggers to detect harm in pediatric in-patient care
FOCUS N Year AEs Preventable
NICU pts(Sharek, 2006)
749 2004/05 -74 AE /100 pts
- 32.4. / 1000 pt d
56%
PICU pts(Larsen, 2007)
259 2002/03 -29 AEs/ 100 pts
-59% of all pts >= 1 AE
36%
ADEs Peds Takata, 2008
960 2002 11.1 ADE/100 pts 15.7/ 1000 pt days
22%
Global Trigger Tool
Modular- Care, - Surgical- Medication, - Intensive Care,
- Perinatal and- Emergency
» (www.ihi.org)
Research Objectives
• To develop a global trigger tool for use with pediatric populations
• Determine the rate of adverse events for hospitalized children and youth in Canada
• To compare the incidence of adverse events in children versus Canadian adults
• Launch QI efforts
• Select triggers from existing tools and adapt to paediatric population
• Vermont Oxford Neonatal Network Tool
• Adverse Drug Events Tool
• CHAI Adverse Drug Events Measurement Kit
• IHI Global Trigger Tool (6 modules)
• Canadian Adverse Events Study Trigger Tool
Trigger Tool Development – Step 1
Trigger Tool Development – Step 2
• Map selected triggers onto IHI modules and cross-reference with the CAES triggers
• Modules:– Care, – Medication, – Surgical, – Intensive Care, – Laboratory (added)
CARE MODULE
C1 Transfusion/ use of blood products
C2 Any code or arrest
C3 Dialysis (New Onset)
C5 Diagnostic Imaging for Embolus/thrombus with/without confirmation
C7 Patient fall
C8 Decubiti / Skin Breakdown
C9 Readmission within 30 days
C10 Restraint use
C11 Infection of any kind
C12 In hospital stroke
C13 Transfer to higher level of care
C14 Procedure complication
C16 Rash
C17 Hypotension
C18 Catheter infiltration/burn
C19 Wrong Maternal Breast Milk
C20 Incorrect Central Venous Catheter (CVC) placement (radiographic)
C21 Complication related to Central Venous Catheter (CVC)
C22 Necrotizing Enterocolitis (NEC)
C23 Seizures
MEDICATION MODULE
M6 Vitamin K (excluding newborns)
M7 Benadryl (Diphenhydramine) - for symptoms of allergic reaction
M8 Romazicon (Flumazenil)
M9 Narcan (Naloxone)
M10 Anti-emetic Use (for treatment of symptoms)
M11 Over sedation / hypotension
M12 Abrupt medication stop
M14Antidiarrheals - Diphenoxylate (Lomotil), Loperamide (Imodium), Kaopectate, Pepto-Bismol
PRELIMINARY CANADIAN PEDIATRIC TRIGGERS
94 47 trig
gers
# Trigger Positive Charts
Trigger Charts Percent
+ve 361 61.08%
-ve 230 38.92%
591 charts
Frequency of Triggers per Chart
12 triggers: not used or always
with another
% of patients with AEs
AE Patients Percent
+ve 89 15.1%
-ve 502 84.9%
60% preventable
Sensitivity and Specificity of the Canadian Paediatric Trigger Tool
Adverse Event
Trigger Yes No Total
Yes 78 283 361
No 11 219 230
Total 89 502 591
Se = 0.88; CI = (0.79-0.94) Sp = 0.44; CI = (0.39-0.48)
AE by Age Group
Adverse Event
Age Group Yes No Total
0 - 28 days 33 (22%) 117 150
29 – 365 days 21 (14%) 127 148
>1 - 5 years 17 (15%) 98 115
> 5 years 18 (10%) 160 178
Total 89 502 591
Comparison of Nurse and Physician Assessment of AEs
Kappa = 0.34, CI (0.23-0.43)
Physician
Nurse Yes No Total
Yes 40 53 93
No 49 449 498
Total 89 502 591
Comparison of Nurse vs MD Assessment of AE
NCC-MERP RN-AE MD-AE
No Harm 422 2 4
E 80 38 34
F 56 41 22
G 2 1 25
H 7 7 0
I 4 4 4
591 93 89
Summary
• 47 trigger CPTT has 0.88 sensitivity
• 61% of charts were trigger positive
• 15% of charts had AE, 60% preventable
• Neonates had highest incidence of AE
• Nurses and doctors differed in their assessments of AEs
Moving Forward
• Refine and validate a modified 35 trigger CPTT
• Enhance its usability to facilitate its use in quality improvement and research initiatives
Thank you
• TTDG- A Matlow, R Baker, B Brady-Fryer, G Cronin, M Fleming, V Flintoft, MA Hiltz, M Lahey, E Orrbine
• Health Canada• Canadian Medical Protective Association, and our partners
– Rx & D– Manitoba Institute of Patient Safety– Winnipeg Regional Health Authority– Calgary Health Region– Stollery Children’s Hospital, Edmonton– IWK Health Centre, Halifax– Spelman Cronin Consulting– CAPHC and the Canadian Paediatric Health Centres
(Calgary, Stollery, Winnipeg, SickKids, CHEO, IWK)