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Global Trigger Tool Program at Melbourne Health. Exclusion Criteria o Admitted for less than two...
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Transcript of Global Trigger Tool Program at Melbourne Health. Exclusion Criteria o Admitted for less than two...
Global Trigger Tool Program at
Melbourne Health
Exclusion Criteria
o Admitted for less than two dayso Below 18 years of ageo Admitted under Mental Healtho Admitted for subacute care
Sensitivity and SpecificityAttributes of the nurse screening process (n=260 records) were:
o sensitivity 97.2%;o specificity 98.7%;o positive predictive value 98.1%; ando negative predictive value 98.0%.
Physician Positive
Physician Negative
Total
Nurse Positive 105 2 107
Nurse Negative 3 150 153
Total 108 152 260
Understanding the Nature of AE
o Florida Hospital categories of harm:• Surgery or Other Procedure• Medication/Intravenous Fluids• Patient Care• Hospital Acquired Infection• Other
These are further divided into subcategories of harm
Results following 42 Audit Cycles(n= 420 records)
o Adverse events per 1000 bed days: 80.3/1000 bed days
o Adverse events per 100 admissions: 39.5/100 admissions
o % of admissions with an adverse event: 32.1%
Results following 42 Audit Cycles (Continued)
Distribution of adverse events by level of harm :
Severity Count %
E: Temporary harm requiring intervention 110 66%
F: Temporary harm requiring initial or prolonged hospitalisation 53 32%
G: Permanent harm 2 1%
H: Intervention required to sustain life 0 0%
I: Death 1 1%
Total 166
Results following 42 Audit Cycles (Continued)
AE by Category and Severity of Harm:
Harm CategoryAdverse Events
Severity
E F G H I
Surgery or Other Procedure 87 58 27 2 0 0
Medication/IV Fluids 38 33 4 0 0 1
Hospital Acquired Infection 18 8 10 0 0 0
Patient Care 13 11 2 0 0 0
Other 10 0 10 0 0 0
Total 166 110 53 2 0 1
Results following 42 Audit Cycles (Continued)
Example of Sub-Harm Category:
Frequency by PeriodCycle 1 to 42 Cycle 37 to 42 (Q7)
Hospital Acquired Infection Sub-Harm Category
Adverse Events %
Adverse Events %
Surgical infection 8 44% 0 0%Ventilator associated pneumonia 3 17% 0 0%VRE 2 11% 0 0%Clostridium difficile 2 11% 0 0%Central line associated bloodstream infection 1 6% 0 0%Catheter associated UTI 1 6% 0 0%Other 1 6% 1 100%
Total 18 1
Database
Lessons Learnto Have a database developed at start of programo Minimise staff turn over for consistencyo Meaningful analysis of data - Use of the Florida Hospital harm
categories and subcategories helps to make data more meaningfulo Reporting - Present data in such a way that it is meaningful to
clinical staff as part of a balanced safety measurement frameworko Develop a clear communication plan - including feedback to
coalface staff and action committees e.g. Skin Integrity; Infection Prevention, etc
Contact Details
Sharon WalshNational Standards and Clinical Governance Coordinator
Email: [email protected]
Phone: 03-9342 4165
