Global Trigger Tool Program at Melbourne Health. Exclusion Criteria o Admitted for less than two...

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Global Trigger Tool Program at Melbourne Health

Transcript of Global Trigger Tool Program at Melbourne Health. Exclusion Criteria o Admitted for less than two...

Page 1: Global Trigger Tool Program at Melbourne Health. Exclusion Criteria o Admitted for less than two days o Below 18 years of age o Admitted under Mental.

Global Trigger Tool Program at

Melbourne Health

Page 2: Global Trigger Tool Program at Melbourne Health. Exclusion Criteria o Admitted for less than two days o Below 18 years of age o Admitted under Mental.

Exclusion Criteria

o Admitted for less than two dayso Below 18 years of ageo Admitted under Mental Healtho Admitted for subacute care

Page 3: Global Trigger Tool Program at Melbourne Health. Exclusion Criteria o Admitted for less than two days o Below 18 years of age o Admitted under Mental.

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

Page 4: Global Trigger Tool Program at Melbourne Health. Exclusion Criteria o Admitted for less than two days o Below 18 years of age o Admitted under Mental.

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

Page 5: Global Trigger Tool Program at Melbourne Health. Exclusion Criteria o Admitted for less than two days o Below 18 years of age o Admitted under Mental.

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%

Page 6: Global Trigger Tool Program at Melbourne Health. Exclusion Criteria o Admitted for less than two days o Below 18 years of age o Admitted under Mental.

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

Page 7: Global Trigger Tool Program at Melbourne Health. Exclusion Criteria o Admitted for less than two days o Below 18 years of age o Admitted under Mental.

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

Page 8: Global Trigger Tool Program at Melbourne Health. Exclusion Criteria o Admitted for less than two days o Below 18 years of age o Admitted under Mental.

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  

Page 9: Global Trigger Tool Program at Melbourne Health. Exclusion Criteria o Admitted for less than two days o Below 18 years of age o Admitted under Mental.

Database

Page 10: Global Trigger Tool Program at Melbourne Health. Exclusion Criteria o Admitted for less than two days o Below 18 years of age o Admitted under Mental.

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

Page 11: Global Trigger Tool Program at Melbourne Health. Exclusion Criteria o Admitted for less than two days o Below 18 years of age o Admitted under Mental.

Contact Details

Sharon WalshNational Standards and Clinical Governance Coordinator

Email: [email protected]

Phone: 03-9342 4165

Page 12: Global Trigger Tool Program at Melbourne Health. Exclusion Criteria o Admitted for less than two days o Below 18 years of age o Admitted under Mental.