Transcript The Canadian Paediatric Trigger Tool Anne Matlow MD FRCPC Hospital for Sick Children, Toronto for CAPHC’s Trigger Tool Design Group.

The Canadian Paediatric
Trigger Tool
Anne Matlow MD FRCPC
Hospital for Sick Children, Toronto
for CAPHC’s Trigger Tool Design Group
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%)
Retrospective Chart Review
Stimulated Voluntary Reports
Automated Flags
Daily chart review
Automated Flags and Daily review
5
30
30
55*
85
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
# Trigger
Positive
Incidence
of AE
3,745 2000
1527 (40.7%)
7.5%
USA (U&C) 14,700 1992
USA (NY)
30,195 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%
NZ
1,326 1998
4197 (62.0%)
12.9%
Canada
N
Year
Use of triggers to detect harm in
pediatric in-patient care
FOCUS
NICU pts
N
Year
749 2004/05
(Sharek, 2006)
PICU pts
AEs
Preventable
-74 AE /100 pts
56%
- 32.4. / 1000 pt d
259 2002/03
-29 AEs/ 100 pts
36%
-59% of all pts >=
(Larsen, 2007)
1 AE
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
Trigger Tool Development –
Step 1
• 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 2
• Map selected triggers onto IHI modules and
cross-reference with the CAES triggers
• Modules:
– Care,
– Medication,
– Surgical,
– Intensive Care,
– Laboratory (added)
PRELIMINARY CANADIAN PEDIATRIC TRIGGERS
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
MEDICATION MODULE
Decubiti / Skin Breakdown
C9
Readmission
30 days
M6 within
Vitamin
K (excluding newborns)
C10
C11
Restraint use
M7
Benadryl (Diphenhydramine) - for symptoms of allergic reaction
Infection of any kind
C12
In hospital
M8stroke
Romazicon (Flumazenil)
C13
Transfer to
level(Naloxone)
of care
M9 higher
Narcan
C14
C16
Procedure complication
M10
Anti-emetic Use (for treatment of symptoms)
Rash
C17
Hypotension
M11
C18
Catheter infiltration/burn
M12
Abrupt medication stop
Wrong Maternal Breast Milk
C19
C20
Over sedation / hypotension
C22
Incorrect Central Venous Catheter (CVC) placement (radiographic)
Antidiarrheals - Diphenoxylate (Lomotil), Loperamide (Imodium),
M14 related to Central Venous Catheter (CVC)
Complication
Kaopectate, Pepto-Bismol
Necrotizing Enterocolitis (NEC)
C23
Seizures
C21
# Trigger Positive Charts
Trigger
Charts
Percent
+ve
361
61.08%
-ve
230
38.92%
591 charts
Frequency of Triggers per Chart
40%
Percent of Charts
35%
12 triggers: not
used or always
with another
30%
25%
20%
15%
10%
5%
0%
0
1
2
3
4
5
6
7
8
9
Number of Triggers
10
11
12
14
% 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
Yes
78
No
283
Total
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
0 - 28 days
Yes
33 (22%)
No
117
Total
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
Physician
Nurse
Yes
No
Total
Yes
40
53
93
No
49
449
498
Total
89
502
591
Kappa = 0.34, CI (0.23-0.43)
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)