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)