IHI Global Trigger Tool - Sikker Patient

IHI Global Trigger Tool
Frank Federico

Objectives
• Describe how to use data collected using
the IHI Global Trigger Tool.
• Discuss the advantages and
disadvantages of different sources of data.

Outline
• Review origin and development of the
trigger tool methodology
• Examine how one organization used the
data
• Review cases

Building a Cascading System of Measures
L 1
Macro Metrics - Outcomes
Structural Measures
Board &
CEO
L 2
Service
Line
L 3
Microsystems: Units, Depts
Meso Metrics – Outcomes +
Processes
Micro Metrics - Processes
Adapted from Lloyd & Caldwell
L 4/ 5
Physician & Patient
Individual Metrics
- Processes

Background
• Computerized triggers for ADE identification and
concurrent intervention David Classen (1990)
• ADE review identifying 14 triggers accounting for
majority of ADE’s David Classen (1994)
• Adverse drug event trigger tool developed for the
IHI Idealized Design of the Medication System
(1999)
• ICU Adverse event trigger tool, IHI Idealized Design
ICU (2002)
• Global Trigger Tool testing and spread to US and
international hospitals (2004)

IHI Definition of Harm
HARM = Unintended physical injury
resulting from or contributed to by
medical care that requires additional
monitoring, treatment or hospitalization,
or that results in death.

Harm from the Patient’s View
• Would you be happy if the event happened to you If the
answer is no, then likely there was harm.
• Was the event part of the natural progression of the disease
process, or a complication of the treatment related to the
disease process The harm identified should be the result
of some medical treatment. The decision is subjective at
times and physician input will be critical.
• Was the event an intended result of the care (e.g., a
permanent scar from surgery) If so, then this is not
considered harm.
• Psychological harm by definition has been excluded as an
adverse event.

Why Use Trigger Tools
• Traditional reporting of errors, incidents, or
events does not reliably occur in the best of
cultures in healthcare
• Voluntary methods underestimate events and
concentrate on what is interpreted as being
preventable
• Easily identifies events without complex
technology
• Can be integrated into a good sampling
methodology

Incidents Detected by Three Methods
Olsen, S. et al. Qual Saf Health Care 2007;16:40-44
Copyright ©2007 BMJ Publishing Group Ltd.

Voluntary Reporting
“We found that less than 4% of all adverse drug
events involving use of rescue drugs were
reported.”
Schade, Am J Med Qual. 2006 Sep-Oct;21(5):335-41
Studies of medical services suggest that only 1.5%
of all adverse events result in an incident report.
O'Neil A,. Ann Intern Med 1993;119:370-376)

Accepting the Harm Burden
Adverse Event and Errors
─ “Error” definition bears upon concept of preventability and human
mistake
─ “Adverse event” describes harm to the patient regardless of error
and is often system-based
─ Relationship between errors and adverse events:
Adverse
Events
Errors
Mortality

Adverse Events
Harm and Error
NEW
• Harm is the focus of
discussion
• Looks at all unintended
results
• Measurement is clear
and direct
• Nothing is theoretically
unpreventable
OLD
• Errors and humans are
the focus of discussion
• Tends to focus only on
those outcomes felt to be
related to error
• Measurement relies on
self-reporting
• Many ADEs are seen as
unpreventable

Category of Harm
NCCMERP Index
• E
Temporary harm, intervention required
• F
Temporary harm, initial or prolonged
hospitalization
• G
Permanent patient harm
• H
Life sustaining intervention required
• I
Contributing to Death

Trigger Definition
Triggers are defined as occurrences,
prompts, or flags found on review of the
medical record that “trigger” further
investigation to determine the presence or
absence of a medication (medical) error
(adverse event).
Classen DC, Pestotnik SL, Evans RS, Burke JP. Computerized Surveillance of
Adverse Drug Events in Hospital Patients. JAMA 1991;266(20):2847-2851.

Seks moduler
• Generel behandling (15)
• Medicinering (12)
• Kirurgi (16)
• Intensiv behandling (4)
• Perinatale behandling (6)
• Akutmodtagelse (2)

Modul G: Generel behandling
• Transfusion
• Tilkald af stophold m.v.
• Dialyse
• Positiv bloddyrkning
• Røntgen eller ultralyd på
mistanke om lungeemboli
eller DVT
• Pludseligt fald i Hb eller
Hct > 25 %
• Fald
• Tryksår
• Genindlæggelse indenfor
30 dage
• Anvendelse af tvang
• Behandlingsrelaterede
infektioner
• Apopleksi under
indlæggelse
• Overflytning til højere
behandlings- eller
plejeniveau
• Komplikationer
• Øvrigt

Modul M: Medicinering
• C. difficile i
fæcesdyrkning
• APTT > 100 sekunder
• INR > 6
• Glukose < 3 mmol/l
• Stigning i karbamid
eller kreatinin til over
to gange øvre normal
• K-vitamin
• Antihistamin
• Flumazenil
• Naloxon
• Antiemetika
• Hypotension eller
oversedering
• Pludseligt ophør med
lægemidler

Modul K: Kirurgi 1
• Reoperation
• Ændret indgreb
• Postop. indlæggelse
på ITA
• (Re)intubation på
opvågning
• Rtg. på OP eller
opvågning
• Intra- eller
postoperativ død
• Respiratorbehandling
> 24 timer
postoperativt
• Intraoperativ
anvendelse af
adrenalin,
noradrenalin, naloxon
eller flumazenil
• Postoperativ øgning
af troponin-T ≥ 0,1
mikrogram/l

Modul K: Kirurgi 2
• Ændret anæstesiform
under operation
• Tilsyn fra andet
speciale på
opvågning
• Normalt patologisvar
eller anden afvigelse
fra præoperativ
diagnose
• Anlæggelse af
a-kanyle eller cvk
under operation
• Operationstid > 6
timer
• Fjernelse/skade på
organ
• Postoperative
komplikationer

Modul I: Intensiv behandling
• Pneumoni
• Genindlæggelse på ITA
• Behandling/indgreb på ITA
• Intubation/reintubation

Modul P: Perinatale triggere
• Apgar < 7 efter 5 min / pH < 7,05 el. BE > 10 i
navlesnorsblod
• Transport eller overflytning af moder eller barn
• Magnesium eller terbutalin
• 3. eller 4. grads bristninger
• Igangsættelse af fødsel
• Blodsukker < 2,2 mmol/l hos barnet

Modul A: Akut modtagelse
• Genindlæggelse via akutmodtagelsen inden
for 48 timer efter udskrivelse
• Ophold i akutmodtagelsen > 6 timer

Pilot Study
91 adverse events/1000 patient days or
40-50 events per 100 admission
Example: Hospital with 10,000
admissions, with average LOS of 4
days will have approximately 4000
adverse events/year

More recent data…
1450 Adult ICU patients
11.3 AEs per 100 ICU days
2.04 AEs per patient
North Carolina Harm Study

More recent data…
74 Adverse Events per 100 admissions;
56% of all Adverse Events “Preventable”
North Carolina Harm Study

What are we finding
NCC MERP Harm Percent
Category
E 57%
F 35%
G 2.20%
H 4%
I 1.4%

Adverse Events by Category
Harm Category
Infectious
Surgical/ Obstetrical
Hematologic
Renal/Fluids/Endocrine
Respiratory
Cardiovascular
Gastrointestinal
Neurologic
Other categories
0 20 40 60 80 100 120
North Carolina Harm Study
Number of harms

Adverse Events within “Infection” Category
Hospital-acquired UTI
Surgical site infection
Nosocomial pneumonia, not ventilator-related
Sepsis/bacteremia unrelated to catheterr
Catheter-related blood stream infection
Ventilator-associated pneumonia
C difficile colitis
Endometritis
Other hospital-acquired infection
Infectious
North Carolina Harm Study
0 5 10 15 20 25 30 35
Number

Conclusions
• IHI GTT is a useful instrument for
internal reviewers to use within hospitals
to track harms over time
• Sensitivity and specificity of the IHI GTT
are very good, particularly compared to
other methods presently used to identify
harm
North Carolina Harm Study

GTT Harm, Danish Pilot
80
84%
97% 98% 98% 100%
100%
Number of AEs
70
60
50
40
30
20
10
80%
60%
40%
20%
Cummulated Percent
0
E F G H I
0%
Thank you to Louise Rabøl
Harm Category

GTT Harm, Danish Pilot
Number of AEs per Patient Day (U Chart)
0.070
0.060
0.050
0.040
0.030
0.020
0.010
0.000
1 3 5 7 9 11 13 15 17 19 21 23 25 27
Thank you to Louise Rabøl
Period (two-week)

The Review Process
• Two primary reviewers
─ Two primary reviewers looking at the same chart
independently will be able to find about 94% of all adverse
events in the chart.
─ Only one primary reviewer alone will find 64% of the adverse
events.
• Physician Reviewer
─ The secondary reviewer focuses only on the adverse events
identified and verifies unless there are questions.
─ If the secondary reviewer also reviews the chart and verifies
two primary reviewers probably will not be needed.

Time Limit
• 20 minutes per chart
• The goal is NOT to find all harm
• Find as much as possible in 20 minutes

Sampling
• 20 randomly selected charts/journals per
month--- or---
• 10 randomly selected charts every two
weeks
• Patients must be older than 18 years
• Greater than 24 hour length of stay

Method of Measurement
Function of Measure
Focus
Group
Chart
Review/
Trigger
Tool
Observation Markers Inspection Point
(Pharmacy Check of
Orders)
Spontaneous
Reporting
Discovery
(preparation and
administration
only)
+/- (weak)
Frequency Estimate
+/- (only if
focused)
(excluding
administration)
Test Specific
Measurement
+/-
System Performance
+/- +/- (only if
focused)
(excluding
administration)
(the stable part of
it)

IHI Global Trigger Tool Issues
• Too many adverse events
• Too few adverse events
• Too much variation between reviewers
• Do not know what to do with information

IHI Global Trigger Tool - Value
The IHI GTT is primarily designed as a
dashboard for Board/Leadership
Organizational awakening to the overall
level of patient and harm and the
safety infrastructure
Thank you to Lee Adler

Experience So Far
2 to 3 Hours to review 10 Charts/Journals
Average 8 minutes to enter data
Experienced Chart Reviewers
>95% Reproducible between Nurses
83% Reproducible between Nurses & Doctor
Sustain Plan Required
Sr. Leaders providing ability & establishing
accountability
Mentorship to new Chart Reviewers
Back-up Chart Reviewers
Database helpful
Metrics – Consistency and Monitoring
Continuous Improvement Cycles
Thank you to Lee Adler

CASE: Man was admitted to the ICU with congestive
heart failure. He was placed on oxygen by nasal
cannula and given IV furosemide. He received an
NGT for feeding because he was not eating. It was
noted during day 2 of his admission that his IV was
hooked up to the NGT. This was corrected, and no
harm to the patient was noted. He was transferred to
the medical surgical unit on day 3 and discharged to
home on day 4
Thank you Sue Barnes, Kaiser Permanente

CASE: Woman was admitted to the pre-op unit on the day of
surgery where she underwent an elective breast reconstruction
procedure s/p left mastectomy 2 months prior. During surgery the
surgeon noted a cyst under her arm on the L side and removed this
prior to completing the breast reconstruction. Otherwise the
procedure went well. In recovery room her level of consciousness
decreased after she was given a dose of morphine IV, and she
began having shortness of breath and became de-saturated
according to blood gases. She was given naloxone with no effect
and then was re-intubated. CXR was clear. After respiratory
support for one hour she was extubated without difficulty and
transferred to a med surg floor.

CASE: Woman was admitted for laminectomy for spinal
stenosis. The hospital stay was uncomplicated and the
patient was discharged two days later. After discharge the
patient had back pain and was seen for this 3 times in
emergency department and outpatient clinic over the
course of the 30 days. One month post operatively a
diagnosis made of spinal abscess and associated permanent
neurological damage. Patient was readmitted for surgical
I&D and IV antibiotics

CASE Man with a history of CVA and left sided weakness,
hypertension, hyperlipidemia, and glaucoma. Was admitted
to hospital after fall at home, diagnosed with
intertrochanteric fracture of his right hip. Underwent ORIF,
tolerated the procedure well and was discharged to long term
care facility 1 week later. He received prophylactic
antibiotics prior to the surgery, which were continued for 3
days post operatively. He was readmitted 1 week after
discharge with watery green diarrhea and abdominal
discomfort. Radiological exam showed possible acute
appendicitis. Diagnostic laparoscopy revealed colitis. Pt
deteriorated clinically, and was transitioned to comfort care
following consultation with family. Pt. expired 3 days later
with cause of death listed as Clostridium difficile colitis.

CASE: Woman admitted with abdominal pain which was determined
to be cholecystitis. From ED she went directly to surgery and from
there was admitted to a medical surgical unit post op. Prior to the lap
cholecystectomy her prophylactic antibiotic was overlooked and not
given. After surgery she was transferred to a med surg unit. On day
two she spiked a temperature of 102 and was started on IV antibiotics
after blood cultures were taken. The fever continued and post op X-ray
showed RFO (retained foreign object). Patient was returned to OR
where a retained lap sponge was removed through an open abdominal
incision. IV antibiotics were continued but the regimen was changed
after an ID consult was obtained. A central line was placed in the OR.
After the procedure she was sent to the ICU and remained on the
ventilator for 36 hours. After extubation on she was transferred back to
the Med Surg Floor and after 3 days was discharged to home.

CASE Patient with a history of atrial fibrillation and
bradycardia, past history of valve replacement and
pacemaker placement. Pneumothorax developed after
pacemaker placement with resolution after chest tube
placement. After discharge to home patient presented to
emergency department 2 weeks later with shortness of
breath and congestive heart failure. Patient admitted to
ICU where despite medical treatment, patient expired 4
days later. Cause of death listed as heart failure to due
cardiomyopathy.

Improving the Process
• Practice with charts
• Periodic meetings to review cases
• Document findings
• Share with others
• Example:
─Kaiser Permanente support for use of trigger
tool: GTT and ADE tools
─Florida Hospitals
─Organization of Saint Francis, Iowa

Summary
• Trigger tools identify harm not usually
identified using other methods
• The tools is not designed to identify every
adverse event
• Over time, the IHI Global Trigger Tool
provides a way to measure safety in an
organization (at least 12 data points)
─Sample of 10 charts every two weeks
─Initial reviews will show wide variation

Summary
• The IHI Global Trigger Tool should be
used as part of a larger measurement
strategy
• Used as a dashboard for Board and
Senior Leaders
• Method for organization to understand the
frequency of harm

References and Support
• IHI.ORG
─IHI Global Trigger Tool White Paper
─Practice Charts
• IHI Trigger Tool Listserv
• Recent Publications