Anne Matlow MD FRCPC Hospital for Sick Children, Toronto for CAPHC’s Trigger Tool Design Group

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

2. 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

3. Rationale for detection of adverse events

4. Act Plan Study Do 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”

5. What is an Adverse Event?

6. 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

7. What is an Adverse Event?Harmcaused by medical management ….. “an injury that is caused bymedical management rather than underlying disease and that prolongs hospitalization, produces a disability at discharge, or both” ….. “an unintendedinjury or complication which results in disability, death or prolonged hospital stay and is caused byhealth care management”. ….. “unintended physical injuryresulting from or contributed to bymedical care that requires additional monitoring, treatment or hospitalization, or that results in death”.

8. 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.

9. 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

10. Detecting Adverse Events Method AE/1000 admissions Incident Reports (2-8%) 5 Retrospective Chart Review 30 Stimulated Voluntary Reports 30 Automated Flags 55* Daily chart review 85 Automated Flags and Daily review 130* *triggers= screening tool Original slide courtesy of Dr Philip Hebert

11. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note reviewBMJ  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

12. Estimating Adverse Event Rates with Triggers

13. Use of triggers to detect harm in pediatric in-patient care

14. Global Trigger Tool Modular - Care, - Surgical - Medication, - Intensive Care, - Perinatal and - Emergency • (www.ihi.org)

16. 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

17. 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

18. 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)

19. PRELIMINARY CANADIAN PEDIATRIC TRIGGERS 9447 triggers

21. # Trigger Positive Charts

22. Frequency of Triggers per Chart 12 triggers: not used or always with another

23. % of patients with AEs 60% preventable

24. Sensitivity and Specificity of the Canadian Paediatric Trigger Tool

25. AE by Age Group

26. Comparison of Nurse and Physician Assessment of AEs Kappa = 0.34, CI (0.23-0.43)

27. Comparison of Nurse vs MD Assessment of AE

28. 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

29. Moving Forward • Refine and validate a modified 35 trigger CPTT • Enhance its usability to facilitate its use in quality improvement and research initiatives

30. 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)