The CAPHC Annual Meeting

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The Canadian Paediatric Trigger Tool
Anne Matlow MD FRCPC Hospital for Sick Children,
Toronto for CAPHCs Trigger Tool Design Group
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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

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Rationale for detection of adverse events
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Rationale for detection of adverse events

• To measure is to know
  Archimedes
• - how you are doing
• - how you compare to others
• You cant improve what you cant measure

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What is an Adverse Event?
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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

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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.

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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.

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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
  patients death

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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

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Sensitivity of routine system for reporting
patient safety incidents in an NHS hospital
retrospective patient case note review
BMJ  200733479

• 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

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Estimating Adverse Event Rates with Triggers
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Use of triggers to detect harm in pediatric
in-patient care
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Global Trigger Tool

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

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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

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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

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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)

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PRELIMINARY CANADIAN PEDIATRIC TRIGGERS
94 47 triggers
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(No Transcript)
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Trigger Positive Charts
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Frequency of Triggers per Chart
12 triggers not used or always with another
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of patients with AEs
60 preventable
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Sensitivity and Specificity of the Canadian
Paediatric Trigger Tool
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AE by Age Group
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Comparison of Nurse and Physician Assessment of
AEs
Kappa 0.34, CI (0.23-0.43)
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Comparison of Nurse vs MD Assessment of AE
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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

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Moving Forward

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

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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 Childrens Hospital, Edmonton
• IWK Health Centre, Halifax
• Spelman Cronin Consulting
• CAPHC and the Canadian Paediatric Health
  Centres(Calgary, Stollery, Winnipeg, SickKids,
  CHEO, IWK)