The CAPHC Annual Meeting

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The Canadian Paediatric Trigger Tool
Barbara Brady-Fryer Stollery Childrens
Hospital Edmonton, Alberta CANADA
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Canadian Association of Pediatric Health Centres
Trigger Tool Design Group

• Anne Matlow, Chair
• G. Ross Baker
• Barbara Brady-Fryer
• Gerarda Cronin
• Mark Fleming
• Virginia Flintoft

• Mary-ann Hiltz
• Michele Lahey
• Cheri Nijssen-Jordan
• Elaine Orrbine
• Margaret Zimmerman

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OBJECTIVES

• To discuss 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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Medical Errors vs Adverse Events
Preventable adverse events
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What constitutes an adverse event ?

• Criteria
• Injury or complication
• and
• 2. Associated Disability
• Prolonged LOS
• Impairment at discharge
• Subsequent hospitalization after index stay or
• Death
• and
• 3. Causation
• Caused by medical management rather than
  underlying disease process

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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 (triggers) 55
• Daily chart review 85
• Automated Flags and Daily review 130

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Estimating Adverse Event Rates with Trigger Tools
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What do we know about harm in pediatric
in-patient care?

• All adverse events 1.0/ 100 patients
• (Woods Pediatrics
  2005 Miller Pediatrics 2003 and 2004)
• Adverse drug events
• 2.3-11/ 100 admissions
• 22- 60 preventable
• (Kaushal JAMA 2001 Holdsworth, APAM 2003
  Takata, Pediatrics, 2008)

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What do we know about harm in pediatric
in-patient care?
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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
• Calgary Adverse Drug Event Measurement Tool
• 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 trigger tool
• Modules
• Care,
• Medication,
• Surgical,
• Intensive Care,
• Laboratory (added)

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PRELIMINARY CANADIAN PEDIATRIC TRIGGERS
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Feasibility Study 3 sites 40
charts/site
Preliminary CPTT Developed
Validation Study 6 sites 100
charts/site
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CPTT Validation Study- Methods
TRIGGERS AEs
AEs
Team 1
Team 1
Hospital 1 Phase 2 Review
Hospital 1 Phase 1 Review
CAES SERVER _at_ UofT
CAES SERVER _at_ UofT
Hospital 2 Phase 2 Review
Hospital 2 Phase 1 Review
Team 2
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Results
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Trigger Positive Charts
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Frequency of Triggers per Chart
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Most Frequently Identified Triggers
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of patients with AEs
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/- Trigger versus /- Adverse Event
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AE by Age Group
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AE by Category
more than 1 category could be selected for each
AE
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Comparison of Nurse and Physician Assessment of
AEs
Kappa 0.34, CI (0.23-0.43)
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Summary

• In a select group of patients the CPTT had a
  sensitivity of 0.88 to detect AEs
• 61 of charts were trigger positive
• 15 of charts reviewed had an AE
• 60 of AEs were judged preventable
• Neonates had highest incidence of AE
• Nurses and doctors differed in their assessments
  of AEs

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Unique Aspects of the CPTT

• Uses specific criteria for designation AE
• Rigorous 2 phase methodology
• Nurses identify triggers
• Physicians designate AE Harm disability
  causation
• Global Pediatric Trigger Tool

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Next Steps

• Consider reducing the number of triggers
• 4 triggers not used at all delete?
• Consider removing/merging triggers with minimal
  effect on sensitivity
• Correct technical problems with the electronic
  version of the tool

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Where we are going
Paediatric CAES
QI tool
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Our sincere thanks to all our Funders

• Health Canada
• Canadian Medical Protective Association
• Partnership funding from
• 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

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In kind support from all six Canadian Paediatric
Health Centres(Calgary, Stollery, Winnipeg,
SickKids, CHEO, IWK)
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Contact for more informationanne.matlow_at_sickkids
.cabarb.bradyfryer_at_capitalhealth.ca