Transcript Insert Title here

Tuesday 29 September 2009
Learning Session 3
A Trigger Tool for Primary Care
William
Whitehead
Primary
LHB
andCare
TrustTrigger
CEOs Tool
12and
May
29Adam
September
2009 Southan
2009
What do we know?
• Healthcare systems are not safe
• Errors harm large numbers of patients
• Many errors are avoidable
• Many patients get worse without an error
occurring
• Much of this harm is also avoidable
Primary Care Trigger Tool 29 September 2009
Harm and risk in
primary care (Pringle)
• Low Risk:
– No general anaesthetics or significant surgery
– Little obstetrics etc
• High Risk:
– First presentation of serious illness including
emergencies
– Prescribing
– Chronic disease management etc
Primary Care Trigger Tool 29 September 2009
Pringle (cont)
• Positive Culture:
– Teams often open to improvement
– Annual appraisal and Clinical Governance
• Negative Culture:
– Both practices and PCTs variable; and
– Contract makes performance management
challenging
– “Someone else’s problem”
Primary Care Trigger Tool 29 September 2009
Inverse reporting law?
Primary Care Trigger Tool 29 September 2009
We need a measure
• Global Trigger Tool
• Develop for primary care
• Must have face validity
Primary Care Trigger Tool 29 September 2009
Issues to consider around a
primary care GTT:
• Concept of a trigger tool. What’s it for?
• What needs to be considered when
developing it?
• How to make it practical?
Primary Care Trigger Tool 29 September 2009
Concept of primary
care GTT
Safety Culture
• Corporate
• Practice
Specific Tools
• Audits
• Walk arounds
• Significant event
analysis
• Case note review
• IT decision making
systems
Primary Care Trigger Tool 29 September 2009
How do you know
whether your practice
is becoming safer?
• Global Trigger Tool
Why Primary Care GTT?
• Major differences between secondary and primary
care
• Multiple consultations with relatively few interventions
per patient contact
• Lower frequency of harm
• Ongoing duty of care to patients
• Need to include harm caused by omission as well as
commission
Wales Primary Care Global Trigger Tool
Trigger tool requirements
•
•
•
•
•
•
Face validity
Content validity
Consistency
Versatility
Practicality
Pick up rate
Wales Primary Care Global Trigger Tool
Trigger tool approach used
• Need a sampling mechanism to identify
cohorts of patients with high pick up rate
• Different approach for both acute and
chronic care
• Need to maximise use of IT
Wales Primary Care Global Trigger Tool
Acute Care Component
Number
Patients seen in previous month on more than one occasion in ten days.
Trigger : No. of patients seen in past month as an unscheduled review or No. of patients who have used an
out of hours provider within ten days of a consultation.
No showing evidence of harm
Grade of harm
E
F
G
Number
Primary Care Trigger Tool 29 September 2009
H
I
Definition of harm
• Taken from UK Global Trigger Tool and the National
Coordinating Council for medication Error Reporting and
prevention
• E: Temporary harm to the patient
• F: Temporary harm to the patient requiring intervention
• G: Permanent harm to the patient
• H: Harm requiring an intervention to sustain life
• I: Patient Death
Primary Care Trigger Tool 29 September 2009
Chronic Care Component
( 20 patients with chronic condition, taking 3 or more medications and seen over past two months)
Number of
triggers
Number
showing harm
H
I
Hospital admission in previous 2 months
Discontinuation of medication in past 2 months
Abnormal Haematology or Biochemistry result in past 2 months
Documented Adverse drug reaction in past 2 months
OOH consultation or A&E attendance past 2 months
Grade of harm
E
F
G
Primary Care Trigger Tool 29 September 2009
Definition of abnormal
lab. results
•
•
•
•
•
•
A fall of > 2 g/dl in Hb
A rise of 25% above baseline of serum creatinine
The development of abnormal LFT
Significantly abnormal [Na] <125 mmol/L or > 150 mmol/L
Significantly abnormal [K] <3 mmol/L or >6mmol/L
An INR >5
Primary Care Trigger Tool 29 September 2009
Summary
Total number of acute and chronic care triggers
Total number of patients showing evidence of harm
Harm rate ( No of patients harmed/ List size )
Primary Care Trigger Tool 29 September 2009
Number
Practice
Minfor
Dat List Size
e
5000
July
09
Acute Care Component
Number
75
Patients seen in previous month on more than one
occasion in ten days.
Trigger : No. of patients seen in past month as an
unscheduled review or No. of patients who have used an
out of hours provider within ten days of a consultation.
No showing evidence of harm
Grade of harm
E
Number
3
12
3
F
G
H
I
Chronic Care Component
Number of
triggers
Hospital admission in previous 2 months
Discontinuation of medication in past 2 months
Abnormal Haematology or Biochemistry result in past 2
months
Documented Adverse drug reaction in past 2 months
3
4
4
Number
showing
harm
0
1
0
2
2
OOH consultation or A&E attendance past 2 months
4
1
Grade of harm
Number
E
4
F
G
H
Summary
Number
Total number of acute and chronic care triggers
29
Total number of patients showing evidence of harm
7
Harm rate ( No of patients harmed/ List size )
0.0014
I
Primary Care Trigger Tool 29 September 2009
Primary Care GTT – experience
in other countries.
• Scotland. Results published summer
2009
• New York Ambulatory Care model
published summer 2009
• English Model. Extensively trialled and
recruiting practices
Primary Care Trigger Tool 29 September 2009
US Experience.
1200 patients notes reviewed
over a 12 month period
Trigger type
All sites
Triggers
ADEs (PPV)
1. Medication stop
590
155 (26.3%)
2. Hospitalisation
101
22 (21.8%)
3. Emergency-room visit
94
14 (14.9%)
4. INR>5
8
8 (100%)
5. TSH<0.03 on thyroxine
10
9 (90%)
6. Creat>2.5
15
2 (13.3%)
7. BUN>60
15
1 (6.7%)
8. ALT>84
13
5 (38.5%)
9. AST>80
15
3 (20%)
Total of all triggers
908
232 (25.5%)
Sensitivity of the top 9 triggers (% of ADEs
detected by these)
94.8%
94.4%
Primary Care Trigger Tool 29 September 2009
Scottish Experience. 500
records over 12 month period
Table 1 Outline of the preliminary primary-care global trigger tool and trigger rationale
Trigger
Description and rationale for use
1. Timing of consultation
>3 contacts with the practice in any given period of a week (this can include
telephone calls, consultations with nurse/GP or home visits)
2. Place of consultation
Any home visit, whether by the GP or by a nurse from the practice serves as
a trigger
3. Frequency of consultation
>10 consultations for the period of review (12 months)
4. Changes to medication
Has any "repeat medication" been added or cancelled in the period under
review?
5. Adverse drug events/allergies
Has a new "read code" for allergy/adverse drug event been added to the
record in the year under review?
6. New clinical read code
Has a high priority clinical "read code" been added to the record in the period
under review?
7. Abnormal blood results
Specific abnormalities in U&E, LFT, INR and FBC levels served as a trigger
8. Out-of-hours and/or A&E
Attendance at either of these services in the period under review served as a
trigger
9. Hospital admission/discharge
Has the patient been admitted to a hospital for any intervention,
management or procedure? The patient should have been admitted for at
least one night
10. >1 outpatient appointments in last year
More than one outpatient appointment or hospitalised as a day-case during
the period under review
Primary Care Trigger Tool 29 September 2009
Scottish Experience. 500
records over 12 month period.
2251 consultations.
Table 4 Positive triggers, harm and severity category
Trigger
Present (n)
Harm Severity Code (n)
A
B
C
D
E
F
G
Preventable
harm (n)
Total
1. Timing
111
–
–
–
1
9
2
–
12
3
2. Place
18
–
–
–
–
2
–
–
2
0
3. Frequency
72
–
–
–
–
2
–
–
2
1
4. Medication
change
53
–
1
1
2
10
1
–
15
6
5. Allergies
17
–
1
–
–
5
–
–
6
2
6. Read
codes
96
2
1
–
–
1
–
–
4
2
7. Abnormal
laboratory
results
55
–
–
1
1
4
–
–
6
4
8. Out-ofhours/emerge
ncy care
99
–
–
1
–
3
–
–
4
1
9. Hospital
care
65
–
2
2
–
1
3
1
9
7
10.
Outpatient
consultation
141
–
–
–
1
2
–
1
4
1
Total
730
2
5
5
5
39
6
2
64
27
Primary Care Trigger Tool 29 September 2009
English Experience
• Extensively trialled
• Results not yet publically available
• Concentrate harm by looking at aged >
75
Primary Care Trigger Tool 29 September 2009
Trigger tool version one
Results
Acute Care
Number
Harm
% triggers
associated with
harm
21
23
Pt seen more
570
than once in 10
days over past
month
No of these
seen as an
unscheduled
review
90
Primary Care Trigger Tool 29 September 2009
Trigger tool version one
results
Chronic Care
No. Of Triggers
No. With harm
Hospital admission in
previous 3 months
12
3
% triggers associated
with harm
25
Discontinuation of
13
medication in 3 months
6
46
Abnormal haematology 17
or biochemistry
1
6
Adverse drug reaction
8
88
OOH consultation or A 14
and E
1
7
Total chronic care
triggers
19
29
9
65
Primary Care Trigger Tool 29 September 2009
Acute Care Triggers
30
UCL=26.684
25
UCL1
20
LCL1
CEN1
15
ZAUPR1
CEN=14.182
ZALWR1
ZBUPR1
ZBLWR1
10
PRISERIES1
5
LCL=1.68
0
01/11/2007
01/01/2008
01/03/2008
01/05/2008
01/07/2008
01/09/2008
01/11/2008
01/01/2009
Primary Care Trigger Tool 29 September 2009
01/03/2009
01/05/2009
01/07/2009
Harm
7
6
UCL=5.9327
5
4
3
CEN=3.2727
2
1
LCL=0.6127
0
01/11/2007
01/01/2008
01/03/2008
01/05/2008
01/07/2008
01/09/2008
01/11/2008
01/01/2009
Primary Care Trigger Tool 29 September 2009
01/03/2009
01/05/2009
01/07/2009
Conclusions
•
•
•
•
•
The Welsh, Scottish and US tools use similar triggers
The triggers which are most predictive of harm are similar in the Welsh,
Scottish and US tools
The Welsh tool is just about sufficiently practical to use on a regular basis
to follow the progress of triggers and the risk of harm, unlike the other
models.
The English tool concentrates on the elderly, unlike the Welsh tool which
looks at all age ranges, particularly in the acute component.
We need to recruit more practices to use the tool regularly and collate the
results.
Primary Care Trigger Tool 29 September 2009
Next steps!
• Recruit a minimum of one practice per former LHB
area
• By October 14 inform local Regional Coordinator of
– Practice list size
– Clinical system
– Practice Lead for project
• By 30 October practice briefed and prepared for first
run
• Results reported by end December
• Drs William Whitehead and Adam Southan will be
available for phone advice throughout trial through
the Regional Coordinators
Primary Care Trigger Tool 29 September 2009
Regional Coordinator
Contact details
• North Wales Regional Coordinator – Andrea Hobbs
[email protected]
• Mid & West Regional Coordinator – Carol Tofts
[email protected]
• South Wales Regional Coordinator – Julie Hopkins
[email protected]