Primary Care Trigger Tool 29 September 2009 LHB and Trust CEOs 12 May 2009 A Trigger Tool for Primary Care Tuesday 29 September 2009 Learning Session 3

Primary Care Trigger Tool 29 September 2009LHB and Trust CEOs 12 May 2009

A Trigger Tool for Primary Care

Tuesday 29 September 2009 Learning Session 3

William Whitehead and Adam Southan

Primary Care Trigger Tool 29 September 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


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


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”


Inverse reporting law?


We need a measure• Global Trigger Tool

• Develop for primary care

• Must have face validity

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?


Concept of primary care GTT


Wales Primary Care 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


Trigger tool requirements

• Face validity

• Content validity

• Consistency

• Versatility

• Practicality

• Pick up rate


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

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 H I

Number


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



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

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 H I

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



Summary Number

Total number of acute and chronic care triggers

Total number of patients showing evidence of harm

Harm rate ( No of patients harmed/ List size )


PracticeMinfor

DateJuly 09

List Size5000

Acute Care ComponentNumber

Patients seen in previous month on more than one occasion in ten days.

75

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.

12

No showing evidence of harm 3Grade of harm E F G H I

Number 3

Chronic Care Component

Number of triggers

Number showing harm

Hospital admission in previous 2 months 3 0Discontinuation of medication in past 2 months 4 1Abnormal Haematology or Biochemistry result in past 2 months

4 0

Documented Adverse drug reaction in past 2 months 2 2

OOH consultation or A&E attendance past 2 months 4 1

Grade of harm E F G H INumber 4

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

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


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%

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

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) Preventable harm (n)A B C D E F G 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-of-hours/emergency 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

English Experience

• Extensively trialled

• Results not yet publically available

• Concentrate harm by looking at aged > 75


Trigger tool version one Results

Acute Care Number Harm % triggers associated with harm

Pt seen more than once in 10 days over past month

570

No of these seen as an unscheduled review

90 21 23


Trigger tool version one resultsChronic Care No. Of Triggers No. With harm % triggers associated

with harmHospital admission in previous 3 months

12 3 25

Discontinuation of medication in 3 months

13 6 46

Abnormal haematology or biochemistry

17 1 6

Adverse drug reaction 9 8 88

OOH consultation or A and E

14 1 7

Total chronic care triggers

65 19 29




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.



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

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]

mailto:[email protected]




























Documents

Primary Care Trigger Tool 29 September 2009 LHB and Trust CEOs 12 May 2009 A Trigger Tool for Primary Care Tuesday 29 September 2009 Learning Session 3