Kaiser Permanente Experience with Automating the IHI Global Trigger Tool (Text Version)
On September 29, 2010, Dot Snow made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (466 KB).
Kaiser Permanente Experience with Automating the IHI Global Trigger Tool
presented at AHRQ 2010 Annual Meeting
September 29, 2010
Dot Snow, MPH
National Patient Safety
Kaiser Permanente Foundation Health Plan
Fast Facts About Kaiser Permanente
Founded in 1945, Kaiser Permanente is the Nation's largest not-for-profit health plan, serving 8.7 million members.
Among the innovations it has brought to U.S. health care are:
- Prepaid insurance which spreads the cost to make it more affordable.
- Physician group practice with a focus on preventing illness as much as on caring for the sick.
- An organized delivery system, putting as many services as possible under one roof.
- Implementation of the largest civilian electronic health record in the world.
Fast Facts About Kaiser Permanente
Medical Centers: 36
Medical Offices: 431
Operate with a Labor Management Partnership
Local markets in Northern California, Southern California, Hawaii, Colorado, Ohio, Georgia, Oregon/Washington and the Mid-Atlantic States.
Trigger Tool/TIDS Experiences
Initial Pilot of IHI Global Trigger Tool
IHI Global Trigger Tools Pilot (2006)
- Data came from 2 medical centers representing 2,363 patient days across 400 patients.
- 37% of patients experienced an adverse event, with 20-25% having more than one adverse event.
- 47% of the adverse events led to increased use of care.
- Automated Adverse Event Monitoring Program (AAEMP)
Other Trigger Tool Study Results
- Adverse Drug Events: ADEs/1000 medication doses = 2.67% (Rozich JD, Haraden CR, Resar RK The adverse drug event trigger tool: A practical methodology for measuring medication-related harm. Journal Quality and Safety in Health Care June 2003).
- ICU Trigger Tool Study: 1450 adverse events found in 55% of patients; with 28% of patients having > 1 event (Resar RK, Rozich JD, Classen D Methodology and rationale for the measurement of harm with trigger tools. Quality and Safety in Health Care. Vol 12 December 2003).
- IHI Collaborative Surgical Trigger Tool Data: adverse events found in 14.6% of patients (Griffin FA, Classen DC. Detection of adverse events in surgical patients using the Trigger Tool approach. Qual. Saf. Health Care 2008 17: 253-258).
- The Office of Inspector General pilot study on national incidence of adverse events in hospitals showed ~30% of MediCare patients experienced some type of adverse event during hospitalization. Results from the National Incidence Study to be released later in 2010. (Lee Adler, MD; 2010 NPSF Congress presentation).
Application of Initial Pilot Results
Initial pilot identified IV heparin therapy as an area for focal trigger tool review.
Four improvement opportunities identified:
- Clarified the logic in the regional algorithm.
- Provided additional teaching of protocol to improve adherence.
- Promoted alternative therapies with less risk for dropping platelets.
- Adjusted tools in ED to allow for documentation of double checks.
Automated Adverse Event Monitoring Program (AAEMP)
- Kaiser-funded research project.
- Represents a collaborative effort between Kaiser Permanente and Computer Sciences Corporation.
- Seeks to automate the IHI GTT methodology utilizing data from KP HealthConnect™.
- Will be used to detect and evaluate triggers that allows for the measurement of adverse events in a health care system.
Process Steps in Building the AAEMP Application
- Identify and define triggers
- Map triggers to locations in data tables from EMR
- Build application
- Validate triggers and data from EMR locations
- Define operational workflows
- Prepare clinical site for pilot test
- Post-pilot: refine trigger definition and application based on sensitivity/specificity analyses
Identify and Define Triggers
- Started with triggers from IHI GTT.
- Triggers must be located in discrete fields within the EMR; info located in text or notes will not be available for trigger detection.
- Worked with AAEMP Steering Committee to carefully define triggers including threshold values for positive triggers and specific inclusion or exclusion criteria.
- Added 7 infection specific triggers to test in AAEMP pilot, including CAUTI, VAP, and sepsis.
Map Triggers to Data Table Locations
- Used Clarity data tables rather than Chronicle server to avoid interference with operations.
- Time intensive step-requires knowledge of regional configurations and info location in tables.
- Want to identify all possible locations of trigger information within EMR to maximize reliability of the application to identify triggers and values.
Build AAEMP Application
- Original proposal called for a Java application and Oracle database.
- Requires collaboration with IT to determine technical specifications, feasibility assessment, system architecture and test plan.
- Front end of application completed.
- Back end not built at that time; ongoing roll-out of EMR to medical centers was top IT priority.
Adapted AAEMP for Access Database
- Identified a medical center that used Access to build a surveillance system similar in concept to AAEMP.
- Vendor modified application to run in Access and incorporate GTT triggers.
- Application loaded onto desktop computers rather than a system server.
Validate Trigger and Data from EMR Locations
The application is tested using real patient data to determine that the information coming back from Clarity tables is indeed the trigger information expected to be returned.
Define Operational Workflows
- Application designed to assess medical records of all hospitalized patients and produce a list of patients with positive trigger firings.
- Nurse reviewer from Quality Department reviews medical record to determine whether an adverse event is present.
- If adverse event is present, categorize severity level according to NCC-MERP levels of harm.
- Physician validates nurse's review and information is added to database.
Prepare Clinical Site for Pilot Test
All members of pilot site team complete required IRB trainings and certifications
Pilot Site Training:
- Overview of IHI GTT and methodology.
- Practice trigger and adverse event evaluation using sample charts.
- Demonstrate AAEMP application and reports.
- Clarify operational workflow.
- Schedule series of check-in meetings to discuss emergent issues.
- May want to review initial cases early in pilot as a check for inter-rater reliability.
Planned Post-Pilot Analyses
- Sensitivity/specificity analyses of triggers with subsequent refinement of trigger definitions and mapping.
- Return on investment (lives saved; shorter LOS; cost reductions).
- How orders in EMR could be changed to re-design/re-build for reliability in order to reduce harm to our patients (e.g., what feedback, directed follow-up, and/or actions need to be hardwired into orders; what best practice alerts need to fire).
- Regions have made unique configuration choices that impact the location of data in Clarity tables after the daily ETL process.
- Trigger information may be documented in multiple places within EMR.
- Implementation demands greatest with initial sites; further spread would benefit from pilot site experiences.
- Articulate agreements for how information will be shared and acted upon.
- Sequencing trigger tool activity within a system's EMR rollout and/or upgrades:
- Validation and testing activities may compete with production schedules and resource commitments.
- AAEMP allows detection of triggers in near real time:
- Paper-based methodology is a retrospective review and trigger identification/detection is well after the fact.
- KP HealthConnect allows Kaiser Permanente to augment the classic IHI global trigger tool methodology in two important and innovative ways:
- Searches the medical records of all hospitalized patients instead of a sample, generating larger samples and revealing consistent patterns.
- Allows for close surveillance of patients for the rapid detection and prevention or amelioration of harm.
- Can replace existing surveillance activities; sampling of records can allow fit with existing resources.
- An automated trigger tool can:
- Shine light on areas of improvement opportunity.
- Assess impact of specific performance improvement initiatives.
Concluding Observations and Thoughts
- A strong multidisciplinary steering committee is essential.
- Numerous IT issues need to be addressed:
- System architecture
- Security considerations
- Vendor relationships
- IT standards and specifications
- Will be a powerful application of a validated adverse event detection tool.