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The Mental Health Trigger Tool

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1 The Mental Health Trigger Tool
二○一七年四月十一日 The Mental Health Trigger Tool Concept and Development A/Prof Chua Hong Choon, Chief Executive Officer Dr Sajith Sreedharan, Consultant (General Psychiatry) Apr 2014 © 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries. The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION. 1

2 Disclosures: None

3 AGENDA The Little Red Dot S’pore Healthcare Services Overview of IMH
Prevalence Studies of AEs Mental Health Trigger Tool

4

5 Republic of Singapore Location: An island in the heart of
Southeast Asia, between Malaysia and Indonesia Area: 710.3 sq km Climate: Tropical 23 – 31 Degrees Celsius Population: 5.18 million Life Expectancy: 81.48 years Ethnic Groups: Chinese 74%, Malay 13%, Indian 9%, other ethnicities 3% Religions: Buddhism, Islam, Christianity, Taoism and Hinduism

6

7 Singapore Healthcare Services & Facilities

8 Primary Healthcare Services
18 Polyclinics 2,400 Private Clinics

9 7 5 1 1 6 Hospital Services Public Hospitals Acute General Hospitals
Women’s & Children’s Hospital 1 Tertiary Psychiatric Hospital 6 National Specialty Centres Hospital services 7 public hospitals: 5 acute general hospitals, a women's and children's hospital and one tertiary psychiatric hospital 6 national specialty centres: cancer, cardiac, eye, skin, neuroscience (neurology), and dental

10 Institute of Mental Health
700 acute; 1,100 long-stay inpatients

11 554 Daily Visits (Outpatient Clinics Only)
About Us Singapore’s only tertiary psychiatric institution National centre part of the NHG Regional Health System 2010 beds Looks after most severe cases Provides acute and long-term care 554 Daily Visits (Outpatient Clinics Only) 37,240 Outpatients (ES Included) 568 Acute 1,177 Long-stay 22 Daily Admissions* 700 acute; 1,100 long-stay inpatients 1,745 Inpatients* (as of 2013) * Excluding 23-hr observation ward

12 Top 5 Disorders Seen in 2012 OUTPATIENT VISITS Schizophrenic Disorders
Depressive Disorder Reaction to Severe Stress Other Anxiety Disorders Unspecified nonorganic psychosis INPATIENT DISCHARGES Schizophrenic Disorders Depressive Disorder Reaction to Severe Stress Mental and behavioural disorders due to use of opioids Unspecified nonorganic psychosis

13 4 Principles Patient-Centred Care Systems Thinking
Learning Organisation Staff Engagement 4 Principles

14 IMH Quality and Safety Framework
DETECTION VALIDATION ANALYSIS IMPROVEMENT Serious Reportable Event Frequent Adverse Events Near Misses General Feedback SPREAD CHANGE QI Framework explains the overview of QPS activities and processes. We detect possible risks , incidents, errors, adverse events , feedback through various QI initiatives / program/ committees. As shown in the pyramid, the first level of detection is from general feedback and second level is to detect near misses . We detect adverse events through various programs such as CRP , eHOR etc. Validation is a new process required by JCI 4th edition. A set of indicators that require to validate are HPOs, QPS, BSC etc. After the validation, we analyze them and proceed to improvement activities like QC, CPIPs, 6S & RIE. Monitor and Evaluate Change Facilitators, Training etc

15 Top Clinical Risks Assault Choking Falls Restraints Suicide
Major permanent injury or inpatient death as a result of these incidents Falls Restraints Suicide Deterioration of patients’ mental health status leading to potential harm to self and others as a result of patients defaulting psychiatric clinic follow-ups Patients defaulting on care

16 Reducing Bedtime Sedatives
Focus Target Interventions Sustain & Spread Frequent usage of PRN* sedatives in Geriatric Psychiatry wards To reduce the administration rate of PRN* bedtime sedatives** by nurses in an acute psycho-geriatric ward by 30% in 6 months. Make environment more conducive for sleep : change shift-handover location Pharmacological education to enhance nurses’ understanding Patient education to address lack of knowledge Introduce sleep monitoring chart to track patients’ sleep patterns Gains sustained & interventions successfully spread to another geriatric psychiatry ward *PRN is a medication that is ordered by a practitioner to be administered on an “As Needed” basis according to written parameters of a practitioner. #Sedatives is a substance that induces sedation by reducing irritability or excitement.

17 Average Administration Rate of Bedtime PRN Sedatives Per Week
51% Reduction

18 Tracking Discharged Patients
Care integration & treatment compliance for patients with Schizophrenia & Delusional Disorders Focus Increased specialist clinic attendance rate of recently discharged IMH patients by 10% in Year 1 as compared to baseline Target Use of risk and needs assessment and stratification Case Management and Case Tracking Integrating systems (between IMH and Community Partners) through right-siting Interventions Sustain & Spread Sharing project interventions & results with other public hospitals and community partners for spread

19

20 Adverse Events Studies
DETECTING HARM Adverse Events Studies

21 Adverse Events Studies 2007/2010
1st stage against a list of 18 triggers (from Harvard Medical Practice Study) as flags for potential adverse events that require further review. 2nd stage by clinician on criteria positive cases to determine occurrence, disability, causation and preventability of AE Double review for inter-rater reliability done for 10% RF1 and RF2 Metrics/Unit of measurement is adverse event, measure disability as estimate of severity, measure preventability as ascertained by clinician reviewers. Methodology similar to AE studies done by Australia, UK, Canada, Scandinavia, USA,WHO

22 Developing a Mental Health Trigger Tool

23 Mental Health Trigger Tool (MHTT)
A tool to effectively Identify Harm or Adverse Events (AE) in a mental health setting and monitor their rate over time

24 Most common methods of identifying and monitoring Harm or AE
Comprehensive File Review Voluntary Reporting Time and resource intensive <20 % reported 90-95% no harm to patients

25 Is there a more efficient method?
Global Trigger tool and Trigger tool Methodology - Developed by Institute of Health Improvement (IHI) “ a retrospective review of randomly selected patient records using triggers (clues) to detect AE” Triggers to identify AE- Jick 1974 Started in 1999 with a tool for adeverse drug events

26 IHI Global Trigger Tool
Harm defined as “Unintended physical injury resulting from or contributed to by medical care that requires additional montioring, treatment or hospitalisation or that results in death” Concentrate on identifying Harm or AE, not errors Only AE through acts of commission, not omission Preventability not a criterion Severity is rated based on NCC MERP index National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index adverse drug events

27 The GTT Review Methodology
Random set of patient records Trained Reviewers - Two Primary Reviewers - One physician Reviewer Excludes Psychiatric and Rehab Patients Trigger Modules : Cares (15) e.g. Transfusion of blood Medication (13) e.g. Abrupt medication stop • Surgical • Intensive Care • Perinatal • Emergency Department 30 to 35 % of all admissions have AE

28 Trigger tool in Mental Health
IHI Trigger Tool for Measuring Adverse Drug Events in a Mental Health Setting 30 triggers Sodium Polystyrene Sulfonate C. difficile Positive Stool Vitamin K Only addresses AE due to medications Not comprehensive / specific enough May not be applicable to all mental health settings Not much evidence base

29 Singapore Mental Health Trigger Tool Project
Developing Trigger Tool Exculsively for Mental Health Setting Resource and Time Efficient Comprehensive Applicable Internationally

30 MHTT Project MHTT Project Steering Committee
Planning (Feb/Mar 13) Preparation (Apr/May 13) Dev of MHTT (Jun/Jul 13) POC trial (Aug/Sep13) MHTT Project Steering Committee Workgroup to Develop the MHTT Team of Reviewers Project Plan / Timeline

31 MHTT Project Team

32 MHTT Project IHI White Paper on GTT A facilitated discussion and
Planning (Feb/Mar 13) Preparation (Apr/May 13) Dev of MHTT (Jun/Jul 13) POC trial (Aug/Sep13) Preliminary review of literature IHI White Paper on GTT Facilitated training A facilitated discussion and training on review of the charts were done with an experienced GTT chart reviewer and physician reviewer

33 MHTT Project Comprehensive Literature Review Focus Group
Planning (Feb/Mar 13) Preparation (Apr/May 13) Dev of MHTT (Jun/Jul 13) POC trial (Aug/Sep13) Comprehensive Literature Review Focus Group Clinical Advisory Panel Modified Delphi Panel

34 Comprehe-nsive Literature Review
Development of MHTT Comprehe-nsive Literature Review Clinical Advisory Panel Modified Delphi Panel Focus Group Trigger List

35 Development of MHTT Clinical Advisory Panel Modified Delphi Panel
Final List of Triggers Literature Review Focus Group Review of adverse events studies in mental health settings across the world Review of existing trigger tools Local adverse events studies/ reports Framework for reducing Adverse medication events in MH services - australia National safety priorities in mental health: a national plan for reducing harm- australia Patient safety in mental health- canada . BC Mental health and adddiction services Serious adverse events in mental health – health quality and safety commission New Zealand With Safety in Mind- patient safety observatory report- NPSA, UK

36 Development of MHTT Clinical Advisory Panel Modified Delphi Panel
Final List of Triggers Literature Reviews Focus Group Multidisciplinary focus group was formed to give input into the development of triggers Determined priority areas for trigger development based on AEs specific to mental health setting

37 Development of MHTT Clinical Advisory Panel Modified Delphi Panel
Final List of Triggers Literature Reviews Focus Group Advice on important AEs that matters in MH setting Advice on potential triggers that may identify those AEs

38 Development of MHTT Clinical Advisory Panel 4-Phase Delphi Process
Final List of Triggers Literature Reviews Focus Group Delphi panel of experts (Multidisciplinary) To collate expert feedback in a structured manner and formulate a consensus judgement on the choice of triggers Initial List = 30 triggers After Delphi Round 1 = 34 triggers After Delphi Round 2 = 38 triggers After Round 3 = 58 triggers After Round 4 = 50 triggers

39 Development of MHTT Clinical Advisory Panel Modified Delphi Panel
List of Triggers Literature Reviews Focus Group List of Triggers = 50 POC Trial planned to test out the trigger list A manual of triggers, their descriptions, guidelines to identify them and potential AEs were prepared

40 Main Challenges Definition of Harm or AE in Mental Health
Need to conform to IHI Trigger Tool system Commission vs Omission events Near Misses vs Actual Harm Psychological harm Not much evidence base

41 Triggers General Care Triggers Laboratory Triggers Medication Triggers
Code Triggers G1 Transfer to General Hospital/Medical Ward G2 Code Blue/ Cardio-Pulmonary arrest G3 Patient fall G4 Fever (Temp reading >37.5 deg) G5 Infection during hospital stay G6 Pressure ulcer G7 Referrals for consultation for medical reasons G8 Re-admission within 30 days G9 Fits/ seizures G10 Initiation of ( e.g. GCS) or increase in frequency of monitoring of parameters after admission (including BP,PR, RR, Temp ) G11 High BMI ( 30 or above) G12 DVT/PE following admission evidenced by imaging and/or D-dimer test G13 Use of urinary catheter General Care Triggers Laboratory Triggers Medication Triggers Mental Health Triggers

42 Triggers General Care Triggers Laboratory Triggers Medication Triggers
Code Triggers L1 X ray / CT Scan / MRI/ Ultrasound L2 Abnormal ECG L3 Serum Sodium <130 mmol/L L4 Platelet count <50000 L5 WBC <3.0 or Neutrophils <1.5 L6 Serum lithium> 1.2 mmol/L L7 Valproic Acid > 200 mg/ml L8 phenytoin > 20mg/ ml L9 Carbamazepine > 10mg/ml L10 Elevated Liver enzymes ALT or AST or GGT (> double the upper end of normal range) L11 Rising Serum Creatinine L12 Raised serum Creatinine Kinase L13 Digoxin level > 2mg/ml L14 International Normalized Ratio INR > 6 L15 Glucose < 3 mmol/L General Care Triggers Laboratory Triggers Medication Triggers Mental Health Triggers

43 Triggers General Care Triggers Laboratory Triggers Medication Triggers
Code Triggers M1 Rash / itching M2 Thyroxine M3 Anti-cholesterol medication (eg..Statins) M4 Hypoglycaemics (eg. Metformin) M5 Abrupt discontinuation of medication M6 Antibiotics/ antimicrobials M7 IV Epinephrine / Norepinephrine / Naloxone/ Esmolol / Flumezenil M8 Laxatives/Rectal Suppository / Enema M9 Oral or Parenteral (IM/IV) Anticholinergics (eg Benzhexol/Procyclidine/Cogentin/Benztropine) M10 Anti-emetics ( eg Metoclopramide) M11 Anti-diarrheals (eg. Loperamide) M12 Anti-histamines (eg. Chlorphenaramine) M13 Tetrabenazine M14 Analgesics/ Anti-inflammatory (eg. Paracetamol/Ibuprofen) M15 Over-sedation/drowsiness M16 Propranolol General Care Triggers Laboratory Triggers Medication Triggers Mental Health Triggers

44 Triggers General Care Triggers Laboratory Triggers Medication Triggers
Code Triggers MH1 Self-harm/ attempted suicide MH2 Violence or physical aggression by patient MH3 Physically or sexually assaulted by another patient MH4 Transfer to Higher Level of Care in Psychiatry (High Dependency Psychiatric Care Unit or DAV ward) MH5 Restraint use MH6 Absconding or missing from the ward Laboratory Triggers Medication Triggers Mental Health Triggers

45 MHTT-Proof Of Concept (POC) Trial
Is it usable? Does it identify triggers and harm? Is it time and resource efficient? Does the definition of harm requires modification? Does it identify harms that are clinically important? Can fewer triggers have the same result? New useful triggers?

46 MHTT-Proof Of Concept Trial
Planning (Feb/Mar 13) Preparation (Apr/May 13) Dev of MHTT (Jun/Jul 13) POC trial (Aug/Sep13) Sample = 140 (randomly chosen files of discharged patients) Excluded cases = 6 Cases excluded as defined in the criteria on length of inpatient stay > 3 days < 90 days Each file reviewed by two 1st level reviewers (nurse/pharmacist) followed by 2nd level physician reviewers Total cases reviewed = 134 Time to review each file = min

47 Triggers with Highest Count
MHTT Trial Findings Triggers with Highest Count Triggers with Highest Count M12 Anti-histamines (45) G10 Initiation of (eg GCS) or increase in frequency of parameters monitoring (39) M14 Analgesic / Anti-inflammatory (37) M8 Laxative/ Rectal suppository (34) MH5 Restraint Use (31)

48 Sensitivity for Individual Triggers (Top 5)
MHTT Trial Findings Sensitivity for Individual Triggers Sensitivity for Individual Triggers (Top 5) M8 Laxatives (0.38) M14 Initiation of (eg GCS) or increase freq of parameters monitoring (0.35) M5 Abrupt discontinuation of medication (0.29) M8 Oral or Parenteral (IM/IV) Anticholinergics (0.26) MH5 Restraint Use (0.21)

49 MHTT Trial Findings Different Triggers Same Harm … Examples Harm
Tardive Dyskinesia, Facial Twitching M5 Abrupt discontinuation of medication M9 Oral or Parenteral (IM/IV) Anticholinergics (Benzhexol/Procyclidine/Cogentin or Benztropine) Drug Allergy - Rash M1 Rash / Itching M12 Antihistamine Bruises / Swelling - due to Restraint MH5 Restraint Use MH2 Violence or Physical Aggression by Patient M14 Analgesics/ Anti-inflammatory MH2 Initiation of (eg GCS) or increase in frequency of parameters monitoring

50 MHTT Trial Findings Trigger Harm Cohen’s Kappa = 0.21
Inter-rater Reliability Trigger Cohen’s Kappa = 0.21 Harm Cohen’s Kappa = 0.48 No. of valid cases = 134

51 Trigger list – Trial on case files with
High Impact Harms in IMH

52 New Triggers Identified
Post Trial – New Triggers Incident Type New Triggers Identified that could lead to AE Intended self harm IM Haloperidol/ Lorazepam Concious Level Chart (CLC) Increased observation for potential suicide (PS) after admission Patient fall Reports of injury (Eg contusion / haematoma) CLC

53 Further Development Consulation with Dr Carol Haraden (IHI)
Multiple rounds of further review on Trigger list through focus group and consultation with Clinical Advisory Panel Eliminated triggers that indicated same harm Eliminated triggers that are unlikely to pick up serious harms Combined triggers with common themes Added new triggers Renamed the triggers for easy identification Current list triggers - Descriptive manual on definition and use - Consensus on Definition of Harm

54 cases with AEs cases without AEs
Validation Study Sample: Reviewers: Each case reviewed by two non-physicians (pharmacist/nurse) and one physician (psychiatrist, registrar and above) Analysis: sensitivity, specificity, positive and negative predictive value of the tool. Inter-rater reliability between the raters cases with AEs cases without AEs

55 二○一七年四月十一日 Thank You © 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries. The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION. 55


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