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The Mental Health Trigger Tool Concept and Development A/Prof Chua Hong Choon, Chief Executive Officer Dr Sajith Sreedharan, Consultant (General Psychiatry)

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Presentation on theme: "The Mental Health Trigger Tool Concept and Development A/Prof Chua Hong Choon, Chief Executive Officer Dr Sajith Sreedharan, Consultant (General Psychiatry)"— Presentation transcript:

1 The Mental Health Trigger Tool Concept and Development A/Prof Chua Hong Choon, Chief Executive Officer Dr Sajith Sreedharan, Consultant (General Psychiatry) Apr 2014

2 Disclosures: None

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

4

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

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7 Singapore Healthcare Services & Facilities

8 Primary Healthcare Services 18 Polyclinics 2,400 Private Clinics

9 Hospital Services 7 Public Hospitals 5 Acute General Hospitals 1 Women’s & Children’s Hospital 1 Tertiary Psychiatric Hospital 6 National Specialty Centres

10 Institute of Mental Health

11 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) 22 Daily Admissions* 1,745 Inpatients* 37,240 Outpatients (ES Included) 37,240 Outpatients (ES Included) 568 Acute 1,177 Long-stay (as of 2013) * Excluding 23-hr observation ward

12 Top 5 Disorders Seen in 2012 INPATIENT DISCHARGES 1.Schizophrenic Disorders 2.Depressive Disorder 3.Reaction to Severe Stress 4.Mental and behavioural disorders due to use of opioids 5.Unspecified nonorganic psychosis INPATIENT DISCHARGES 1.Schizophrenic Disorders 2.Depressive Disorder 3.Reaction to Severe Stress 4.Mental and behavioural disorders due to use of opioids 5.Unspecified nonorganic psychosis OUTPATIENT VISITS 1.Schizophrenic Disorders 2.Depressive Disorder 3.Reaction to Severe Stress 4.Other Anxiety Disorders 5.Unspecified nonorganic psychosis OUTPATIENT VISITS 1.Schizophrenic Disorders 2.Depressive Disorder 3.Reaction to Severe Stress 4.Other Anxiety Disorders 5.Unspecified nonorganic psychosis

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

14 IMH Quality and Safety Framework DETECTION VALIDATION ANALYSIS IMPROVEMENT SPREAD CHANGE Monitor and Evaluate Change Facilitators, Training etc

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

16 Reducing Bedtime Sedatives *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. 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

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

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

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20 DETECTING HARM Adverse Events Studies

21 Adverse Events Studies 2007/2010 Metrics/Unit of measurement o is adverse event, o measure disability as estimate of severity, o measure preventability as ascertained by clinician reviewers.

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 Time and resource intensive Voluntary Reporting Comprehensive File Review <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”

26 IHI Global Trigger Tool 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 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” 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”

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

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

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

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

31 MHTT Project Team

32 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 Planning (Feb/Mar 13) Planning (Feb/Mar 13) Preparation (Apr/May 13) Preparation (Apr/May 13) Dev of MHTT (Jun/Jul 13) Dev of MHTT (Jun/Jul 13) POC trial (Aug/Sep13) POC trial (Aug/Sep13) MHTT Project

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

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

35 Literature Review Focus Group Clinical Advisory Panel Modified Delphi Panel Final List of Triggers Review of adverse events studies in mental health settings across the world Review of existing trigger tools Local adverse events studies/ reports Development of MHTT

36 Literature Reviews Focus Group Clinical Advisory Panel Modified Delphi Panel Final List of Triggers 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 Development of MHTT

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

38 Literature Reviews Focus Group Clinical Advisory Panel 4-Phase Delphi Process Final List of Triggers 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 Development of MHTT

39 Literature Reviews Focus Group Clinical Advisory Panel Modified Delphi Panel List of Triggers Development of MHTT 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

41 General Care Triggers General Care Triggers Laboratory Triggers Laboratory Triggers Medication Triggers Medication Triggers Mental Health Triggers Mental Health Triggers CodeTriggers G1Transfer to General Hospital/Medical Ward G2Code Blue/ Cardio-Pulmonary arrest G3Patient fall G4Fever (Temp reading >37.5 deg) G5Infection during hospital stay G6Pressure ulcer G7Referrals for consultation for medical reasons G8Re-admission within 30 days G9Fits/ seizures G10Initiation of ( e.g. GCS) or increase in frequency of monitoring of parameters after admission (including BP,PR, RR, Temp ) G11High BMI ( 30 or above) G12DVT/PE following admission evidenced by imaging and/or D-dimer test G13Use of urinary catheter Triggers

42 General Care Triggers General Care Triggers Laboratory Triggers Laboratory Triggers Medication Triggers Medication Triggers Mental Health Triggers Mental Health Triggers CodeTriggers L1 X ray / CT Scan / MRI/ Ultrasound L2Abnormal ECG L3Serum Sodium <130 mmol/L L4Platelet count <50000 L5WBC <3.0 or Neutrophils <1.5 L6Serum lithium> 1.2 mmol/L L7Valproic Acid > 200 mg/ml L8phenytoin > 20mg/ ml L9Carbamazepine > 10mg/ml L10Elevated Liver enzymes ALT or AST or GGT (> double the upper end of normal range) L11Rising Serum Creatinine L12Raised serum Creatinine Kinase L13Digoxin level > 2mg/ml L14International Normalized Ratio INR > 6 L15Glucose < 3 mmol/L

43 General Care Triggers General Care Triggers Laboratory Triggers Laboratory Triggers Medication Triggers Medication Triggers Mental Health Triggers Mental Health Triggers CodeTriggers M1Rash / itching M2Thyroxine M3Anti-cholesterol medication (eg..Statins) M4Hypoglycaemics (eg. Metformin) M5Abrupt discontinuation of medication M6Antibiotics/ antimicrobials M7IV Epinephrine / Norepinephrine / Naloxone/ Esmolol / Flumezenil M8Laxatives/Rectal Suppository / Enema M9Oral or Parenteral (IM/IV) Anticholinergics (eg Benzhexol/Procyclidine/Cogentin/Benztropine) M10Anti-emetics ( eg Metoclopramide) M11Anti-diarrheals (eg. Loperamide) M12Anti-histamines (eg. Chlorphenaramine) M13Tetrabenazine M14Analgesics/ Anti-inflammatory (eg. Paracetamol/Ibuprofen) M15Over-sedation/drowsiness M16 Propranolol

44 General Care Triggers General Care Triggers Laboratory Triggers Laboratory Triggers Medication Triggers Medication Triggers Mental Health Triggers Mental Health Triggers CodeTriggers MH1Self-harm/ attempted suicide MH2Violence or physical aggression by patient MH3Physically or sexually assaulted by another patient MH4Transfer to Higher Level of Care in Psychiatry (High Dependency Psychiatric Care Unit or DAV ward) MH5Restraint use MH6Absconding or missing from the ward

45 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? MHTT-Proof Of Concept (POC) Trial

46 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 1 st level reviewers (nurse/pharmacist) followed by 2 nd level physician reviewers Total cases reviewed = 134  Time to review each file = min Planning (Feb/Mar 13) Planning (Feb/Mar 13) Preparation (Apr/May 13) Preparation (Apr/May 13) Dev of MHTT (Jun/Jul 13) Dev of MHTT (Jun/Jul 13) POC trial (Aug/Sep13) POC trial (Aug/Sep13) MHTT-Proof Of Concept Trial

47 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) MHTT Trial Findings Triggers with Highest Count

48 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) MHTT Trial Findings Sensitivity for Individual Triggers

49 MHTT Trial Findings Different Triggers Same Harm … Examples HarmTriggers 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 M5 Abrupt discontinuation of medication 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 Trigger – Cohen’s Kappa = 0.21 Harm – Cohen’s Kappa = 0.48 No. of valid cases = 134 MHTT Trial Findings Inter-rater Reliability

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

52 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 - 26 triggers - Descriptive manual on definition and use - Consensus on Definition of Harm

54 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 Thank You


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