1. Trigger Tools
Fran Collins
Associate
NHS Institute for Innovation and Improvement

2. What are we trying to achieve?
No avoidable deaths or disease
No harm
No unnecessary pain
No waste
No delays
No feelings of helplessness
No inequality
Safety
Reliability
Flow
Ideal Care
Getting patients better faster and safer

3. Background to Trigger Tools
Traditional effort to detect AEs is via voluntary reporting
10-20% of total are reported
Of those 90-95% no harm events
Need a more effective and consistent way to detect harm events
Recent research and publications describe trigger tools

4. Background
David Classen, Microbiologist, starts to use “Trigger Tools” within microbiology in USA. (JAMA 1990)
Institute for Healthcare Improvement develop the Trigger Tools in other areas of medical practice. Eg ITU
Roger Resar of IHI leads the development of Trigger Tools. (QSHC 2003) IHI tests and spreads GTT 2004.
Luton & Dunstable Hospital begins using Trigger Tools in 2003 within the IHI Matrix Studies. .
The Global Trigger Tool is a trimmed down selection of the better triggers

5. Commons Select Committee 6th Report Patient Safety June 2009
Current Position of TT
Commons Select Committee 6th Report Patient Safety June 2009
Measurement and evaluation
In order to monitor whether or not services are being made safer, data on the incidence of harm must be systematically collected. The best available means of doing this is by reviewing samples of patients' case notes at periodic intervals, in order to calculate a rate of harm. This should be undertaken by all hospitals and data produced in this way should be gathered together by the NPSA.
CQUIN Indicators
From April 2010 some areas now include use of TT as a mandatory indicator
Commissioning for Quality & Innovation.- Payment framework developed to ensure a proportion of the provider income is determined by their work towards quality & innovation

6. Aim of TT To detect (physical)HARM events Not preventability / error
Harm from perspective of patient
Organisational rate of harm
Identifies a trend
Would you be happy if the event in question happened to you?

7. Trigger modules General Care; G1-G8 Surgical Care; S1-S3
Intensive Care; I1-I2
Medication;M1-M5
Lab test;L1-L14
5 modules
31 triggers

8. General care module Lack of early warning score Patient fall Decubiti
Readmission within 30 days
Shock or cardiac arrest
DVT / PE following admission
Complication of treatment or procedure
Transfer to higher level of care

9. Surgical / Intensive care modules
Surgical Care Module
Return to theatre
Change in planned procedure
Removal / injury or repair of organ
Intensive care module
Readmission to ICU or HDU
Unplanned transfer to ICU or HDU

10. Medication module Vitamin K Naloxone Flumazenil Glucagon / 50% glucose
Abrupt medication stop

11. Lab test module INR > 5 MRSA bacteraemia C difficile Transfusion
Abrupt drop in Hb > 25%
Rising urea / creatinine > 2x baseline
Electrolyte abnormalities
Na , 120 > or > 160
K ,2.5 or > 6.5
Hypoglycaemia <3 mmol/l
Raised troponin > 1.5 ng/ml
MRSA bacteraemia
C difficile
VRE
Wound infection
Nosocomial pneumonia
Positive blood culture

12. Preparing & Sampling Agree definition of harm event
Small, regular, random sampling
10 records every 2/52 ie 20 per month
20 minutes per record
Useful to keep a record of the agreed definition

13. Reviewers 2 initial case note reviewers Nurses Pharmacists
Junior doctors ?
Physician (consultant) to confirm link between trigger and event and severity of event

14. Review process Random selection ( Trust / Division / Service)
LOS > 24hrs and < 30 days
Completed case notes – should include discharge summary and coding
20 min max per set
First 20 independent reviewers to establish inter- rate reliability
Look at all parts of case notes

15. Review process Trigger is presence of an item on list eg INR >5
Trigger itself is not AE
Trigger leads to close review to establish if AE occurred
May find triggers without AEs
If AE found then grade according to category of harm
Complete GTT sheet
Data entry onto spreadsheet includes AE type ( G1 etc) and severity (E-I)
Bleeding
Haematoma
Anaemia

16. Points / FAQs
Triggers can be multiples in one box e.g. G4 readmission x3
Severity Scores - two Harms can have two different scores.
Length of Stay - count each calendar day of admission
Need to agree internally on how to grade certain events
eg peri-operative bleeding / transfusion / drop in Hb

17. Case 1 Pt admitted for Hip replacement on 29/12/06, discharge 04/01/07
No EWS (G1)
Foot drop (G7)
Drop in Hb (L3) ? dilutional
Transfusion (L2) ? Given
Other findings
Admission form – Right Total Hip Replacement- Consent and procedure Left
Penicillin allergy – prescribed cefuroxime
Clexane / diclofenac – epidural
Codeine regular & PRN ,
MST regular & oromorph PRN
Cyclizine administration
7.5 l fluid administration / Low BP
Category ?G
Pull more notes than you need
Pull notes with completed discharge summary (may be 3-6 /12 behind)
Samples should be consecutive
Have several trained reviewers ( A/L / sickness)
Serious incidents not previously identified should be reported through the risk system and notified to relevant team (rare)
Anonymise data record forms and destroy them after use
‘Other’ findings are useful- keep a list

18. Success with GTT Measurement for Improvement in your Trust
Dedicated time
Dedicated people
Dedicated support for ;
Random case note selection
Data entry
Analysis
Reporting
Commitment
Reporting internally and on PSF extranet
Measurement for Improvement in your Trust
It is not a science
It requires practice & good communication
Use it to create tension to reduce avoidable harm and death