Baylor-Health-Care-System-ADE-Trigger-Tool-Impleme.ppt

Targeted Injury Detection System for Adverse Drug Events:An AHRQ-Funded Patient Safety InitiativeTIDS-ADE The Quality ColloquiumAugust 20,2008Andrew Masica,MD,MSCIAndrew Masica,MD,MSCIBaylor Health Care System-Dallas,TXBaylor Health Care System-Dallas,TXTIDS-ADE BackgroundTrigger tool methodologyfocused mechanism for risk reductionevent precipitates a responseExample:IHI Adverse drug eventscommon/costlyusually actionableclinical/IT interfaceProject GoalsDevelop a functional trigger tool for ADEs in hospitalized patients that can be disseminated broadlyDetection at multiple time points related to event occurrence(before,during,or after)Potential benefits in clinical care setting:1.Prevention of ADEs2.Mitigation of ongoing ADEs3.Capture of“true”ADE rateToolkit for real-world implementationDefinitionsTrigger=alert:any event prompting further investigation by clinician.ADE criteria=if event attributed to drug and:reaches a level of harm that is durable orrequires a change in the treatment plan due to unacceptable level of risk for harm or patient discomfort Example of“unacceptable risk”for patient harm:-INR-INR 6.0 and active warfarin order 6.0 and active warfarin order-event prompted discontinuation of drug=ADE Broader concept of ADEs Broader concept of ADEs Organizational Structure Coordinating CenterRTI Conference Calls AHRQ In-person meetingsSite leads Local Test Site Pharmacy champion Pharmacy IT Pharmacy Staff Site System Leadership Patient Safety Health Care Improvement Project champion -oversight -data managementImplementation:Site Environments Site leader meetingsActivation of IT/programming resources Project introduction to site staff Validation of triggersLaunch 3-9 months prior to start2-6 months prior to start1-4 months prior to start4-6 weeks prior to startBegin pilotTaskTimingImplementation:TriggersChoice/set-up of triggers:higher yield alerts(Classen,Evans JAMA 1991)core set of 1520 consensus,tiered TIDS alertstailoring to local site capabilities/priorities Trigger validation steps(3-phases):programmers bank of“dummy data”real-time pre-launch tests by site IT pharmacistpost-launch troubleshooting for obvious“misses”Uniform process for evaluating trigger utility TIDS-ADE WorkflowAlert Work List Patient ID Date/location Trigger details TriageAlert Review Chart Patient InterventionTrigger Evaluation Respond to?s Data Warehouse Biweekly meetings Central Pharmacy FloorVirtual 15 minutes 1-2 minutes(review)1-2 minutes 1 minute(response)Per alertResultsTest site average:5-10 alerts per 100 patient daysPreliminary data from alpha-site testing Trigger EvaluationWas the alert useful?Trigger EvaluationDid the alert detect an adverse event or trend?Trigger EvaluationDid the alert change patient care?Trigger evaluationDid a drug cause the adverse event or trend?TIDS-ADE:Trigger SummaryResults can guide refinement of alerts.Impact on ADE Detection ratesExpanded definition of ADEs for project:patient harm or unacceptable risk for patient harmTIDS Alerts considered to have detected an ADE if:alert detected an adverse event or trendadverse event or trend was caused by a drugBaylor Grapevine 40 cases meeting both conditions over 10 weeksApproximately 4-5 ADEs detected per week with TIDS2.3 ADEs per 100 admissions Voluntary reporting:0.5 ADEs per 100 admissionsLower ADE rate at Baylor?Sites in published literature:3-6 ADEs per 100 admissionsacademic centers/training programsmature EHRs/CPOEexperience with trigger tool methodologyvs.Community setting paper based with varying degrees of IT supportstaffing limitationsacceptance of trigger approach to ADEs verification process can be difficultAdditional OutcomesQualitative Feedbacklevel of detail in alert felt to be beneficialfavorable view of alerts with trending evaluation piece undermined perceived usefulnesssharp learning curvefits well into existing practice patternsQuantitative 80 hours of programming time for study triggers45 minutes pharmacist time daily High risk situations can be captured prospectively with use of a trigger tool Need to resource multi-site collaboration general framework for implementation Outcomes are influenced by site characteristicsperformance of specific triggers ADE detection rateDynamic evaluation process for alerts is criticaloptimizes performance of the triggering systemreduction in alert fatigueLessons learned from TIDS-ADETIDS-ADE:Future DirectionsFull analysis/toolkit development in progressIncorporation of broader ADE definition into daily patient care Clarify endpoints for“successful”triggersCross-cutting projectrealistic planning for resource allocationsTIDS-ADE Leaders/Sitesthanks to all!Michael Harrison,PhDAHRQJim Battles,PhDAHRQ Amy Helwig,MD,MSAHRQShula Bernard,RN,PhD*RTIJonathan Nebeker,MD,MSUniversity of Utah/VAScott Evans,MS,PhDIntermountain Brent James,MD,MSIntermountainBruce Bayley,PhDProvidence Health CareSteve Pickette,PharmD,BCPS Providence Health CareHoward Peckman,PharmDUNC-Chapel HillBaylor Grapevine Pharmacy StaffBaylor Health CareAndrew Masica,MD,MSCIBaylor Health Care*Principal Investigator;Senior Scientist