‘Trigger Tool’ Available for Hospitals and SNFs

How can ‘trigger tools’ identify adverse events?

authors Lynne Jeter

The use of trigger tools for healthcare facilities to identify adverse events (AE), their possible sources and the level of harm to patients has been an accepted and challenging practice for patient safety since the mid-2000s.

Now, an easy-to-use tool focused on the specific needs of skilled nursing facilities (SNFs) recently became available.

AE – defined as unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalization, or that results in death – are frequent and costly to patients, insurers, and providers.

Last December at the Institute for Healthcare Improvement’s (IHI) 27th Annual National Forum on Quality Improvement in Healthcare in Orlando, Fla., presenters reviewed a methodology developed to identify AE in SNFs.

The IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events is based on the IHI Global Trigger Tool (GTT) methodology, which involves a retrospective review of a random sample of inpatient hospital records, using clues or “triggers” to identify possible AE. 

“In our earlier work on the GTT, as we were trying to improve safety, we discovered that it was very difficult to find an appropriate measure to understand whether we were improving,” said Frank Federico, RPh, vice president and senior expert on patient safety for the IHI. “Many relied on voluntary reports in what we’d describe as incident reporting systems. Those systems are a source of information but they’re not reliable in the sense that you have to know that there was harm, or a mistake. You have to be willing to report; there has to be a culture of safety to report and it has to be easy.”

The harm rates in SNFs are similar to those in acute care hospitals, but the setting presents unique challenges.

In 2014, the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) estimated that 33 percent of Medicare beneficiaries admitted to SNFs following a hospital stay experienced an AE event during their SNF stay. Fifty-nine percent of the identified harm events were preventable, largely because of substandard treatment, inadequate resident monitoring, and failure to provide necessary care, according to the report. The report also found that hospital care resulting from AE in SNFs cost Medicare an estimated $208 million in a month and $2.8 billion in a year.

“We looked at developing a methodology that took advantage of information that already existed in the medical record. The gold standard for any research has been total chart review. That is, you look at the chart for the entire stay, you read every page, every note, and every lab value. That’s quite expensive and time consuming. It can be done if you’re doing research, but if you want a constant measure of how well you’re performing, it’s so prohibitively expensive and time consuming that no one would do it,” he said.

Based on that OIG report results and findings, the Centers for Medicare & Medicaid Services (CMS) developed the Adverse Drug Event Trigger Tool.

“The tool was made available by the OIG,” Federico said, adding that IHI helped with training on the use of the tool. “When we determined the tool was valuable, we decided to develop a guide to use the tool because we knew if we just put it out there, it wouldn’t be used in the manner designed. That’s why we developed the SNF trigger tool that’s on our website. It provides both the instructions on the tool and the tool itself.”

Input for developing the SNF tool, according to Federico, came from geriatricians, geriatric nurses, nurse practitioners and pharmacists.

Based on the GTT methodology, the IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events provides a method for accurately identifying AE and measuring the rate of AE incidence over time in SNFs.

“We adopted a methodology that took some of the best of the chart review, used a sampling methodology and as a result, facilities are able to determine their rate of harm,” according to Federico.

The SNF tool also provides a detailed guidance on designing a trigger tool review, a list of SNF-specific triggers and definitions, examples of AE that occur in SNFs, and an extensive FAQ section.

The SNF tool emphasizes scanning for specific patterns that might reveal triggers that would indicate harm. Federico said they recommend two people be in the review process, because they found that using two sets of eyes has a 20 percent higher rate of identifying an AE.

However, Federico acknowledged that it’s a labor intensive process so it’s acceptable to use just one nurse, as long as there’s consistency using the same methodology. He said too, that IHI is working on an automated way of looking at in-patient charts using the GTT methodology, with a goal of taking that concept and applying it to the electronic health record for SNFs, but that’s still in development.

The second phase of review adds a physician. Because of their training, they can determine whether what’s considered harm is related to the care or the disease process.

The SNF tool has extensive charting to determine the severity of harm.

The National Coordinating Council for Medication Error Reporting and Prevention’s (NCC MERP) Medication Error Index is frequently used to classify harm caused by AE. The index was originally developed to classify medication errors, based on the severity of the outcome, and included nine severity levels. Levels A through D describe near-miss events and Levels E through I characterize harm that reached the patient. To make a determination on the level of harm caused by an error, the index considers factors such as whether the error reached the patient and if the patient is harmed, to what degree.

Federico said it’s not all harm; it’s a rate of harm.

“The triggers are things that normally exist in the medical record like lab values, medications, nursing notes, change in levels of care, operative notes,” he said.

Federico pointed out that what they did differently from other tools available, was too focused on any harm the patient experienced whether it was preventable or non-preventable. The process doesn’t care how many triggers you collect; it matters the degree of understanding of how much harm the patient experienced.

“So a trigger might be the administration of an anti-histamine that could be either because the patient had an allergic reaction, or it could be to help a child sleep. If the trigger fires, you’d look in the notes and ask ‘why did this patient get an antihistamine?’ and if it’s because they had an allergic reaction, then it’s counted as harm,” he said.

Federico said it’s important to count everything.

“The reason we do that is, if we spend more time deciding if something is preventable or non-preventable, we spend too much time debating and not enough time improving,” he emphasized.

The SNF tool as presented is still very new with scant results at this point. However, the IHI is working with long-term care facilities and SNFs to implement its use. Federico said that as of January 13, there were 1,656 views of the tool and 587 downloads. “Generally, we have an offering where we train people through WebX or other technology to use the tools, and it’s during that time, we hear about qualitative information on the tool,” he said. “When you’re running a healthcare organization, one key critical to success is asking, ‘are we providing good care to our patients?’ Unless you have some other indicator that’s able to give you this kind of information, then you should be using this tool.”



The IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Effects

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