Adverse event detection at Adventist Health System
Adventist Health System is a not-for-profit healthcare organization spanning portions of the southwestern, Midwestern, Appalachian, and southeastern regions of the United States. The 42 campuses that comprise Adventist Health System include 25 acute care, critical care, and rehabilitation hospitals ranging in size from 25 beds to 1,080 beds. These hospitals, combined, admit a total of 335,000 inpatients annually.
AHS was able to use findings from Risk Trigger to inspire and motivate health care providers, the executive team, and hospital boards of directors to make and support needed changes.
In 2009, Adventist Health System began using Risk Trigger – Pascal Metrics’ enhanced version of the IHI’s Global Trigger Tool (GTT) 1 – to more accurately gauge the number, percentages, types, and levels of severity of adverse events occurring in its facilities. Researchers have found the GTT identifies at least 10 times more serious adverse events than other methods of adverse event detection, and suggest that when the GTT is automated and integrated with electronic medical record systems as it is in Risk Trigger, adverse event detection becomes less labor intensive, less costly, and more generalizable than when the original paper-based version is used. 2
Risk Trigger enables hospital partners the ability to import patient demographic and visit-specific information, minimizing the amount of manual data entry required of GTT team members. In addition, the summary review and physician authentication process is available online through Pascal Metrics’ Web-based platform, HealthBench, which decreases additional data entry requirements.
The Adventist Health System Office of Clinical Effectiveness reports the adverse events it identifies through its use of Risk Trigger to all of its facilities quarterly in a packet that includes three reports generated by HealthBench: a cumulative report for all Adventist Health System hospitals, showing the top five harms for each facility within the system; an individual facility report showing the top five harms for that particular hospital; and a de-identified listing of all the harms found system-wide. HealthBench allows the Adventist Health System Office of Clinical Effectiveness the opportunity to drill down and analyze these data in greater detail.
Figure 1 indicates the number of hospital-acquired adverse events across categories within AHS for the time period of 2 years.
Using Risk Trigger, Adventist Health System reviewed 11,392 patient records between January 2009 and December 2010, finding a total of 4,418 adverse events clustered in the following five categories: surgery or other procedures, healthcare-associated infections, medication/intravenous fluids, patient care, and perinatal care. The top adverse events across Adventist Health System were associated with medication-related glycemic management. To act on this finding, reducing medication-related glycemic adverse events became the focus of Adventist Health System’s Glycemic Collaborative and one of their clinical accountabilities for 2010.
The Adventist Health System Glycemic Collaborative is a short-term (6 to 15 months) project that brings together a large number of teams from its hospitals and clinics to seek improvement in medication-related glycemic management. Allan Frankel, M.D., of Pascal Metrics, trained Adventist Health System leadership and staff in using the IHI Collaborative Model for Improvement, which uses small tests of change as opposed to the “big bang” approach to maximize the potential for success.
Figure 2 indicates the number of hospital-acquired adverse events per 1000 patient days across severity levels (based on the NCC-MERP scale) for the time period of 2 years.
The goal of Adventist Health System has been to increase the percentage of patients experiencing glycemic control by implementing standard evidence-based order sets focused on insulin administration. Adventist Health System has identified small tests of change to be executed and tracked using run-charts on a bi-weekly basis, annotating small tests on each of the run charts at the local facility level. The Adventist Health System Office of Clinical Effectiveness holds monthly conference calls and site visits to support the Collaborative, fostering shared learning among facilities and providing additional training on specific protocols. Some facilities participating in the Glycemic Collaborative have achieved zero hypoglycemic events for more than 6 months after implementing the new protocol.
The Risk Trigger tool on HealthBench has the eye-opening effect of allowing healthcare providers to connect patient harm with patient care. Adventist Health System was able to use findings from Risk Trigger to inspire and motivate health care providers, the executive team, and hospital boards of directors to make and support needed changes. These changes include making adjustments in process and practice, providing resources to facilitate change, removing barriers to change, and transforming the institutional culture in a system-wide commitment to reduce patient harm.
1. Global Trigger Tool and IHI Global Trigger Tool are trademarks of the Institute for Healthcare Improvement (IHI), Cambridge, Massachusetts, USA (www.ihi.org).
2. Classen DC, Resar R, Griffin F, Federico F, Frankel T, Kimmel N, Whittington JC, Frankel A, Seger A, James BC: ‘Global Trigger Tool’ shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs 2011;30(4):581-589. 2011.
