Improvement and Utilization of Wandering Unfavorable Occasion Trigger Devices Amy K. Rosen, PhD AHRQ Meeting Sept. 14, 2.


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Kaafarani H, Rosen AK, et al. Improvement of Trigger Tools for Surveillance of Adverse Events in Ambulatory Surgery. VA HSR&D QUERI National Meeting, Phoenix, AZ. ...
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Advancement and Use of Ambulatory Adverse Event Trigger Tools Amy K. Rosen, PhD AHRQ Conference Sept. 14, 2009 Boston University School of Public Health, Boston, MA, VA Center for Healthcare Quality, Outcomes, and Economic Research (CHQOER), Bedford MA akrosen@bu.edu

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Acknowledgments PI Amy Rosen, PhD Co-PI Jonathan Nebeker, MD, MS Co-Investigators: Stephan Gaehde, MD Haytham Kaafarani, MD, MPH Brenna Long, MA Hillary Mull, MPP Brian Nordberg, BS Steve Pickard, MS Peter Rivard, PhD Lucy Savitz, PhD, MBA Chris Shanahan, MD, MPH Stephanie Shimada, PhD Sponsored by AHRQ Contract No. HHSA290200600012, Task Order Officer Amy Helwig, MD

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Project Goal and Settings Goal: Develop antagonistic occasion (AEs) triggers for the outpatient setting Outpatient surgery Outpatient unfriendly medication occasions (ADEs) Three destinations for patient information: Boston Medical Center (BMC) Intermountain Healthcare Veterans Health Administration (VA)

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Background Triggers are calculations that utilization electronic patient information to recognize designs predictable with a conceivable unfavorable occasion e.g. , the blend of a lab esteem edge and a dynamic remedy Global versus AE particular trigger: Flags the outline for the suspicion of event of any AE or the event of a particular AE Interventionist triggers: Mostly ADEs Gives suppliers an opportunity to react and maintain a strategic distance from ready over-burden

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Literature Review Clinical Input Focus Groups Clinical Advisory Panel Modified Delphi Panel Final List of Triggers Methods Document existing triggers Establish predominance of outpatient AEs Establish essential drivers of outpatient AEs

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Literature Review Clinical Input Focus Groups Modified Delphi Panel Final List of Triggers Methods Document existing triggers Establish pervasiveness of outpatient AEs Establish essential drivers of outpatient AEs Review epidemiological premise for AEs Input clinical learning and information required into trigger standards Clinical Advisory Panel

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Literature Review Clinical Input Focus Groups Clinical Advisory Panel Modified Delphi Panel Final List of Triggers Methods Document existing triggers Establish commonness of outpatient AEs Establish essential drivers of outpatient AEs Review epidemiological premise for AEs Input clinical learning and information required into trigger tenets Research information restrictions Determine need ranges for trigger improvement Develop strategies to evaluate triggers

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Literature Review Clinical Input Focus Groups Clinical Advisory Panel Modified Delphi Panel Methods Document existing triggers Establish predominance of outpatient AEs Establish essential drivers of outpatient AEs Review epidemiological premise for AEs Input clinical learning and information required into trigger guidelines Research information impediments Determine need regions for trigger advancement Develop techniques to investigate triggers Refine rules/trigger rationale Refine need zones need regions for trigger improvement Final List of Triggers

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Literature Review Clinical Input Focus Groups Clinical Advisory Panel Modified Delphi Panel Final List of Triggers Methods Document existing triggers Establish commonness of outpatient AEs Establish essential drivers of outpatient AEs Review epidemiological premise for AEs Input clinical learning and information required into trigger principles Research information constraints Determine need zones for trigger advancement Develop techniques to study triggers Refine rules/trigger rationale Refine need zones need zones for trigger improvement Rate need of AE causes Rate need of AEs Rate triggers in light of framework and patient-level points of view

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Methods Obtained de-distinguished clinical information from every site Combined the information fields from every site into a SQL database Created a counterfeit electronic therapeutic record (EMR) interface to empower case arrangement Boston Medical Ctr Intermountain VA (VISN 19) Mock EMR Trigger Database

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Global Trigger Tools – Outpatient Surgery

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AE-Specific Trigger Tools – Outpatient Surgery

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Surgery Trigger Logic: Procedure Fire if: Same-day surgery AND strategy (interventional radiological OR urological OR cardiovascular OR gastroenterological) OR re-operation ≤ 30 days

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AE-Specific Trigger Tools – ADE

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AE-Specific Trigger Tools – ADE (cont\'d)

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ADE Trigger Logic: Change in Renal Clearance Fire if: Subsequent increment in creatinine > 33% and dosage > than measurement preceding creatinine estimation (This is the reference creatinine level) AND NOT (trimethoprim began in interim between 1 day before creatinine estimation and after reference creatinine level) AND NOT (all GFR reducers and renal poisons suspended or lapsed > 3 months before activating quality) Remove trigger if reaction taken inside window: Renal poison stopped or GFR reducer dosage lessened 0-6 days in the wake of terminating criteria fulfilled OR Creatinine came about 0-6 days in the wake of terminating criteria fulfilled

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Data Challenges – Accessing Data Political/Logistical Barriers Gaining consent to get to the information Developed de-recognizable proof calculation Challenge meeting HIPAA consistence Administrative boundaries to getting access Encrypting/guaranteeing safe exchange of information between destinations Safe stockpiling of information from various organizations IT Resources Availability of work force for information pulls Computing foundations Pulling notes too asset escalated

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Data Challenges – Data Elements "IT Black Box" Researchers dependent on IT staff\'s customizing, no real way to find out culmination of information Inconsistencies in coding crosswise over organizations Same data, distinctive coding: Gender: M/F versus 1/2/3 Units of measure: metric versus US versus missing ICD-9-CM codes put away with or without periods ICD-9-CM methodology codes were distracted for a few systems Lab titles conflicting crosswise over settings Lack of documentation re: coding rehearses Numeric results inside content information

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Data Challenges – Data Elements (cont\'d) Missing information Loss of data from content de-ID calculation Fuzzy example and word coordinating expelled some key clinical terms from clinical notes De-ID made notes hard to peruse Removal of dates brought about loss of data about clinical request Missing National Drug Codes (NDCs) in drug store information Free content versus institutionalized day by day measurement data TAKE ONE-HALF TABLET BY MOUTH EVERY DAY FOR 2 WEEKS, THEN TAKE  ONE-HALF TABLET TWO (2) TIMES A DAY FOR 2 WEEKS, THEN TAKE ONE TABLET  TWO (2) TIMES A DAY FOR 2 WEEKS, THEN TAKE TWO TABLETS TWO (2) TIMES A  DAY FOR 2 WEEKS, THEN TAKE THREE TABLETS TWO (2) TIMES A DAY FOR 2  WEEKS, THEN TAKE FOUR TABLETS TWO (2) TIMES A DAY INCREASE DOSE  GRADUALLY.  WHEN GOING FROM 25 TO 50 MG START WITH INCREASING THE AM  DOSE FOR 2WEEKS, THEN THE AM AND PM DOSE.  DO THIS WHEN INCREASING  FROM 50 TO 75 AND 75 TO 100.  IF QUESTIONS PLEASE CALL. Absence of units in lab information

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Next Steps Case characterization RNs arranging surgery AE trigger-hailed cases Pharmacists ordering ADE trigger-hailed cases Calculate positive prescient worth (PPV) for every trigger Conduct a second round of center gatherings at every organization Hold telephone call with trigger specialists to audit rationale and examine comes about

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Dissemination to Date Triggers and Targeted Injury Detection Systems (TIDS)Expert Panel Meeting , Rockville, MD. June 2008. See procedures at http://www.ahrq.gov/QUAL/triggers/Mull HJ & Nebeker, JR. Informatics Tools for the Development of Triggers for Outpatient Adverse Drug Events. AMIA Annual Symposium Proceedings . Nov 2008, 6:505-9. Kaafarani H, Rosen AK, et al. What is a Trigger Tool to a Surgeon: Designing Trigger Tools for Surveillance of Adverse Events in Ambulatory Surgery . Massachusetts Chapter of the American College of Surgeons 55 th Annual Meeting, Boston, MA. Dec 2008. Kaafarani H, Rosen AK, et al. Advancement of Trigger Tools for Surveillance of Adverse Events in Ambulatory Surgery. VA HSR&D QUERI National Meeting , Phoenix, AZ. Dec 2008. Kaafarani H, Rosen AK, et al. Creating Trigger Tools for Surveillance of Adverse Events in Same-Day Surgery: A Literature-Based, End-User Inspired & Expert-Evaluated Methodology. VA HSR&D Annual Meeting, Baltimore, MD. Feb 2009. Shimada S, Rivard P, et al. Needs & Preferences of Potential Ambulatory Trigger Tool Users. AcademyHealth Annual Research Meeting, Chicago, IL. June 2009. Kaafarani H, Rosen AK, et al. Creating Trigger Tools for Surveillance of Adverse Events in Same-Day Surgery: A Literature-Based, End-User Inspired and Expert-Evaluated Methodology. AHRQ Annual Meeting, Bethesda, MD. Sept 2009. Kaafarani H, Rosen AK, et al. Improvement of Trigger Tools for Surveillance of Adverse Events in Ambulatory Surgery . Quality and Safety in Health Care . (prospective)

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