Adverse events in critical care: Search and active detection through the Trigger Tool

ARTICLE HIGHLIGHTS

Research background

The Global Trigger Tool (GTT) enables data acquisition and subsequent analysis and management through time of the causes of adverse events (AEs). This tool has facilitated the detection of, at least, 10 times more events than those reported by passive search methods. GTT is a type of active detection of AEs. Just three studies carried out in intensive care units (ICUs), which included only patients who in the following 96 h died or 7 d prior to ICU admission. The importance of our survey is that it was performed during the entire hospital stay in ICU.

Research motivation

The main motivations for the study were the low amount of reports on AEs and the issue that the search and report systems do not detect all events that could present in our institution. Although there is a high incidence of AEs in hospitalized patients in the ICU, current search and report systems fail to detect them all. For this reason, we are inclined to the GTT methodology. One of the problems was that these triggers were initially extracted from the literature, and then corroborated by each of the service intensivists, and subsequently, a consensus was obtained at a group meeting. Therefore, it is essential that the medical team of each ICU in the world defines which would be the most useful triggers. Another difficulty we had was the review of all the patients’ records to identify the triggers. One solution is to carry out prospective studies that include data for the detection of triggers in each patient’s evolution chart. In the future, it will be worthwhile to carry out a multicenter study in this sense.

Research objectives

The authors intended to establish the incidence of AEs by using the GTT in a high-complexity academic ICU. The authors determined which were the most frequent triggers and AEs, along with their severity, which was carried out with the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) classification, that stipulates criteria on a scale from A to I, and from A to D. In addition, analysis was performed to explore the association between AEs and admission diagnoses. For future prospective multicenter research, the association of triggers with AEs should be evaluated.

Research methods

A retrospective descriptive study was conducted in a 12-bed ICU. The inclusion criteria were subjects aged over 18 years, with at least 24 h of hospitalization, and who had a complete medical history that could be accessed. A training team of reviewers (nurses and intensivists) were standardized in review criteria, established times and process order. Each team analyzed the medical records in the event of a trigger. Sixteen triggers were used to detect AEs. These triggers were initially extracted from the literature, and then corroborated by each of the service intensivists; subsequently, a consensus was obtained at a group meeting.

Research results

The main finding of this study was that the incidence of AEs in the ICU is 52.1%. The most frequent triggers were skin defects or lacerations (14.7%), excitation or somnolence of the patient according to the RASS scale (+3 or -3) (13.9%), and hypotension (13.5%). The most predominant AEs were pressure ulcers (17.6%), followed by complications or reactions to medical devices (4.3%), and lacerations or skin defects (3.7%). This search yielded a total of 178 AEs in 49 subjects, with an incidence of 52.1%; on average, 3.6 events per patient were recorded, and 1.98 triggers for each AE. One of the problems of this retrospective study was the detection of the severity of AEs. For this reason, the authors sent the data to two intensivists to agree on the severity of these AEs; we think that this aspect could be better solved in a prospective research study.

Research conclusions

The Global Trigger Detection Tool is a useful instrument to detect AEs in an ICU. As a descriptive study, no theory could be generated from our findings. In this survey, the clinical chart review methodology, suggested by the IHI, was taken as a reference, although the research team made variations in the manner of selecting patients (systematic randomized sampling), along with the review time of clinical records (review all charts), which allowed the detection of more triggers and AEs that could be useful for future investigations. Including GTT methodology to the study implies an increase in the frequency of AEs, and thus adopts measures that reduce their incidence in the future.

Research perspectives

The authors suggest the adoption of the methodology in the institution with a trained team in this tool. In future investigations, it is recommended to determine the effectiveness of the tool through analytical studies (cases and controls) that show statistically significant differences between passive and active methods of AE detection. The authors suggest prospective projects that validate the methodology to verify that they could anticipate the presentation of AEs.