The Mental Health Trigger ToolConcept and Development

A/Prof Chua Hong Choon, Chief Executive OfficerDr Sajith Sreedharan, Consultant (General Psychiatry)

Apr 2014

Disclosures: None

S’pore Healthcare Services

Mental Health Trigger Tool

Prevalence Studies of AEs

Overview of IMH

The Little Red Dot

AGENDA

• Location: An island in the heart of Southeast Asia, between Malaysia and

Indonesia• Area: 710.3 sq km• Climate: Tropical 23 – 31 Degrees Celsius• Population: 5.18 million • Life Expectancy: 81.48 years• Ethnic Groups: Chinese 74%, Malay 13%, Indian 9%, other

ethnicities 3%• Religions: Buddhism, Islam, Christianity, Taoism and Hinduism

Republic of Singapore

Singapore HealthcareServices & Facilities

Primary Healthcare Services

18Polyclinics

2,400 Private Clinics

Hospital Services

7Public

Hospitals

5 Acute General

Hospitals

1Women’s & Children’s Hospital

1Tertiary

Psychiatric Hospital

6National Specialty Centres

Institute of Mental Health

About Us

• Singapore’s only tertiary psychiatric institution• National centre part of the NHG Regional Health System• 2010 beds• Looks after most severe cases • Provides acute and long-term care

554 Daily Visits

(Outpatient Clinics Only)

22Daily Admissions*

1,745 Inpatients*

37,240 Outpatients

(ES Included)

568 Acute

1,177Long-stay

(as of 2013)* Excluding 23-hr observation ward

Top 5 Disorders Seen in 2012

INPATIENT DISCHARGES

1. Schizophrenic Disorders

2. Depressive Disorder

3. Reaction to Severe Stress 4. Mental and behavioural

disorders due to use of opioids

5. Unspecified nonorganic psychosis

OUTPATIENT VISITS

1. Schizophrenic Disorders

2. Depressive Disorder

3. Reaction to Severe Stress

4. Other Anxiety Disorders 5. Unspecified nonorganic

psychosis

• Patient-Centred Care • Systems Thinking• Learning Organisation • Staff Engagement

4 Principles

IMH Quality and Safety Framework

DET

ECTI

ON

VALI

DATI

ON

ANAL

YSIS

IMPR

OVE

MEN

T

Serious Reportable

Event

Frequent Adverse Events

Near Misses

General Feedback

SPREAD CHANGE

Monitor and Evaluate Change

Facilitators, Training etc

Top Clinical Risks

Assault Choking

Falls Restraints

Suicide

Patients defaulting on care

Major permanent injury or inpatient death as a result of these incidents

Deterioration of patients’ mental health status leading to potential harm to self and others as a result of patients defaulting psychiatric clinic follow-ups

Reducing Bedtime Sedatives

*PRN is a medication that is ordered by a practitioner to be administered on an “As Needed” basis according to written parameters of a practitioner.#Sedatives is a substance that induces sedation by reducing irritability or excitement.

Focus

Target

Interventions

Sustain & Spread

Frequent usage of PRN* sedatives in Geriatric Psychiatry wards

To reduce the administration rate of PRN* bedtime sedatives** by nurses in an acute psycho-geriatric ward by 30% in 6 months.

•Make environment more conducive for sleep : change shift-handover location •Pharmacological education to enhance nurses’ understanding •Patient education to address lack of knowledge•Introduce sleep monitoring chart to track patients’ sleep patterns

Gains sustained & interventions successfully spread to another geriatric psychiatry ward

51% Reduction

Average Administration Rate of Bedtime PRN Sedatives Per Week

Focus

Target

Sustain & Spread

Tracking Discharged PatientsCare integration & treatment compliance for patients with Schizophrenia & Delusional Disorders

Increased specialist clinic attendance rate of recently discharged IMH patients by 10% in Year 1 as compared to baseline

Interventions

•Use of risk and needs assessment and stratification

•Case Management and Case Tracking

•Integrating systems (between IMH and Community Partners) through right-siting

Sharing project interventions & results with other public hospitals and community partners for spread

DETECTING HARMAdverse Events Studies

Adverse Events Studies 2007/2010 1st stage against a

list of 18 triggers (from Harvard Medical Practice Study) as flags for potential adverse events that require further review.

2nd stage by clinician on criteria positive cases to determine occurrence, disability, causation and preventability of AE

Double review for inter-rater reliability done for 10% RF1 and RF2

• Metrics/Unit of measurement o is adverse event, o measure disability as estimate of severity,o measure preventability as ascertained by clinician reviewers.

Developing a Mental Health Trigger Tool

Mental Health Trigger Tool (MHTT)

A tool to effectively Identify Harm or Adverse Events (AE) in a mental health setting and

monitor their rate over time

Most common methods of identifying and monitoring Harm or AE

Time andresourceintensive

Voluntary Reporting

Comprehensive File Review

• <20 % reported

• 90-95% no harm to patients

Is there a more efficient method?

• Global Trigger tool and Trigger tool Methodology- Developed by Institute of Health Improvement (IHI)

“ a retrospective review of randomly selected patient records using triggers (clues) to detect AE”

IHI Global Trigger Tool

Concentrate on identifying Harm or AE, not errors Only AE through acts of commission, not omission Preventability not a criterion Severity is rated based on NCC MERP index

Harm defined as “Unintended physical injury resulting from or contributed to by medical care that requires additional montioring, treatment or hospitalisation

or that results in death”

The GTT Review Methodology

• Random set of patient records• Trained Reviewers - Two Primary Reviewers - One physician Reviewer Excludes Psychiatric and Rehab Patients

Trigger Modules : • Cares (15) e.g. Transfusion of blood• Medication (13) e.g. Abrupt medication stop• Surgical • Intensive Care • Perinatal • Emergency Department

Trigger tool in Mental Health

• IHI Trigger Tool for Measuring Adverse Drug Events in a Mental Health Setting

• 30 triggers• Sodium Polystyrene Sulfonate• C. difficile Positive Stool• Vitamin K Only addresses AE due to medications Not comprehensive / specific enough May not be applicable to all mental health settings

Singapore Mental Health Trigger Tool Project

Developing Trigger Tool Exculsively for Mental Health

Setting

Resource and Time Efficient

Comprehensive

Applicable Internationally

• MHTT Project Steering Committee

• Workgroup to Develop the MHTT

• Team of Reviewers

• Project Plan / Timeline

Planning(Feb/Mar 13)

Preparation(Apr/May 13)

Dev of MHTT(Jun/Jul 13)

POC trial(Aug/Sep13)

MHTT Project

MHTT Project Team

• Preliminary review of literatureIHI White Paper on GTT

• Facilitated trainingA facilitated discussion and training on review of the charts were done with an experienced GTT chart reviewer and physician reviewer

Planning(Feb/Mar 13)

Preparation(Apr/May 13)

Dev of MHTT(Jun/Jul 13)

POC trial(Aug/Sep13)

MHTT Project

• Comprehensive Literature Review• Focus Group• Clinical Advisory Panel• Modified Delphi Panel

Planning(Feb/Mar 13)

Preparation(Apr/May 13)

Dev of MHTT(Jun/Jul 13)

POC trial(Aug/Sep13)

MHTT Project

Comprehe-nsive

Literature Review

FocusGroup

ClinicalAdvisory

Panel

ModifiedDelphi Panel

Trigger List

Development of MHTT

Literature

ReviewFocusGroup

ClinicalAdvisory

Panel

ModifiedDelphi Panel

FinalList of

Triggers

• Review of adverse events studies in mental health settings across the world

• Review of existing trigger tools

• Local adverse events studies/ reports

Development of MHTT

Literature Reviews

FocusGroup

ClinicalAdvisory

Panel

ModifiedDelphi Panel

FinalList of

Triggers

• Multidisciplinary focus group was formed to give input into the development of triggers

• Determined priority areas for trigger development based on AEs specific to mental health setting

Development of MHTT

Literature Reviews

FocusGroup

ClinicalAdvisory

Panel

ModifiedDelphi Panel

FinalList of

Triggers

• Advice on important AEs that matters in MH setting

• Advice on potential triggers that may identify those AEs

Development of MHTT

Literature Reviews

FocusGroup

ClinicalAdvisory

Panel

4-PhaseDelphi Process

FinalList of

Triggers

• Delphi panel of experts (Multidisciplinary)

• To collate expert feedback in a structured manner and formulate a consensus judgement on the choice of triggers

• Initial List = 30 triggers• After Delphi Round 1 = 34 triggers

• After Delphi Round 2 = 38 triggers

• After Round 3 = 58 triggers

• After Round 4 = 50 triggers

Development of MHTT

Literature Reviews

FocusGroup

ClinicalAdvisory

Panel

ModifiedDelphi Panel

List ofTriggers

Development of MHTT

• List of Triggers = 50 • POC Trial planned to test out the trigger

list

• A manual of triggers, their descriptions, guidelines to identify them and potential AEs were prepared

Main Challenges

• Definition of Harm or AE in Mental Health• Need to conform to IHI Trigger Tool system• Commission vs Omission events• Near Misses vs Actual Harm• Psychological harm

General Care Triggers

LaboratoryTriggers

MedicationTriggers

Mental HealthTriggers

Code TriggersG1 Transfer to General Hospital/Medical WardG2 Code Blue/ Cardio-Pulmonary arrestG3 Patient fallG4 Fever (Temp reading >37.5 deg)G5 Infection during hospital stayG6 Pressure ulcerG7 Referrals for consultation for medical reasonsG8 Re-admission within 30 daysG9 Fits/ seizures

G10 Initiation of ( e.g. GCS) or increase in frequency of monitoring of parameters after admission (including BP,PR, RR, Temp )

G11 High BMI ( 30 or above)G12 DVT/PE following admission evidenced by

imaging and/or D-dimer test

G13 Use of urinary catheter

Triggers

General Care Triggers

LaboratoryTriggers

MedicationTriggers

Mental HealthTriggers

TriggersCode Triggers

L1 X ray / CT Scan / MRI/ UltrasoundL2 Abnormal ECGL3 Serum Sodium <130 mmol/LL4 Platelet count <50000L5 WBC <3.0 or Neutrophils <1.5L6 Serum lithium> 1.2 mmol/L L7 Valproic Acid > 200 mg/mlL8 phenytoin > 20mg/ mlL9 Carbamazepine > 10mg/ml

L10 Elevated Liver enzymes ALT or AST or GGT (> double the upper end of normal range)

L11 Rising Serum Creatinine L12 Raised serum Creatinine Kinase L13 Digoxin level > 2mg/mlL14 International Normalized Ratio INR > 6L15 Glucose < 3 mmol/L

General Care Triggers

LaboratoryTriggers

MedicationTriggers

Mental HealthTriggers

TriggersCode Triggers

M1 Rash / itchingM2 Thyroxine M3 Anti-cholesterol medication (eg..Statins) M4 Hypoglycaemics (eg. Metformin) M5 Abrupt discontinuation of medicationM6 Antibiotics/ antimicrobials M7 IV Epinephrine / Norepinephrine / Naloxone/

Esmolol / Flumezenil

M8 Laxatives/Rectal Suppository / Enema M9 Oral or Parenteral (IM/IV) Anticholinergics

(eg Benzhexol/Procyclidine/Cogentin/Benztropine)

M10 Anti-emetics ( eg Metoclopramide)M11 Anti-diarrheals (eg. Loperamide)M12 Anti-histamines (eg. Chlorphenaramine)M13 TetrabenazineM14 Analgesics/ Anti-inflammatory

(eg. Paracetamol/Ibuprofen)

M15 Over-sedation/drowsinessM16 Propranolol

General Care Triggers

LaboratoryTriggers

MedicationTriggers

Mental HealthTriggers

Triggers

Code TriggersMH1 Self-harm/ attempted suicide

MH2 Violence or physical aggression by patient

MH3 Physically or sexually assaulted by another patient

MH4 Transfer to Higher Level of Care in Psychiatry (High Dependency Psychiatric Care Unit or DAV ward)

MH5 Restraint use

MH6 Absconding or missing from the ward

• Is it usable? • Does it identify triggers and harm?• Is it time and resource efficient?• Does the definition of harm requires

modification?• Does it identify harms that are clinically

important?• Can fewer triggers have the same result?• New useful triggers?

MHTT-Proof Of Concept (POC) Trial

Sample = 140 (randomly chosen files of discharged patients)

• Excluded cases = 6

Cases excluded as defined in the criteria on length of inpatient stay- > 3 days - < 90 days

• Each file reviewed by two 1st level reviewers (nurse/pharmacist)

followed by 2nd level physician reviewers• Total cases reviewed = 134

Time to review each file = 20-30 min

Planning(Feb/Mar 13)

Preparation(Apr/May 13)

Dev of MHTT(Jun/Jul 13)

POC trial(Aug/Sep13)

MHTT-Proof Of Concept Trial

Triggers with Highest Count

M12 Anti-histamines (45)

G10 Initiation of (eg GCS) or increase in frequency of parameters monitoring (39)

M14 Analgesic / Anti-inflammatory (37)

M8 Laxative/ Rectal suppository (34)

MH5 Restraint Use (31)

MHTT Trial FindingsTriggers with Highest Count

Sensitivity for Individual Triggers (Top 5)

M8 Laxatives (0.38)

M14 Initiation of (eg GCS) or increase freq of parameters monitoring (0.35)

M5 Abrupt discontinuation of medication (0.29)

M8 Oral or Parenteral (IM/IV) Anticholinergics (0.26)

MH5 Restraint Use (0.21)

MHTT Trial FindingsSensitivity for Individual Triggers

MHTT Trial FindingsDifferent Triggers Same Harm … Examples

Harm Triggers

Tardive Dyskinesia, Facial Twitching

• M5 Abrupt discontinuation of medication• M9 Oral or Parenteral (IM/IV) Anticholinergics

(Benzhexol/Procyclidine/Cogentin or Benztropine)

Drug Allergy - Rash

• M1 Rash / Itching• M5 Abrupt discontinuation of medication• M12 Antihistamine

Bruises / Swelling- due to Restraint

• MH5 Restraint Use• MH2 Violence or Physical Aggression by Patient• M14 Analgesics/ Anti-inflammatory• MH2 Initiation of (eg GCS) or increase in frequency of

parameters monitoring

• Trigger– Cohen’s Kappa = 0.21

• Harm– Cohen’s Kappa = 0.48

No. of valid cases = 134

MHTT Trial FindingsInter-rater Reliability

Trigger list – Trial on case files with High Impact Harms in IMH

Post Trial – New Triggers

Incident Type New Triggers Identified that could lead to AE

Intended self harm

IM Haloperidol/ Lorazepam Concious Level Chart (CLC) Increased observation for potential suicide

(PS) after admission

Patient fall Reports of injury (Eg contusion /

haematoma) CLC

Further Development

• Consulation with Dr Carol Haraden (IHI)• Multiple rounds of further review on Trigger list through focus

group and consultation with Clinical Advisory Panel• Eliminated triggers that indicated same harm• Eliminated triggers that are unlikely to pick up serious harms• Combined triggers with common themes• Added new triggers• Renamed the triggers for easy identification---------------Current list - 26 triggers - Descriptive manual on definition and use - Consensus on Definition of Harm

Validation Study

• Sample:

• Reviewers: Each case reviewed by two non-physicians (pharmacist/nurse) and one physician (psychiatrist, registrar and above)

• Analysis: sensitivity, specificity, positive and negative predictive value of the tool.

• Inter-rater reliability between the raters

cases with AEs

cases without AEs

Thank You