Kaafarani HM (VA Boston Healthcare System; Center for Health, Quality, Outcomes and Economic Research (CHQOER)), Nebeker J
(Salt Lake City VAMC; University of Utah), Shimada S
(CHQOER; Boston University School of Public Health), Mull H
(CHQOER; Boston University School of Public Health), Rivard P
(CHQOER; Suffolk University), Shin M
(CHQOER; Boston University School of Public Health), Itani K
(VA Boston Healthcare System; Harvard Medical School; Boston University School of Medicine), Long B
(Salt Lake City VAMC; University of Utah), Savitz L
(Intermountain Healthcare), Rosen AK
(CHQOER; Boston University School of Public Health)
As same-day surgery (SDS) becomes more complex and involves patients with advanced age and more comorbidities, the incidence of post-SDS adverse events (AEs) will likely increase. The trigger tool methodology uses algorithms derived from clinical logic to electronically “flag” medical records with a high probability of occurrence of AEs. We sought to create surgical trigger algorithms to focus efforts at AE surveillance in SDS.
A systematic literature review for trigger tools was first performed. Next, multidisciplinary focus groups (e.g., physicians, nurses, pharmacists and information technology specialists) from three healthcare systems, including the VA, provided user input on their preferences and use of triggers. Finally, a three-phase Delphi process (surgical and trigger tool experts) refined and rated the utility of the suggested triggers.
Only 4.6% of available triggers in the literature targeted surgical AEs. Focus groups stressed the need to choose clinically sound, easily implemented triggers that targeted potentially preventable AEs. An initial set of ten triggers was designed including five global triggers that flagged charts for the suspicion of any AE (e.g. more than 2 postoperative clinic visits within 30 days from surgery), and five AE-specific triggers that flagged charts for the suspicion of a specific AE (e.g. hematocrit check at 14 days AND hematocrit drop > 6 units from preoperative baseline; AE = postoperative bleeding). Round 1 of the Delphi process showed significant divergence of the panelists’ ratings reflecting different perspectives on the utility and relevance of the suggested triggers. As the triggers were modified, and their ratings discussed among the panelists, we observed an expected convergence of ratings with narrower ranges in Round 3. Based on the last Delphi round median and range of ratings, a final set of five electronic trigger tools (global and specific) was selected for testing.
We propose an innovative methodology to design trigger tools that takes into consideration previously published work, end-user preferences, and expert opinion.
Global triggers will serve to potentially provide a more convenient sample for chart review in looking for AEs, while specific triggers with reasonable sensitivity and specificity can be used for AE rate estimation.