Developing and implementing a standardized process for global trigger tool application across a large health system.

BACKGROUND: To complement voluntary adverse event reporting, which may detect only specific categories of harms and may represent merely a fraction of actual adverse events, the Adventist Health System (AHS) began using the Institute for Healthcare Improvement (IHI) Global Trigger Tool (GTT) to more accurately gauge the number, types, and severity levels of adverse events and developed a centralized process to do so uniformly. METHODS: AHS began using the GTT in 2009 in 25 of its 42 hospitals that used a common electronic medical record (EMR). The common EMR and centralized record review enables AHS to apply the GTT uniformly and provides consistency of data collected. AHS sends quarterly reports to participating facilities to communicate findings and provides case studies illustrating the most egregious harms. Case study recipients are encouraged to further examine patient records, explore events leading to harm, and share the information with process/quality improvement committees, medical executive committees, and boards of directors to identify opportunities for quality improvement. AHS staffing and record review processes have evolved since 2009. RESULTS: A GTT review of 17,295 patient records indicated that adverse events clustered as medication-related glycemic events; medication-related delirium, confusion, or oversedation related to analgesics, sedatives, and muscle relaxants; pressure ulcers; medication-related bleeding; and medication-related skin/mucosal reaction/itching. CONCLUSIONS: The AHS process demonstrates how a large health system uses the GTT to detect harms. Since 2009 AHS has improved and streamlined its reporting, data entry and review processes. AHS used major harms findings to initiate systemwide collaborative improvement projects for glycemic management and pressure ulcers.

Risk of postoperative hypoglycemia in cardiovascular surgical patients receiving computer-based versus paper-based insulin therapy.

OBJECTIVE: To evaluate the safety and efficacy of replacing a paper-based protocol with a computer-guided glucose management system (CGMS) for the treatment of postoperative hyperglycemia in the cardiovascular intensive care unit (CVICU). METHODS: With use of a before-and-after analysis, adult patients (≥18 years) discharged from the CVICU and treated with the paper protocol were compared with patients discharged from the CVICU and treated with the CGMS. Of the 1,648 patients analyzed, 991 were in the CGMS group. Clinical end points were evaluated by using the Wilcoxon test. Unadjusted and adjusted hazard ratios (HRs) for each hypoglycemic end point were calculated from Cox models with use of the proportional hazards regression procedure, and clinical end points were adjusted for potential confounders. RESULTS: Patients treated with the paper protocol were 6 times as likely to experience clinical hypoglycemia (blood glucose ≤70 mg/dL) as patients treated with the CGMS (adjusted HR = 6.06; P<.0001) and more than 7 times as likely to experience severe hypoglycemia (blood glucose ≤40 mg/dL) (adjusted HR = 7.59; P=.01). Despite the increased risk of hypoglycemia, no significant difference in length of stay or mortality was observed between the groups. CONCLUSION: CGMS treatment of postoperative hyperglycemia in CVICU patients can successfully attain goal glucose levels with a significant reduction in hypoglycemia in comparison with a paper protocol. This association persists after controlling for covariates.