The accuracy of the Global Trigger Tool is higher for the identification of adverse events of greater harm: a diagnostic test study.

Global Trigger Tool (GTT) of the Institute for Healthcare Improvement (IHI) has been used as a measurement strategy for patient safety by several institutions and national programs. Although the greater ability of the GTT to identify adverse events (AEs) compared to other methods has already been demonstrated, there are few data on its accuracy, and studies suggest lower sensitivity for minor AEs. This study aimed to assess the accuracy of the GTT for identifying AEs in adult inpatients for all AEs and for the subgroup of AEs with greater harm to the patient, classified as F-I on the IHI-GTT adapted version of the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index for Categorizing Errors. In this diagnostic test study, GTT is the index test and identification of AEs (yes/no) represents the condition of interest. Due to the lack of a gold standard test, a composite reference standard method was developed. Reference standard method combined real-time (during hospitalizations) and retrospective search of medical records and administrative data for screening criteria and AEs. Both tests were applied to a random sample of 211 hospitalizations of adult inpatients during October-November 2016 in a large public hospital in Belo Horizonte, Brazil. The accuracy of the GTT was evaluated using sensitivity, specificity, and global accuracy. A total of 176 AEs were identified in 67 admissions using reference standard method and 129 AEs in 76 admissions using GTT, resulting in rates of 126 and 93 AEs/1000 patient-days, respectively. Sensitivity, specificity, and global accuracy of the GTT for the identification of individual AEs were, respectively, 0.41 (95% confidence interval [CI] 0.34; 0.49), 0.68 (95% CI 0.60; 0.74), and 0.54 (95% CI 0.49; 0.60) for all AEs, regardless of the harm categorization, and 0.85 (95% CI 0.72; 0.93), 0.88 (95% CI 0.82; 0.92), and 0.87 (95% CI 0.82; 0.91) for the subgroup of AEs categorized as harm F-I. Among the main AEs missed by the GTT are AEs related to nursing care, such as those related to peripheral venous access and gastric/enteric catheters. GTT proved to be a valid method for identifying AEs in adult inpatients. Its accuracy increases when minor harm AEs are not counted. Among the main AEs missed by the GTT are those related to nursing care. Therefore, the GTT should be used in conjunction with other measurement strategies to achieve results that are representative of the quality profile of the care provided and, thus, guide the best improvement strategies.

Assessment of the reliability of the IHI Global Trigger Tool: new perspectives from a Brazilian study.

OBJECTIVE: To assess the reliability of the Institute for Healthcare Improvement's Global Trigger Tool (IHI-GTT) between nurses and medical students as primary reviewers to measure adverse events (AEs). DESIGN: Interrater reliability study. SETTING: A 500-bed general public hospital in Belo Horizonte, Brazil. PARTICIPANTS: A randomly selected sample of 220 hospital admissions of adults (≥18 years) from Oct-Nov, 2016. INTERVENTION: Two 4th-5th year-medical students and two experienced nurses applied a Portuguese-translated version of the IHI-GTT to medical records. The role of medical reviewer was performed by two senior physicians specialists in Internal Medicine. MAIN OUTCOME MEASURES: Ability to identify AEs was compared between pairs and against medical reviewer through percentage inter-examiner agreement and Kappa coefficient (K). Two outcomes -- "AE identification" and "category of harm" -- were evaluated according to two different denominators -- "admissions" (the total number of admissions evaluated in the sample; reflects the presence or not of at least one AE in each admission) and "all possibilities of agreement" (obtained by adding each identified AE to the admissions without events; allows agreement assessment to be performed for each AE individually). RESULTS: Were identified 199 adverse events in 90 hospitalizations, with rates of 40.9% of admissions with AEs, 76.1 AEs/1,000 patient-days and 90.5 AEs/100 admissions. Comparing student-pair and nurse-pair, we found K = 0.76 (95% IC 0.62-0.88) and K = 0.17 (95% IC 0.06-0.27) for "AE identification" outcome and K = 0.28 (95% IC 0.01-0.55) and K = 0.46 (95% IC 0.28-0.64) for "category of harm" outcome to denominators "admission" and "all possibilities of agreement", respectively. There was no significant difference between the performances of the different primary reviewers composed in any analyses. CONCLUSION: IHI-GTT reliability varies considerably depending on the denominator used to calculate agreement. As the purpose of the tool is, in addition to measuring, promoting opportunities for quality of care improvement, the individual analysis of the AEs seems more appropriate. Further studies are needed to assess the implications of the slight agreement reached between primary reviewers on the test's overall accuracy. Moreover, advanced medical students may be considered for primary review in settings where unavailability of staff is a barrier to IHI-GTT adoption.

Contexto de quedas notificadas em um hospital universitário / Context of falls notified in a university hospital

Objetivo analisar as circunstâncias das quedas notificadas em um hospital universitário de alta complexidade. Método estudo descritivo, com abordagem quantitativa, realizado em um hospital universitário. A coleta de dados foi realizada de janeiro de 2015 a julho de 2016, por meio dos dados secundários, e em outubro de 2016. A mediana foi calculada para as variáveis contínuas com distribuição não normal e as frequências e proporções foram calculadas para as variáveis categóricas. Resultados a taxa de incidência de quedas foi de 2,21% ao mês. Considerando os dois momentos de coleta, respectivamente, as quedas foram mais frequentes na faixa-etária de 60 anos ou mais (42,86%) e 20 a 59 anos (70,00%), no turno da manhã (47,37% e 60,00%) e em pessoas com doenças cardiovasculares (35,71%). Os profissionais que mais notificaram quedas foram enfermeiros. Conclusão as circunstâncias das quedas notificadas em um hospital universitário de alta complexidade foram avaliadas na maioria dos casos e foram mais frequentes em pacientes do sexo masculino, com 60 anos ou mais, com doenças cardiovasculares, em uso de anti-hipertensivos e diuréticos. Além disso, notou-se que potencialmente existe subnotificação de quedas na instituição.

Objetivo analizar las circunstancias de las caídas notificadas en un hospital universitario de alta complejidad. Método estudio descriptivo con enfoque cuantitativo realizado en un hospital universitario. Los datos se recolectaron de enero de 2015 a julio de 2016, por medio de los datos secundarios, y en octubre de 2016. Se calculó la mediana para las variables continuas con distribución no normal, y se calcularon frecuencias y proporciones para las variables categóricas. Resultados el índice de incidencia de caídas fue de 2,21% por mes. Las caídas fueron más frecuentes en los grupos etarios de 60 años o más (42,86%) y de 20 a 59 años (70,00%), en el turno de la mañana (47,37% y 60,00%) y en personas con enfermedades cardiovasculares (35,71%). Los profesionales que notificaron más caídas fueron los enfermeros. Conclusión las circunstancias de las caídas notificadas en un hospital universitario de alta complejidad se evaluaron en la mayoría de los casos, y fueron más frecuentes en pacientes de sexo masculino, de al menos 60 años, con enfermedades cardiovasculares, y en tratamiento con anti-hipertensivos y diuréticos. Además, se notó que existe un potencial de subnotificación de caídas en la institución.

Objective to analyze the circumstances of falls reported in a high-complexity university hospital. Method a descriptive study with a quantitative approach, conducted in a university hospital. Data collection was performed from January 2015 to July 2016, using the secondary data, and in October 2016. The median was calculated for continuous variables with non-normal distribution and frequencies and proportions were calculated for categorical variables. Results the incidence rate of falls was 2.21% per month. Falls were more frequent in the age group 60 years old or older (42.86%) and 20 to 59 years old (70.00%), in the morning shift (47.37%) and in people with diseases's circulatory system (35.71%). The professionals who most reported falls were nurses. Conclusion the circumstances of falls reported in a high-complexity university hospital were assessed in most cases and were more frequent in male patients, aged 60 years old or older, with cardiovascular disease, using antihypertensive drugs and diuretics. In addition, it was noted that there is potentially underreporting of falls in the institution.

Variation rhythms of lymphocyte subsets during healthy aging.

Immunological alterations associated with aging (immunosenescence) do not represent a simple unidirectional decline in all functions but develop as a complex remodeling of the immune system, involving multiple reorganization and developmentally regulated changes. In general, most data available about aging were obtained at particular age intervals and most of them come from Caucasian individuals from either Europe or the United States. Here, we report the frequencies of major lymphocyte subsets in healthy Brazilian individuals from 2 distinct geographic regions (Southeast and South) at several age intervals spanning a lifetime period (0-86 years). Overall, we demonstrated that changes in the frequencies of cells related to both innate and adaptive immunity clearly occur with aging in these individuals. These changes were not progressive and equally steady for all cell populations tested but instead showed an oscillatory or rhythmic behavior that was distinctive of each population at different age intervals. We also observed that abrupt changes in the frequencies of immune cells may occur in healthy individuals over 75 years old, suggesting there is an impaired flexibility of the immune system at late stages of life to sustain homeostasis via immune mechanisms. We presented reference ranges for healthy Brazilian individuals at all ages. The knowledge of these parameters in further detail will allow interventions to optimize immune function in advanced age and to improve the quality of life in the elderly.

Projeto cathivar: o desafio de enfrentar a finitude humana / Cathivar project: the challenge if facing human finitude

O projeto Cathivar desenvolve atividades de pesquisa e extensão sobre os temas do processo de morrer e dos cuidados paliativos. Foi criado por estudantes de Medicina e busca superar a dificuldade de enfrentar a morte e o processo de morrer em nossa sociedade. São realizados estudos qualitativos pela estratégia de pesquisa-ação. Foram efetuados estudos numa clínica filantrópica e em um serviço de atendimento domiciliar público, onde foram acompanhados pacientes e familiares. Resultados mostraram que os entrevistados preferem essas modalidades de atenção em um hospital. A clínica oferecia atendimento integral ao paciente e tinha a preocupação de reproduzir um ambiente acolhedor. No atendimento domiciliar ressaltaram-se a sobrecarga do familiar cuidador e o peso financeiro sobre a família. Concluiu-se que ainda não há suporte do sistema de saúde suficiente para essas formas de atenção. A clínica foi fechada posteriormente por alegação de seu alto custo e a atenção domiciliar é restrita aos que podem arcar com o ônus do cuidado do paciente em casa. Para a formação médica, a experiência de convívio com essa realidade contribui para mostrar a importância dos aspectos psicossociais da interação com o paciente e dos valores humanistas e éticos da prática médica.

The Cathivar project develops community service and research activities on the themes of dying process and palliative care. It was created by medical students and aims at overcoming the difficulty of facing death and the dying process in our society. Qualitative studies are performed using the research-action strategy. Studies were carried out in a philanthropic clinic and in a public home care service, where both patients and family members were followed up. Results show that interviewees prefer to have these modalities of care in a hospital. The clinic offered integral assistance to the patient and had the preoccupation of producing a welcoming environment. In home care, family caregiver overload and financial burden on the family were highlighted. We concluded that there is not enough support from the public health system to this health care modality. The clinic was closed later on, under the allegation of its high costs and that home care is restricted to those who can afford it. As far as medical training is concerned, the experience of living with this reality contributes to show the importance of the psychosocial aspects of interaction with the patient and of the ethical and humanistic values of medical practice.