Description of the development and validation of the Canadian Paediatric Trigger Tool

Abstract

ObjectiveTo describe the process of developing and validating the Canadian Association of Paediatric Health Centres Trigger Tool (CPTT).MethodsFive existing trigger tools were consolidated with duplicate triggers eliminated. After a risk analysis and modified Delphi process, the tool was reduced from 94 to 47 triggers. Feasibility of use was tested, reviewing 40 charts in three hospitals. For validation, charts were randomly selected across four age groups, half medical/half surgical diagnoses, from six paediatric academic health sciences centres. 591 charts were reviewed by six nurses (for triggers and adverse events (AEs)) and three physicians (for AEs only). The incidence of trigger- and AE-positive charts was documented, and the sensitivity and specificity of the tool to identify charts with AEs were determined. Identification of AEs by nurses and physicians was compared. The positive predictive value (PPV) of each trigger was calculated and the ratio of false- to true-positive AE predictors analysed for each trigger.ResultsNurses rated the CPTT easy to use and identified triggers in 61.1% (361/591; 95% CI 57.2 to 65.0) of patient charts; physicians identified AEs in 15.1% (89/ 591, 95% CI 0.23 to 0.43). Over a third of patients with AEs were neonates. The sensitivity and specificity were 0.88 and 0.44, respectively. Nurse and physician AE assessments correlated poorly. The PPV for each trigger ranged from 0 to 88.3%. Triggers with a false/true-positive ratio of >0.7 were eliminated, resulting in the final 35-trigger CPTT.ConclusionsThe CPTT is the first validated, comprehensive trigger tool available to detect AEs in children hospitalised in acute care facilities.

Adverse events among children in Canadian hospitals: the Canadian Paediatric Adverse Events Study

“…8 In addition, the threshold of harm we used to define an adverse event was similar to that used in national studies 26 but higher than that used in previous pediatric studies. 2,3,5,6 For this reason, our results reflect the more serious events but underestimate the total harm in children admitted to hospital.…”

Performance of the Global Assessment of Pediatric Patient Safety (GAPPS) Tool

“…23 Our work builds on the IHI GTT as well as multiple pediatric trigger tools. [7][8][9][10] To our knowledge, no previous adult or pediatric study has conducted the detailed trigger-by-trigger analysis we conducted, leading to a robustly scrutinized set of manual and automatable triggers. This process and the resulting components of GAPPS may be informative in future efforts to refine adult, as well as pediatric, tools.…”

“…[8][9][10][11][12][13][14] In addition, we spoke with trigger developers, including those who developed PACHMT and the IHI GTT, to identify any additional triggers and inform GAPPS development. 7 From our review, we compiled a list of 78 candidate triggers for possible inclusion in GAPPS; this list of candidate triggers was compiled by the GAPPS team with input from the developers of PACHMT.…”

Performance of a Trigger Tool for Identifying Adverse Events in Oncology

“…13 Ouroncologytool's performance is in line with that of tools in other clinical settings. 7,14,15 It is important to note that it can be difficult to distinguish expected toxicities from unnecessary harm in oncology, which could influence our assessment of the tool's performance for identifying preventable or mitigable AEs. We used best practice and required consensus by two physician reviewers but recognize the inherent subjectivity.…”