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2008 Annual Meeting Abstracts

Feasibility and Development of Trigger Tools for Surveillance of Adverse Events in Ambulatory Surgery
Haytham M.A. Kaafarani, MD, MPH1,2,3, Amy K. Rosen, PhD2,4, Jonathan Nebeker, MD, MS5,6, Stephanie Shimada, PhD2,4, Hillary Mull, MPP2,4, Peter Rivard, PhD, MHSA2,4,7, Brenna Long, BA8, Lucy Savitz, PhD9, Kamal M.F. Itani, MD1,10,11.
1Department of Surgery, Boston VA Healthcare System, West Roxbury, MA, USA, 2Center for Health, Quality, Outcomes and Economic Research (CHQOER), Bedford, MA, USA, 3Harvard School of Public Health, Boston, MA, USA, 4Boston University School of Public Health, Boston, MA, USA, 5University of Utah School of Medicine, Salt Lake City, UT, USA, 6Salt Lake City VA Medical Center, Salt Lake City, UT, USA, 7Center for Organization, Leadership, and Management Research (COLMR), Boston, MA, USA, 8University of Utah, Salt Lake City, UT, USA, 9Intermountain Healthcare, Salt Lake City, UT, USA, 10Boston University School of Medicine, Boston, MA, USA, 11Harvard Medical School, Boston, MA, USA.

The trigger tool methodology uses clinical algorithms applied electronically to “flag” patient medical records where adverse events (AEs) have most likely occurred. The ultimate goal is to improve quality of care by focusing efforts at AE surveillance. As part of a larger study funded by the Agency for Healthcare Research and Quality (AHRQ), we sought to create surgical triggers applicable to ambulatory care.
Three consecutive steps were used to develop ambulatory surgery triggers. First, we conducted a comprehensive literature review for surgical triggers. Second, a series of multidisciplinary focus groups (physicians, nurses, pharmacists and information technology specialists) provided user input on trigger selection. Third, a rigorous three-phase Delphi process (surgical and trigger tool experts) evaluated and refined a set of ten triggers.
Ambulatory surgery
Ambulatory surgery patients
Main Outcome Measure
Surgical adverse events
Of the 75 potential surgical triggers found in literature, most were redundant, non-specific or solely applicable to inpatients. We designed an initial set of ten triggers including five global triggers (flagging the chart for the suspicion of any AE), and five AE-specific triggers (flagging the chart for the suspicion of a specific AE). In Table 1, we report our final set of five surgical triggers based on the Delphi members ranking of the triggers’ utilities for system intervention.
Trigger tools promise an innovative, efficient and focused methodology for surveillance of adverse events in ambulatory surgery. The next step is to measure the test characteristics of the designed triggers.

Table1: Surgical Triggers
Trigger RulesTrigger Type
Same-day Surgery AND Subsequent ED visit ≤ 21 daysGlobal
Same-day Surgery AND Unscheduled re-admission to hospital ≤ 30 daysGlobal
Same-day surgery AND Unscheduled procedure (interventional radiological OR urological OR dental OR cardiac OR gastroenterological) OR re-operation ≤ 30 daysGlobal
Scheduled same-day surgery AND Hospital length of stay > 24 hoursGlobal
Same-Day surgery AND Postoperative lower extremity Doppler U/S order entry AND (ICD code for DVT OR ICD code for PE ≤ 30 days)AE-specific


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