EMPOWERING RADICAL CHANGE WITH ANALYSING UNSTRUCTURED HEALTHCARE DATA FOR BETTER PATIENT CARE

Transcription

1 EMPOWERING RADICAL CHANGE WITH ANALYSING UNSTRUCTURED HEALTHCARE DATA FOR BETTER PATIENT CARE Juha Öhman Tampere University Hospital Department of Neurosciences and Rehabilitation

2 To err is human to manage errors is expertise

3 PATIENT SERVICE PYRAMID Equity Timeliness Efficacy Effectiveness Patient Centeredness Ready for you! Getting it right first time without extra costs Getting it right Nothing about me without me You are safe at our hospital Safety

4 HOW DANGEROUS IS HEALTHCARE? Less than 1 death per 100,000 encounters Nuclear power European railways Scheduled airlines One death in < 100,000 but > 1000 encounters Normal traffic Chemical manufacturing More than 1 death per 1000 encounters Bunjee jumping Mountain climbing Health care

5 NATURE AND SCOPE OF THE PROBLEM 10% of all patients suffer injuries associated with hospital stay In Finland estimated cases the injury contributes to death Half of the injuries are considered avoidable A total of patient days in 2008 This means unnecessary days in hospital (10 % of all) The cost is ca. 400 M

6 METHODS TO DETECT HEALTH RELATED INJURIES Optional adverse events reporting detects only 10-20% of all medical adverse events In most cases adverse events do not lead to health/treatment related injuries As a supplement, structured retrospective chart review can be used to detect adverse events and patient injury

7

8 OFFICIAL DO NOT USE LIST Do Not Use Potential problem Use Instead U (unit) IU (International Unit) Q.D., QD, q.d., qd (daily) µg Mistaken for 0 (zero) Mistaken for IV (intravenous) or the number 10 (ten) Mistaken for each other Mistaken for mg (milligrams) resulting in one thousand-fold overdose Write "unit" Write "International Unit" Write "daily" Write "mcg" or micrograms

9 FOUR CRITERIA FOR ACCOUNTABILITY MEASURES THAT ADDRESS PROCESSES OF CARE

10 IMPROVEMENT IN PERFORMANCE ON ACCOUNTABILITY CORE MEASURES FROM 2002 THROUGH 2009

11 IHI GLOBAL TRIGGER TOOL (GTT) Cambridge, Massachusetts, USA Instructions for training reviewers to conduct retrospective reviews of patient records using 53 triggers to identify possible adverse events A list of known adverse event triggers Instructions for selecting records Instructions and forms for collecting data to track three measures Adverse events per 1,000 patient days Adverse events per 100 admissions Percent of admissions with an adverse event

12 DEFINITION OF ERROR The actor who commits an error recognizes it only after the fact, with the perspective provided by hindsight, and either an actor or an external judge needs a model of task performance in order decide whether an action has been correctly executed. Further: Error occurs when a planned series of actions fails to achieve its desired outcome, and when this failure cannot be attributed to the intervention of some chance occurrence. For instance, a chess expert sees things that the novice cannot see. The novice, therefore, does not do things that an expert would do. Since the novice cannot even conceive of the expert s move, it may not be entirely correct to say that he or she made an error. It seems more reasonable to say that where there is no possibility of correct performance there can be no error, even though the performance may be imperfect Senders, J., Moray, N. (1991). Human Error: Cause, Prediction, and Reduction. Lawrence Erlbaum Associates, Hillsdale, New Jersey.

13 HARM VERSUS ERROR Medical error = failure in process of care Potentially harmful, but often not linked to the injury of the patient Event = clinical outcome Consists of system factors leading to adverse event experienced by the patient Natural progression of the disease process, or a complication of the treatment related to the disease process? Intended result of the care? Psychological harm adverse event

14 SEVERITY RATING A: Circumstances or events that have the capacity to cause error B: An error that did not reach the patient C: An error that reached the patient but did not cause harm D: An error that reached the patient and required monitoring or intervention to confirm that it resulted in no harm to the patient E: Temporary harm to the patient and required intervention F: Temporary harm to the patient and required initial or prolonged hospitalization G: Permanent patient harm H: Intervention required to sustain life I: Patient death

15 ADVERSE EVENT RULES AND STANDARDS The definition one can consider is, Would you be happy if it happened to you? Is the patient happy after intracerebral hemorrhage and subsequent hemiparesis? Can diseases with poor outcomes be assessed with GTT? SAH has a mortality of 50% within one year no matter how you treat the patient Care must be taken not to mix natural course of the disease to treatment failures

16 THE SHELL(S) AND THE CORE Natural course or treatment related Unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalization, or that results in death Active delivery of care (commission) vs. substandard care (omission)

17 The basic idea is finding the solution from your own perspective

18 and solving problems together without judging

19 STUDY DESIGN Selection of patient groups (ICD10) Traumatic Brain Injury (TBI) S06.* Spontaneous Intracranial Hemorrhage (ICH) I60.*-I62.* Cervical Spine Degenerative Disease M50.*-M51.* Time between , or 250 cases/group Common diseases S and I-groups many severely ill patients many triggers (?) M-group no triggers control

20 Hyper/hypotension Disturbances in fluid balance Re-intubation Prolonged intensive care Readmission within 30 days Infection Hydrocephalus (CSF) Wound problem Treatment complication Procedure change in clinical condition Unplanned radiological examination Neuroworsening Trigger shelf

21 1. Neuroworsening 1. GCS down 3 points (3-15 points) 2. Decreased consciousness TRIGGERS 1 2. Unplanned radiological examination 3. Procedure due to change in clinical condition 1. Angiography (therapeutic) 2. Reoperation 4. Treatment complication 1. Pneumothorax 2. Catheter-Cystofix etc. 5. Wound problem 6. Hydrocephalus (CSF)

22 TRIGGERS 2 7. Infection 1. Severe (pneumonia etc.) 2. Mild (UTI etc.) 8. Readmission within 30 days 1. Readmission to the ICU 2. Readmission to University Hospital 9. Prolonged intensive care for non-neurological causes 10.Re-intubation 11.Disturbances in fluid balance 1. Electrolyte disturbance requiring treatment 2. Fluid balance disturbance requiring treatment 12.Hyper/hypotension

23 Trigger modification according to the guidelines of European Association of Neurosurgical Societies European Brain Injury Consortium American Association of Neurological Surgeons Congress of Neurological Surgeons American Brain Injury Consortium

24 STUDY DESIGN Patient record search according to ICD 10 Dg number Trigger listing (Excel) PRF review (screen) Exclusion of: Misdiagnoses Controls Out-patients Random trigger checking

25 TBI N=195 60,9±15,3 ICH N=211 53,9±7,1 23,0% 36,0% Spine N=150 5,3%

26 211 PATIENTS 315 ADVERSE EVENTS 74 PATIENTS WITH TRIGGER 254 PATIENT EXPERIENCES

27 TOP 4 TBI ICH Spine X-ray Infection New procedure Neuroworsening

28 No of Patients No of Triggers Patient/trigger Spine TBI ICH

29 Triggers/ICH Triggers/ TBI

30 Rebound ICH 15 patients TBI 15 patients AVOIDABDLE EVENTS Treatment related complication ICH 8 TBI 1 Theoretically avoidable events ICH 30.3% TBI 36% Problems related to triggers and events Severely ill patients Trigger versus disease related complication Further studies necessary

31 USING GTT AND TEXT MINING IN ELECTRONIC PRF FOR AUTOMATIC IDENTIFICATION OF ADVERSE EVENTS Automating parts of the GTT method How well can the triggers be found with text mining? SAS Analytic Intelligence as the technical solution SAS Enterprise Miner, SAS Text Miner Teaching the program by help of the pilot study Text data extraction from electronic Patient Record Forms (Miranda ) Manual review of randomly selected PRF:s

32 STREAMLINING OPERATIONS SAS Text Miner

33

34 PROBABLE BENEFITS OF THE AUTOMATED TOOL Reduce decision time through automated processes Intelligent algorithms and vocabulary processing techniques are generated automatically and executed consistently over the whole text mass Enhance the discovery process by uncovering associations and relationships previously undetected Besides known items program provides data-driven method for identifying new concepts with paths and links for in-depth document analysis Visually present a high-level view of data with the ability to drill down to specific phrases in documents Visual presentation of the entire data-mining process with the ability to drill down to relevant detail illustrating the connections and exploring the links between items in document collections Recognize trends and spot possible signs of treatment errors Analysis of information of whole service and product chains

35 ONLINE AUTOMATED TOOL Towards structured patient records Immediate vs. slow development of the event Time of error detection Increase accuracy in injury detection Identify important combination of triggers Identify triggers most predictive of avoidable injury

36

37