American College of Physicians: Internal Medicine — Doctors for Adults ®

Tuesday, October 27, 2015

Trigger happy?

The University of Maryland group has just published two new papers on the safety of contact precautions. One is an analysis of the data from the BUGG study (published in Clinical Infectious Diseases), which was a multicenter study of intensive care unit patients, and the other is a matched prospective cohort analysis at an academic medical center (published in Infection Control & Hospital Epidemiology).

Here's a quick summary of the 2 papers:

The authors' conclusions for both papers are essentially the same: concerns about the safety of contact precautions should not limit the implementation of contact precautions. One paper showed no difference in adverse events and the other paper showed that contact precautions was actually safer than not being in contact precautions, which I think is a counterintuitive finding for many of us.

The problem that I have with both of these papers is the use of the Institute for Healthcare Improvement (IHI) Global Trigger Tool (GTT) to determine the rates of adverse events. I have 3 concerns:
1. Are all of the events identified by the GTT causally linked to the exposure? For example, in the ICHE study, the strongest association was found for surgical events, and the association was highly counterintuitive: postoperative hemorrhage was found in 1 in148 patients in contact precautions vs 12 in 148 patients not in contact precautions. Given what we know about contact precautions, particularly that it reduces healthcare worker visits, what could be the causal mechanism for a higher rate of post-operative hemorrhage in patients not in contact precautions? Is there a confounder at play here? There may very well be a causal mechanism but I'm hard pressed to think of one.
2. The IHI GTT only looks for errors of commission, not errors of omission, and it seems likely that errors of omission would occur more commonly when a barrier to care is implemented (contact precautions).
3. The IHI GTT sets a 20-minute time limit for the detection of errors when reviewing a patient chart whether the patient was hospitalized for 1 day or 100 days. In the ICHE study, the patients were matched on length of stay; however, I don't think this resolves the problem. The GTT's ability to detect error is time dependent. So when comparing two groups, if one group truly has a significantly higher rate of adverse events, a lower proportion of the events will be detected in the group that has more events, reducing the difference between the two groups. In effect we have surveillance bias.

Even the IHI openly admits that this is an issue. Here's a direct quote from the GTT manual:

The IHI Global Trigger Tool was never intended to identify all adverse events. Experienced reviewers familiar with the IHI Global Trigger Tool will identify almost all events greater than category E in a patient record that can be reviewed completely within the 20-minute time limit. Events in the E category of harm involve more judgment and at times are not as obvious, so these are less easily identified and may be missed. When the 20-minute time limit is enforced not all adverse events are expected to be identified.

In both of the papers, the 3 issues cited above are likely biasing towards the null, making contact precautions to appear to be safer than it is. So I continue to be concerned that contact precautions may result in less safe care. I think that most people in the hospital epidemiology community regard the University of Maryland researchers as some of the best methodologists in the field, and I certainly hold them in very high regard. Nonetheless, I'm curious about their love for the Global Trigger Tool, and hope that they share their views with us on this blog.

Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on improving the quality and safety of health care, and sees patients in the inpatient and outpatient settings. This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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Blogger Unknown said...

Hi all, I had responded to this same post on the HAI controversies and didn't realize it was also on ACP internist. Here is what I posted there:

Hi Mike, thanks for the thorough read and being held in high regard! Hope to not change that with my response. Like you I have concerns with the IHI Trigger Tool. However, what else do you use to monitor all cause adverse events? Previous studies of adverse events are less refined in either using passively reported events (missing great majority of events) or just doing a chart review (based on one's own whims). We chose the Trigger tool as the most thought out format for a chart review. In reality the "Trigger Tool" is mostly a list of items to review for potential signs of adverse events. Even in the fully electronic VA, it would be hard to look for trigger items first without reviewing standard notes. What happens, in effect, with the trigger tool is reviewing discharge summary, some other key notes, labs and medications. Although harm from care (errors of commission) are highlighted, the trigger tool includes pressure ulcers, falls and electrolyte disorders, so it would catch items from Stelfox or other papers. I don't think the 20 minute cutoff was much of a factor after training was complete (definitely not for severe adverse events). The main criticism I have of the Trigger Tool is that it is essentially still a chart review without such clear guidance on which areas of the chart to focus on. It also includes a general description of adverse events as harm due to medical care and not an underlying condition but would call a nursing home acquired pneumonia a harm but not neutropenia due to chemotherapy (so one has to come up with standardized rules across chart reviews). As to whether Contact Precautions have adverse effects, I am still not convinced one way or another (just like I'm not convinced they prevent infections). Most likely, if aggressively applied they can prevent transmission (with actual compliance monitoring etc.) but that is not the reality in most hospitals. Likewise, harms are more likely if they are used aggressively and really limit healthcare worker visits/patient contact. It seems clear they are a burden for healthcare workers though and I'm not sure we need high quality proof of harm to use them less frequently if we don't have similar proof of benefit. (I think we both know smart people who argue for or against them)

October 27, 2015 at 4:19 PM  

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Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

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Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

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Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

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