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Development of trigger tools for surveillance of adverse events in ambulatory surgery
  1. Haytham M A Kaafarani1,2,3,
  2. Amy K Rosen2,4,
  3. Jonathan R Nebeker5,6,
  4. Stephanie Shimada2,4,
  5. Hillary J Mull2,4,
  6. Peter E Rivard2,7,
  7. Lucy Savitz8,
  8. Amy Helwig9,
  9. Marlena H Shin2,4,
  10. Kamal M F Itani1,10,11
  1. 1Department of Surgery, VA Boston Healthcare System, West Roxbury, Massachusetts, USA
  2. 2Center for Health, Quality, Outcomes and Economic Research (CHQOER), a VA Center of Excellence, Bedford, Massachusetts, USA
  3. 3Harvard School of Public Health, Boston, Massachusetts, USA
  4. 4Boston University School of Public Health, Boston, Massachusetts, USA
  5. 5VA Salt Lake City Geriatrics Research, Education, and Clinical Center, Salt Lake City, Utah, USA
  6. 6University of Utah, Salt Lake City, Utah, USA
  7. 7Suffolk University, Boston, Massachusetts, USA
  8. 8Intermountain Healthcare, Salt Lake City, Utah, USA
  9. 9Agency for Healthcare Research and Quality, Rockville, Maryland, USA
  10. 10Boston University School of Medicine, Boston, Massachusetts, USA
  11. 11Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Dr Kamal M F Itani, VABHCS (112), Department of Surgery, 1400 VFW Parkway, West Roxbury, MA 02132, USA; kitani{at}


Background The trigger tool methodology uses clinical algorithms applied electronically to ‘flag’ medical records where adverse events (AEs) have most likely occurred. The authors sought to create surgical triggers to detect AEs in the ambulatory care setting.

Methods Four consecutive steps were used to develop ambulatory surgery triggers. First, the authors 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 clinical advisory panel designed an initial set of 10 triggers. Finally, a three-phase Delphi process (surgical and trigger tool experts) evaluated and rated the suggested triggers.

Results The authors designed an initial set of 10 surgical triggers including five global triggers (flagging medical records for the suspicion of any AE) and five AE-specific triggers (flagging medical records for the suspicion of specific AEs). Based on the Delphi rating of the trigger's utility for system-level interventions, the final triggers were: (1) emergency room visit(s) within 21 days from surgery; (2) unscheduled readmission within 30 days from surgery; (3) unscheduled procedure (interventional radiological, urological, dental, cardiac or gastroenterological) or reoperation within 30 days from surgery; (4) unplanned initial hospital length of stay more than 24 h; and (5) lower-extremity Doppler ultrasound order entry and ICD code for deep vein thrombosis or pulmonary embolus within 30 days from surgery.

Conclusion The authors therefore propose a systematic methodology to develop trigger tools that takes into consideration previously published work, end-user preferences and expert opinion.

  • Quality of care
  • surgery
  • ambulatory care
  • adverse event
  • information technology

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  • Funding Funding was provided by the Agency for Healthcare Research and Quality (AHRQ), contract no HHSA290200600012540.

  • Competing interests None.

  • Ethics approval Ethics approval was provided by the IRB from all participating institutions was obtained for the project, but this manuscript did not invlove human subjects itself.

  • Provenance and peer review Not commissioned; externally peer reviewed.