Electronic Trigger Research Articles

Electronically Triggered Sepsis Alert in Non-Intensive Care Inpatients Using Modified Systemic Inflammatory Response Syndrome Criteria: A Retrospective Observational Study with In-Depth Analysis of Surgical Patients.

Background: Our center initiated an electronic Sepsis Best Practice Alert (sBPA) protocol to aid in early sepsis detection and treatment. However, surgery alters peri-operative physiology, which may trigger an sBPA for noninfectious causes. This study aimed to provide early evaluation of automated sBPA utility in surgical patients. Methods: This study was a retrospective review of the outcomes of patients admitted to the University of Minnesota Medical Center (but not to the intensive care unit) from August 2015-March 2016 and compared how the sBPA performed in those having and not having surgery. An sBPA prompted nursing to draw blood for an immediate lactate assay if two modified systemic inflammatory response syndrome (mSIRS) criteria or three mSIRS criteria within 24 hours after surgery were met. Physicians were notified if the lactate concentration was >2 mmol/L. Further review was performed of data collected prospectively on the surgical patients. Results: A total of 10,335 patients were admitted (2,158 surgery and 8,177 non-surgery). Of these, 33% of the surgery patients and 35% of the patients not having surgery triggered sBPAs. In surgery patients, 13% of lactate concentrations were >2 mmol/L versus 25% in patients not having surgery. An sBPA was triggered more frequently after procedures with a wound class of 4 (5% vs. 2%), emergency operation (23% vs. 10%), and longer operations (280 min vs. 222 min (p < 0.05 for all). Surgery patients triggering sBPAs had longer hospital stays (9.6 vs. 4.4 days; p < 0.05), more surgical site infections (7% vs. 2%; p < 0.05), and a similar mortality rate (3% vs. 4%; p = 0.15) than those who did not trigger an sBPA. Conclusion: An sBPA fired in a third of all inpatients, and an sBPA that prompted lactate measurements was less likely to be abnormal in surgery patients than in those not having surgery. There was no difference in the mortality rate in surgical patients who fired and those who did not; however, the sBPA did identify patients with a more complicated post-operative course. Further refinements of the electronic trigger should increase BPA specificity.

Using Electronic Health Records to Identify Adverse Drug Events in Ambulatory Care: A Systematic Review.

Objective We identified the methods used and determined the roles of electronic health records (EHRs) in detecting and assessing adverse drug events (ADEs) in the ambulatory setting. Methods We performed a systematic literature review by searching PubMed and Google Scholar for studies on ADEs detected in the ambulatory setting involving any EHR use published before June 2017. We extracted study characteristics from included studies related to ADE detection methods for analysis. Results We identified 30 studies that evaluated ADEs in an ambulatory setting with an EHR. In 27 studies, EHRs were used only as the data source for ADE identification. In two studies, the EHR was used as both a data source and to deliver decision support to providers during order entry. In one study, the EHR was a source of data and generated patient safety reports that researchers used in the process of identifying ADEs. Methods of identification included manual chart review by trained nurses, pharmacists, and/or physicians; prescription review; computer monitors; electronic triggers; International Classification of Diseases codes; natural language processing of clinical notes; and patient phone calls and surveys. Seven studies provided examples of search phrases, laboratory values, and rules used to identify ADEs. Conclusion The majority of studies examined used EHRs as sources of data for ADE detection. This retrospective approach is appropriate to measure incidence rates of ADEs but not adequate to detect preventable ADEs before patient harm occurs. New methods involving computer monitors and electronic triggers will enable researchers to catch preventable ADEs and take corrective action.

The ATLAS Electron and Photon Trigger

ATLAS electron and photon triggers covering transverse energies from 5 GeV to several TeV are essential to record signals for a wide variety of physics: from Standard Model processes to searches for new phenomena. To cope with ever-increasing luminosity and more challenging pile-up conditions in proton-proton collisions delivered by the LHC at a centre-of-mass energy of 13 TeV, the trigger selections need to be optimised to control the rates and keep efficiencies high. The ATLAS electron and photon trigger performance in Run 2 will be presented, including both the role of the ATLAS calorimeter in electron and photon identification and details of new techniques developed to maintain high performance even in high pile-up conditions.

Application of electronic trigger tools to identify targets for improving diagnostic safety

Progress in reducing diagnostic errors remains slow partly due to poorly defined methods to identify errors, high-risk situations, and adverse events. Electronic trigger (e-trigger) tools, which mine vast amounts of...

Development of an Adverse Event Surveillance Model for Outpatient Surgery in the Veterans Health Administration.

Develop and validate a surveillance model to identify outpatient surgical adverse events (AEs) based on previously developed electronic triggers. Veterans Health Administration's Corporate Data Warehouse. Six surgical AE triggers, including postoperative emergency room visits and hospitalizations, were applied to FY2012-2014 outpatient surgeries (n=744,355). We randomly sampled trigger-flagged and unflagged cases for nurse chart review to document AEs and measured positive predictive value (PPV) for triggers. Next, we used chart review data to iteratively estimate multilevel logistic regression models to predict the probability of an AE, starting with the six triggers and adding in patient, procedure, and facility characteristics to improve model fit. We validated the final model by applying the coefficients to FY2015 outpatient surgery data (n=256,690) and reviewing charts for cases at high and moderate probability of an AE. Of 1,730 FY2012-2014 reviewed surgeries, 350 had an AE (20 percent). The final surveillance model c-statistic was 0.81. In FY2015 surgeries with >0.8 predicted probability of an AE (n=405, 0.15 percent), PPV was 85 percent; in surgeries with a 0.4-0.5 predicted probability of an AE, PPV was 38 percent. The surveillance model performed well, accurately identifying outpatient surgeries with a high probability of an AE.

RESEARCH ON DYNAMIC TEST TECHNOLOGY FOR WIND TURBINE BLADE AIRFOIL

The dynamic oscillation process of wind turbine blades is usually accompanied by pitching and yaw. Due to the unclear understanding of many dynamic problems previously, a safer design is adopted at the expense of increasing the weight of the blade structure in engineering, usually neglecting the influence of the yaw oscillation. The design of large wind turbines has put forward higher requirements for obtaining more comprehensive and accurate dynamic loads of airfoils. It is of great significance to study the influence of yaw oscillation on the dynamic aerodynamic characteristics of airfoil. In view of this, the dynamic wind tunnel test on yaw oscillation of airfoil is carried out in this paper for the first time. The “electronic cam” technology is used instead of the mechanical cam to realize the stepless adjustment of oscillation frequency and oscillation angle. Based on the designed electronic external trigger device, the real-time measurement of the dynamic flow field is realized. Meanwhile, the synchronous acquisition of wind tunnel flow, model angular displacement and dynamic pressure data is realized. Furthermore, the static pressure measurement, pitching / yaw dynamic pressure measurement, PIV and fluorescent wire test are carried out respectively. The accuracy of the test results is high, and the regular pattern is reasonable. Besides, the influence mechanism of wall interference in dynamic test is analyzed. Research shows that: there is also obvious hysteresis effect on the dynamic aerodynamic parameters of yaw oscillation airfoil with the changing of the angle of attack. And with the increase of oscillation frequency, the aerodynamic hysteresis characteristics of the airfoil under pitching and yaw oscillation are all enhanced. The dynamic stall vortex at the positive stroke is delayed due to the pitching oscillation. The pressure distribution of the airfoil is greatly influenced by the strong three-dimensional effect at the intersection of the wind tunnel wall and the model tip. Overall, the dynamic test technique of yaw oscillation established in this paper can provide technical support for the study of the dynamic swept effect of the wind turbines.

Creating a comprehensive, unit-based approach to detecting and preventing harm in the neonatal intensive care unit

Background Error detection and analysis alone cannot create or sustain a culture of safe, high-quality, compassionate care for patients. Some experts have endorsed a unit-based approach to improving quality, but there are few examples and those rarely focus on reducing all preventable harms and engaging frontline clinicians, patients, and families. Approach: We implemented a unit-based approach comprising seven building blocks for creating a comprehensive approach to detect and prevent harm at the unit level within a hospital: (1) unit quality council and stakeholder buy-in, (2) parent engagement and advisory council, (3) frontline clinician and parent quality improvement training, (4) measurement of organizational contextual factors, (5) electronic health record trigger development and synthesis of harm measures, (6) subcommittees to review harm, and (7) quality improvement teams. Challenges and Lessons Learned: Challenges include conceptualizing triggers for a unit unfamiliar with this methodology, establishing unit resources for collecting and analyzing data, and creating processes to integrate parents in unit quality efforts. The seven essential building blocks helped overcome these challenges and could be adopted by other healthcare organizations. Conclusion These building blocks create a generalizable foundation for establishing a unit-based approach to detecting and preventing harm.

Feasibility of Electronic Health Record-Based Triggers in Detecting Dental Adverse Events.

We can now quantify and characterize the harm patients suffer in the dental chair by mining data from electronic health records (EHRs). Most dental institutions currently deploy a random audit of charts using locally developed definitions to identify such patient safety incidents. Instead, selection of patient charts using triggers and assessment through calibrated reviewers may more efficiently identify dental adverse events (AEs). Our goal was to develop and test EHR-based triggers at four academic institutions and find dental AEs, defined as moderate or severe physical harm due to dental treatment. We used an iterative and consensus-based process to develop 11 EHR-based triggers to identify dental AEs. Two dental experts at each institution independently reviewed a sample of triggered charts using a common AE definition and classification system. An expert panel provided a second level of review to confirm AEs identified by sites reviewers. We calculated the performance of each trigger and identified strategies for improvement. A total of 100 AEs were identified by 10 of the 11 triggers. In 57% of the cases, pain was the most common AE identified, followed by infection and hard tissue damage. Positive predictive value (PPV) for the triggers ranged from 0 to 0.29. The best performing triggers were those developed to identify infections (PPV = 0.29), allergies (PPV = 0.23), failed implants (PPV = 0.21), and nerve injuries (PPV = 0.19). Most AEs (90%) were categorized as temporary moderate-to-severe harm (E2) and the remainder as permanent moderate-to-severe harm (G2). EHR-based triggers are a promising approach to unearth AEs among dental patients compared with a manual audit of random charts. Data in dental EHRs appear to be sufficiently structured to allow the use of triggers. Pain was the most common AE type followed by infection and hard tissue damage.

Integration of physical abuse clinical decision support into the electronic health record at a Tertiary Care Children’s Hospital

To evaluate the effect of a previously validated electronic health record-based child abuse trigger system on physician compliance with clinical guidelines for evaluation of physical abuse. A randomized controlled trial (RCT) with comparison to a preintervention group was performed. RCT-experimental subjects' providers received alerts with a direct link to a physical abuse-specific order set. RCT-control subjects' providers had no alerts, but could manually search for the order set. Preintervention subjects' providers had neither alerts nor access to the order set. Compliance with clinical guidelines was calculated. Ninety-nine preintervention subjects and 130 RCT subjects (73 RCT-experimental and 57 RCT-control) met criteria to undergo a physical abuse evaluation. Full compliance with clinical guidelines was 84% pre-intervention, 86% in RCT-control group, and 89% in RCT-experimental group. The physical abuse order set was used 43 times during the 7-month RCT. When the abuse order set was used, full compliance was 100%. The proportion of cases in which there was partial compliance decreased from 10% to 3% once the order set became available (P = .04). Male gender, having >10 years of experience and completion of a pediatric emergency medicine fellowship were associated with increased compliance. A child abuse clinical decision support system comprised of a trigger system, alerts and a physical abuse order set was quickly accepted into clinical practice. Use of the physical abuse order set always resulted in full compliance with clinical guidelines. Given the high baseline compliance at our site, evaluation of this alert system in hospitals with lower baseline compliance rates will be more valuable in assessing the efficacy in adherence to clinical guidelines for the evaluation of suspected child abuse.

Using the electronic health record to build a culture of practice safety: evaluating the implementation of trigger tools in one general practice.

Identifying patients at risk of harm in general practice is challenging for busy clinicians. In UK primary care, trigger tools and case note reviews are mainly used to identify rates of harm in sample populations. This study explores how adaptions to existing trigger tool methodology can identify patient safety events and engage clinicians in ongoing reflective work around safety. Mixed-method quantitative and narrative evaluation using thematic analysis in a single East London training practice. The project team developed and tested five trigger searches, supported by Excel worksheets to guide the case review process. Project evaluation included summary statistics of completed worksheets and a qualitative review focused on ease of use, barriers to implementation, and perception of value to clinicians. Trigger searches identified 204 patients for GP review. Overall, 117 (57%) of cases were reviewed and 62 (53%) of these cases had patient safety events identified. These were usually incidents of omission, including failure to monitor or review. Key themes from interviews with practice members included the fact that GPs' work is generally reactive and GPs welcomed an approach that identified patients who were 'under the radar' of safety. All GPs expressed concern that the tool might identify too many patients at risk of harm, placing further demands on their time. Electronic trigger tools can identify patients for review in domains of clinical risk for primary care. The high yield of safety events engaged clinicians and provided validation of the need for routine safety checks.

On-orbit operations and offline data processing of CALET onboard the ISS

The CALorimetric Electron Telescope (CALET), launched for installation on the International Space Station (ISS) in August, 2015, has been accumulating scientific data since October, 2015. CALET is intended to perform long-duration observations of high-energy cosmic rays onboard the ISS. CALET directly measures the cosmic-ray electron spectrum in the energy range of 1 GeV to 20 TeV with a 2% energy resolution above 30 GeV. In addition, the instrument can measure the spectrum of gamma rays well into the TeV range, and the spectra of protons and nuclei up to a PeV.In order to operate the CALET onboard ISS, JAXA Ground Support Equipment (JAXA-GSE) and the Waseda CALET Operations Center (WCOC) have been established at JAXA and Waseda University, respectively. Scientific operations using CALET are planned at WCOC, taking into account orbital variations of geomagnetic rigidity cutoff. Scheduled command sequences are used to control the CALET observation modes on orbit. Calibration data acquisition by, for example, recording pedestal and penetrating particle events, a low-energy electron trigger mode operating at high geomagnetic latitude, a low-energy gamma-ray trigger mode operating at low geomagnetic latitude, and an ultra heavy trigger mode, are scheduled around the ISS orbit while maintaining maximum exposure to high-energy electrons and other high-energy shower events by always having the high-energy trigger mode active. The WCOC also prepares and distributes CALET flight data to collaborators in Italy and the United States.As of August 31, 2017, the total observation time is 689 days with a live time fraction of the total time of ∼ 84%. Nearly 450 million events are collected with a high-energy (E > 10 GeV) trigger. In addition, calibration data acquisition and low-energy trigger modes, as well as an ultra-heavy trigger mode, are consistently scheduled around the ISS orbit. By combining all operation modes with the excellent-quality on-orbit data collected thus far, it is expected that a five-year observation period will provide a wealth of new and interesting results.

The role of the CMS electron and photon trigger in the study of the Higgs boson and high mass searches

The Compact Muon Solenoid (CMS) experiment implements a sophisticated two-level triggering system composed of the Level-1, instrumented by custom-design hardware boards, and a software High-Level-Trigger. A new Level-1 trigger architecture with improved performance is now being used to maintain the thresholds used in LHC Run I for the more challenging conditions experienced during Run II. We present the performance of the upgraded CMS electron and photon trigger in the context of Higgs boson decays into final states with photons and electrons. The calorimeter trigger system plays a central role in achieving the ambitious physics program of Run II. The upgraded trigger uses the full granularity of the calorimeters to optimally reconstruct and calibrate the electromagnetic trigger objects. It also implements combinations of calorimeter objects to provide new Level-1 quantities such as invariant mass. Optimized software selection techniques have been developed and advanced algorithms to mitigate the impact of event pileup have been implemented. The selection techniques used to trigger efficiently on these benchmark analyses will be presented, along with the strategies employed to guarantee efficient triggering for new resonances and other new physics signals involving electron/photon final states.

Electronic Triggers to Identify Delays in Follow-Up of Mammography: Harnessing the Power of Big Data in Health Care

PurposeWe previously developed electronic triggers to automatically flag records for patients experiencing potential delays in diagnostic evaluation for certain cancers. Because of the unique clinical, logistic, and legal aspects of mammography, this study was conducted to evaluate the effectiveness of a trigger to flag delayed follow-up on mammography. MethodsAn algorithm was developed to detect delays in follow-up of abnormal mammographic results (>60 days for BI-RADS® 0, 4, and 5 and >7 months for BI-RADS 3) using clinical data in the electronic health record. Flagged records were then manually reviewed to determine the trigger’s performance characteristics (positive and negative predictive value, sensitivity, and specificity). The frequency of delays and patient communication related to abnormal results, reasons for lack of follow-up, and whether patients were subsequently diagnosed with breast cancer were also assessed. ResultsOf 365,686 patients seen between January 1, 2010, and May 31, 2015, the trigger identified 2,129 patients with abnormal findings on mammography, of whom it flagged 552 as having delays in follow-up. From these, review of 400 randomly selected records revealed 283 true delays (positive predictive value, 71%; 95% confidence interval, 66%-75%), including 280 records without any documented plan and three patients with plans that were not adhered to. Transcription and reporting inconsistencies were identified in 27% of externally performed mammographic reports. Only 335 records (84%) contained specific documentation that the patient was informed of the abnormal result. ConclusionsCare delays appear to continue despite federal laws requiring patient notification of mammographic results within 30 days. Clinical application of mammography-related triggers could help detect these delays.

Calcium uptake and cytochrome c release from normal and ischemic brain mitochondria

At abnormally elevated levels of intracellular Ca2+, mitochondrial Ca2+ uptake may compromise mitochondrial electron transport activities and trigger membrane permeability changes that allow for release of cytochrome c and other mitochondrial apoptotic proteins into the cytosol. In this study, a clinically relevant canine cardiac arrest model was used to assess the effects of global cerebral ischemia and reperfusion on mitochondrial Ca2+ uptake capacity, Ca2+ uptake-mediated inhibition of respiration, and Ca2+-induced cytochrome c release, as measured in vitro in a K+-based medium in the presence of Mg2+, ATP, and NADH-linked oxidizable substrates. Maximum Ca2+ uptake by frontal cortex mitochondria was significantly lower following 10 min cardiac arrest compared to non-ischemic controls. Mitochondria from ischemic brains were also more sensitive to the respiratory inhibition associated with accumulation of large levels of Ca2+. Cytochrome c was released from brain mitochondria in vitro in a Ca2+-dose-dependent manner and was more pronounced following both 10 min of ischemia alone and following 24 h reperfusion, in comparison to mitochondria from non-ischemic Shams. These effects of ischemia and reperfusion on brain mitochondria could compromise intracellular Ca2+ homeostasis, decrease aerobic and increase anaerobic cerebral energy metabolism, and potentiate the cytochrome c-dependent induction of apoptosis, when re-oxygenated mitochondria are exposed to abnormally high levels of intracellular Ca2+.

Polarization-Multiplexed Phase Modulation of Single Photons in a Sagnac Interferometer

Polarization-multiplexed phase modulation was demonstrated in a Sagnac interferometer for polarization-auto-compensating quantum key distribution. The Sagnac interferometer was composed of a polarization beam splitter to split the signal pulses into clockwise and counter-clockwise beams of different polarizations, a Faraday rotator to rotate the polarizations of the split clockwise and counter-clockwise beams, and two phase-modulators asymmetrically set in the Sagnac ring. With this structure, the delays of the electronic triggering signals for the two phase-modulators could be set separately, reducing the difficulty in the setup and achieving more precise phase modulation on different polarized beams. Such polarization-multiplexed phase modulation was appropriately gated in sequential time gates to ensure the long-term stability of automatic polarization compensation in the long-distance quantum key distribution system. Polarization-multiplexed phase modulation was implemented in a protocol quantum key distribution system of 25-km communicating fiber length, generating 20-kHz sifted key rate with a qubit error rate lower than 5%.

An electronic trigger tool to optimise intravenous to oral antibiotic switch: a controlled, interrupted time series study

BackgroundTimely switch from intravenous (iv) antibiotics to oral therapy is a key component of antimicrobial stewardship programs in order to improve patient safety, promote early discharge and reduce costs. We have introduced a time-efficient and easily implementable intervention that relies on a computerized trigger tool, which identifies patients who are candidates for an iv to oral antibiotic switch.MethodsThe intervention was introduced on all internal medicine wards in a teaching hospital. Patients were automatically identified by an electronic trigger tool when parenteral antibiotics were used for >48 h and clinical or pharmacological data did not preclude switch therapy. A weekly educational session was introduced to alert the physicians on the intervention wards. The intervention wards were compared with control wards, which included all other hospital wards. An interrupted time-series analysis was performed to compare the pre-intervention period with the post-intervention period using ‘% of i.v. prescriptions >72 h’ and ‘median duration of iv therapy per prescription’ as outcomes. We performed a detailed prospective evaluation on a subset of 244 prescriptions to evaluate the efficacy and appropriateness of the intervention.ResultsThe number of intravenous prescriptions longer than 72 h was reduced by 19% in the intervention group (n = 1519) (p < 0.01) and the median duration of iv antibiotics was reduced with 0.8 days (p = <0.05). Compared to the control group (n = 4366) the intervention was responsible for an additional decrease of 13% (p < 0.05) in prolonged prescriptions.The detailed prospective evaluation of a subgroup of patients showed that adherence to the electronic reminder was 72%.ConclusionsAn electronic trigger tool combined with a weekly educational session was effective in reducing the duration of intravenous antimicrobial therapy.

Utilization of an electronic medical record trigger to promote palliative care consultation in ambulatory oncology.

e18201 Background: Research insupportive care demonstrates improvements in overall survival, quality of life, symptom management, and reductions in the cost of care. Despite the American Society of Clinical Oncology recommendation for early concurrent supportive care in patients with advanced cancer and high symptom burden, integrating supportive services is challenging. Our aims were to 1) implement an electronic medical record (EMR) provider alert of high symptom burden based on Edmonton Symptom Assessment Scale (ESAS) criteria and 2) determine the impact an alert has on supportive service referrals. Methods: ESAS scores were implemented in medical ambulatory oncology clinics to quantitatively assess symptom burden. An EMR alert was programmed for a total ESAS score &gt; 30 and any single response of ≥9 to capture approximately 15% of our high symptom burden patient population. The provider could elect to accept the alert placing an order for palliative consultation or decline the prompt. Referral rates and symptom assessment scores were followed as metrics for EMR alert efficiency. Results: Over 10 months, 9,710 patient visits used the ESAS system resulting in 7,707 fully completed ESAS scores (79.4% completion rate). There were 78 total consults to palliative care, a referral rate of less than 1% of the population, which was unchanged from prior to trigger implementation. Of the total completed ESAS forms, the trigger alerted 686 times (8.9% of patient visits) with only 55 of those triggers leading to a supportive care referral (8.0%). Conclusions: This project highlights the challenges of an EMR based alert system and the need for continued efforts to improve supportive care referrals through provider education and tool implementation. [Table: see text]

Optimising the use of medicines to reduce acute kidney injury in children and babies

The majority of medications in children are administered in an unlicensed or off-label manner. Paediatricians are obliged to prescribe using the limited evidence available. The 2007 EU regulation on the use of paediatric drugs means pharmaceutical companies are now obliged to (and receive incentives for) contributing to paediatric drug data and carrying out paediatric clinical trials. This is important, as the efficacy and adverse effect profiles of medicines vary across childhood. Additionally, there are significant age-related changes in the pharmacodynamic and pharmacokinetic activity of many drugs. This may be related to physiological (differential expressions of cytochrome P450 enzymes or variable glomerular filtration rates at different ages for example) and psychological (increasing autonomy and risk perception in teenage years) changes. Increasing numbers of children are surviving life-threatening childhood conditions due to medical advances. This means there is an increasing population who are at risk of the consequences of the long-term, early exposure to nephrotoxic agents. The kidney is an organ that is particularly vulnerable to damage as a consequence of drugs. Drug-induced acute kidney injury (AKI) episodes in children and babies are principally due to non-steroidal anti-inflammatory drugs, antibiotics or chemotherapeutic agents. The renal tubules are vulnerable to injury because of their concentrating ability and high-energy hypoxic environment. This review focuses on drug-induced AKI and the methods to minimise its effect, including general management plus the role of child-specific pharmacokinetic data, the use of pharmacogenomics and early detection of AKI using urinary biomarkers and electronic triggers.

The CMS Level-1 electron and photon trigger: for Run II of LHC

The Compact Muon Solenoid (CMS) employs a sophisticated two-level online triggering system that has a rejection factor of up to 105. Since the beginning of Run II of LHC, the conditions that CMS operates in have become increasingly challenging. The centre-of-mass energy is now 13 TeV and the instantaneous luminosity currently peaks at 1.5 ×1034 cm−2s−1. In order to keep low physics thresholds and to trigger efficiently in such conditions, the CMS trigger system has been upgraded. A new trigger architecture, the Time Multiplexed Trigger (TMT) has been introduced which allows the full granularity of the calorimeters to be exploited at the first level of the online trigger. The new trigger has also benefited immensely from technological improvements in hardware. Sophisticated algorithms, developed to fully exploit the advantages provided by the new hardware architecture, have been implemented. The new trigger system started taking physics data in 2016 following a commissioning period in 2015, and since then has performed extremely well. The hardware and firmware developments, electron and photon algorithms together with their performance in challenging 2016 conditions is presented.

Performance of a Trigger Tool for Identifying Adverse Events in Oncology.

Although patient safety is a priority in oncology, few tools measure adverse events (AEs) beyond treatment-related toxicities. The study objective was to assemble a set of clinical triggers in the medical record and assess the extent to which triggered events identified AEs. We performed a retrospective cohort study to assess the performance of an oncology medical record screening tool at a comprehensive cancer center. The study cohort included 400 patients age 18 years or older diagnosed with breast (n = 128), colorectal (n = 136), or lung cancer (n = 136), observed as in- and outpatients for up to 1 year. We identified 790 triggers, or 1.98 triggers per patient (range, zero to 18 triggers). Three hundred four unique AEs were identified from medical record reviews and existing AE databases. The overall positive predictive value (PPV) of the original tool was 0.40 for total AEs and 0.15 for preventable or mitigable AEs. Examples of high-performing triggers included return to the operating room or interventional radiology within 30 days of surgery (PPV, 0.88 and 0.38 for total and preventable or mitigable AEs, respectively) and elevated blood glucose (> 250 mg/dL; PPV, 0.47 and 0.40 for total and preventable or mitigable AEs, respectively). The final modified tool included 49 triggers, with an overall PPV of 0.48 for total AEs and 0.18 for preventable or mitigable AEs. A valid medical record screening tool for AEs in oncology could offer a powerful new method for measuring and improving cancer care quality. Future improvements could optimize the tool's efficiency and create automated electronic triggers for use in real-time AE detection and mitigation algorithms.