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Bunney G, Bloos SM, Graber-Naidich A, Pasao MA, Kabeer R, Kim D, Miller K, Yiadom MYAB. Maximizing Equity in Acute Coronary Syndrome Screening across Sociodemographic Characteristics of Patients. Diagnostics (Basel) 2023; 13:2053. [PMID: 37370948 DOI: 10.3390/diagnostics13122053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/22/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
We compared four methods to screen emergency department (ED) patients for an early electrocardiogram (ECG) to diagnose ST-elevation myocardial infarction (STEMI) in a 5-year retrospective cohort through observed practice, objective application of screening protocol criteria, a predictive model, and a model augmenting human practice. We measured screening performance by sensitivity, missed acute coronary syndrome (ACS) and STEMI, and the number of ECGs required. Our cohort of 279,132 ED visits included 1397 patients who had a diagnosis of ACS. We found that screening by observed practice augmented with the model delivered the highest sensitivity for detecting ACS (92.9%, 95%CI: 91.4-94.2%) and showed little variation across sex, race, ethnicity, language, and age, demonstrating equity. Although it missed a few cases of ACS (7.6%) and STEMI (4.4%), it did require ECGs on an additional 11.1% of patients compared to current practice. Screening by protocol performed the worst, underdiagnosing young, Black, Native American, Alaskan or Hawaiian/Pacific Islander, and Hispanic patients. Thus, adding a predictive model to augment human practice improved the detection of ACS and STEMI and did so most equitably across the groups. Hence, combining human and model screening--rather than relying on either alone--may maximize ACS screening performance and equity.
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Affiliation(s)
- Gabrielle Bunney
- Department of Emergency Medicine, Stanford University, Palo Alto, CA 94304, USA
| | - Sean M Bloos
- Department of Emergency Medicine, Stanford University, Palo Alto, CA 94304, USA
- Tulane University School of Medicine, New Orleans, LA 70112, USA
| | | | - Melissa A Pasao
- Department of Emergency Medicine, Stanford University, Palo Alto, CA 94304, USA
| | - Rana Kabeer
- Department of Emergency Medicine, Stanford University, Palo Alto, CA 94304, USA
| | - David Kim
- Department of Emergency Medicine, Stanford University, Palo Alto, CA 94304, USA
| | - Kate Miller
- Quantitative Sciences Unit, Stanford University, Palo Alto, CA 94304, USA
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Liberman AL, Holl JL, Romo E, Maas M, Song S, Prabhakaran S. Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis. Acad Emerg Med 2023; 30:187-195. [PMID: 36565234 DOI: 10.1111/acem.14648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/03/2022] [Accepted: 12/21/2022] [Indexed: 12/25/2022]
Abstract
INTRODUCTION To date, many emergency department (ED)-based quality improvement studies and interventions for acute stroke patients have focused on expediting time-sensitive treatments, particularly reducing door-to-needle time. However, prior to treatment, a diagnosis of stroke must be reached. The ED-based stroke diagnostic process has been understudied despite its importance in assuring high-quality and safe care. METHODS We used a learning collaborative to conduct a failure modes, effects, and criticality analysis (FMECA) of the acute stroke diagnostic process at three health systems in Chicago, IL. Our FMECA was designed to prospectively identify, characterize, and rank order failures in the systems and processes of care that offer opportunities for redesign to improve stroke diagnostic accuracy. Multidisciplinary teams involved in stroke care at five different sites participated in moderated sessions to create an acute stroke diagnostic process map as well as identify failures and existing safeguards. For each failure, a risk priority number and criticality score were calculated. Failures were then ranked, with the highest scores representing the most critical failures to be targeted for redesign. RESULTS A total of 28 steps were identified in the acute stroke diagnostic process. Iterative steps in the process include information gathering, clinical examination, interpretation of diagnostic test results, and reassessment. We found that failure to use existing screening scales to identify patients with large-vessel occlusions early on in their ED course ranked highest. Failure to obtain an accurate history of the index event, failure to suspect acute stroke in triage, and failure to use established stroke screening tools at ED arrival to identify potential stroke patients were also highly ranked. CONCLUSIONS Our study results highlight the critical importance of upstream steps in the acute stroke diagnostic process, particularly the use of existing tools to identify stroke patients who may be eligible for time-sensitive treatments.
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Affiliation(s)
- Ava L Liberman
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Jane L Holl
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Elida Romo
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Matthew Maas
- Department of Neurology, Northwestern University, Chicago, Illinois, USA
| | - Sarah Song
- Department of Neurology, Rush University, Chicago, Illinois, USA
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
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Slocum JD, Holl JL, Love R, Shi M, Mackersie R, Alam H, Loftus TM, Andersen R, Bilimoria KY, Stey AM. Defining obstacles to emergency transfer of trauma patients: An evaluation of retriage processes from nontrauma and lower-level Illinois trauma centers. Surgery 2022; 172:1860-1865. [PMID: 36192213 PMCID: PMC10111878 DOI: 10.1016/j.surg.2022.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/15/2022] [Accepted: 08/24/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Retriage is the emergency transfer of severely injured patients from nontrauma and lower-level trauma centers to higher-level trauma centers. We identified the barriers to retriage at sending centers in a single health system. METHODS We conducted a failure modes effects and criticality analysis at 4 nontrauma centers and 5 lower-level trauma centers in a single health system. Clinicians from each center described the steps in the trauma assessment and retriage process to create a process map. We used standardized scoring to characterize each failure based on frequency, impact on retriage, and prevention safeguards. We ranked each failure using the scores to calculate a risk priority number. RESULTS We identified 26 steps and 93 failures. The highest-risk failure was refusal by higher-level trauma centers (receiving hospitals) to accept a patient. The most critical failures in the retriage process based on total risk, frequency, and safeguard scores were (1) refusal from a receiving higher-level trauma center to accept a patient (risk priority number = 191), (2) delay in a sending center's consultant examination of a patient in the emergency department (risk priority number = 177), and (3) delay in receiving hospital's consultant calling back (risk priority number = 177). CONCLUSION We identified (1) addressing obstacles to determining clinical indications for retriage and (2) identifying receiving level I trauma centers who would accept the patient as opportunities to increase timely retriage. Establishing clear clinical indications for retriage that sending and receiving hospitals agree on represents an opportunity for intervention that could improve the retriage of injured patients.
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Affiliation(s)
- John D Slocum
- Surgical Outcomes and Quality Improvement Center, Northwestern University, Chicago, IL
| | - Jane L Holl
- Department of Neurology, Center for Healthcare Delivery Science and Innovation, University of Chicago, IL
| | - Remi Love
- Surgical Outcomes and Quality Improvement Center, Northwestern University, Chicago, IL
| | - Meilynn Shi
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Robert Mackersie
- Department of Surgery, School of Medicine, University of California-San Francisco, CA
| | - Hasan Alam
- Department of Surgery, School of Medicine, University of California-San Francisco, CA
| | - Timothy M Loftus
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Rebecca Andersen
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Karl Y Bilimoria
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Anne M Stey
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL.
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Holl JL, Khorzad R, Zobel R, Barnard A, Hillman M, Vargas A, Richards C, Mendelson S, Prabhakaran S. Risk Assessment of the Door-In-Door-Out Process at Primary Stroke Centers for Patients With Acute Stroke Requiring Transfer to Comprehensive Stroke Centers. J Am Heart Assoc 2021; 10:e021803. [PMID: 34533049 PMCID: PMC8649509 DOI: 10.1161/jaha.121.021803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Patients with acute stroke at non- or primary stroke centers (PSCs) are transferred to comprehensive stroke centers for advanced treatments that reduce disability but experience significant delays in treatment and increased adjusted mortality. This study reports the results of a proactive, systematic, risk assessment of the door-in-door-out process and its application to solution design. Methods and Results A learning collaborative (clinicians, patients, and caregivers) at 2 PSCs and 3 comprehensive stroke centers in Chicago, Illinois participated in a failure modes, effects, and criticality analysis to identify steps in the process; failures of each step, underlying causes; and to characterize each failure's frequency, impact, and safeguards using standardized scores to calculate risk priority and criticality numbers for ranking. Targets for solution design were selected among the highest-ranked failures. The failure modes, effects, and criticality analysis process map and risk table were completed during in-person and virtual sessions. Failure to detect severe stroke/large-vessel occlusion on arrival at the PSC is the highest-ranked failure and can lead to a 45-minute door-in-door-out delay caused by failure to obtain a head computed tomography and computed tomography angiogram together. Lower risk failures include communication problems and delays within the PSC team and across the PSC comprehensive stroke center and paramedic teams. Seven solution prototypes were iteratively designed and address 4 of the 10 highest-ranked failures. Conclusions The failure modes, effects, and criticality analysis identified and characterized previously unrecognized failures of the door-in-door-out process. Use of a risk-informed approach for solution design is novel for stroke and should mitigate or eliminate the failures.
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Affiliation(s)
- Jane L Holl
- Department of Neurology Biological Sciences Division University of Chicago Chicago IL
| | | | | | - Amy Barnard
- Northwestern Medicine Lake Forest Hospital Lake Forest IL
| | | | | | - Christopher Richards
- Department of Emergency Medicine University of Cincinnati College of Medicine Cincinnati OH
| | - Scott Mendelson
- Department of Neurology Biological Sciences Division University of Chicago Chicago IL
| | - Shyam Prabhakaran
- Department of Neurology Biological Sciences Division University of Chicago Chicago IL
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Chilakamarri P, Finn EB, Sather J, Sheth KN, Matouk C, Parwani V, Ulrich A, Davis M, Pham L, Chaudhry SI, Venkatesh AK. Failure Mode and Effect Analysis: Engineering Safer Neurocritical Care Transitions. Neurocrit Care 2021; 35:232-240. [PMID: 33403581 DOI: 10.1007/s12028-020-01160-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 11/18/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND/OBJECTIVE Inter-hospital patient transfers for neurocritical care are increasingly common due to increased regionalization for acute care, including stroke and intracerebral hemorrhage. This process of transfer is uniquely vulnerable to errors and risk given numerous handoffs involving multiple providers, from several disciplines, located at different institutions. We present failure mode and effect analysis (FMEA) as a systems engineering methodology that can be applied to neurocritical care transitions to reduce failures in communication and improve patient safety. Specifically, we describe our local implementation of FMEA to improve the safety of inter-hospital transfer for patients with intracerebral and subarachnoid hemorrhage as evidence of success. METHODS We describe the conceptual basis for and specific use-case example for each formal step of the FMEA process. We assembled a multi-disciplinary team, developed a process map of all components required for successful transfer, and identified "failure modes" or errors that hinder completion of each subprocess. A risk or hazard analysis was conducted for each failure mode, and ones of highest impact on patient safety and outcomes were identified and prioritized for implementation. Interventions were then developed and implemented into an action plan to redesign the process. Importantly, a comprehensive evaluation method was established to monitor outcomes and reimplement interventions to provide for continual improvement. RESULTS This intervention was associated with significant reductions in emergency department (ED) throughput (ED length of stay from 300 to 149 min, (p < .01), and improvements in inter-disciplinary communication (increase from pre-intervention (10%) to post- (64%) of inter-hospital transfers where the neurological intensive care unit and ED attendings discussed care for the patient prior to their arrival). CONCLUSIONS Application of the FMEA approach yielded meaningful and sustained process change for patients with neurocritical care needs. Utilization of FMEA as a change instrument for quality improvement is a powerful tool for programs looking to improve timely communication, resource utilization, and ultimately patient safety.
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Affiliation(s)
- Priyanka Chilakamarri
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Veteran Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Emily B Finn
- Yale Center for Healthcare Innovation, Redesign and Learning, New Haven, CT, USA
| | - John Sather
- Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Ave. Suite 260, New Haven, CT, 06519, USA
| | - Kevin N Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Vivek Parwani
- Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Ave. Suite 260, New Haven, CT, 06519, USA
| | - Andrew Ulrich
- Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Ave. Suite 260, New Haven, CT, 06519, USA
| | - Melissa Davis
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Laura Pham
- Yale New Haven Hospital Patient and Physician Access, New Haven, CT, USA
| | - Sarwat I Chaudhry
- Yale New Haven Hospital, Center for Outcomes Research and Evaluation, New Haven, CT, USA
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Ave. Suite 260, New Haven, CT, 06519, USA.
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Miljković N, van Overbeeke E, Godman B, Kovačević M, Anastasi A, Bochenek T, Huys I, Miljković B. Practical Implications From European Hospital Pharmacists on Prospective Risk Assessment for Medicine Shortages. Front Med (Lausanne) 2020; 7:407. [PMID: 32850907 PMCID: PMC7419473 DOI: 10.3389/fmed.2020.00407] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/29/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: This study aimed to obtain a comprehensive overview on the perception, attitudes, and experience of European pharmacists with prospective risk assessment procedures in everyday practice, as well as to identify challenges and solutions. This is a follow-up study to the surveys on prospective risk assessment previously carried out within the COST Action 15105 among pharmacists across Europe. Methodology: In-depth interviews were performed using an interview guide comprising 25 questions. Interviews were transcribed ad verbatim and imported into NVivo 10 for framework analysis. In NVivo, the interviews were coded through assigning text segments to a responding code from a coding tree, covering the full content of the interviews. Coded text segments were then charted into a matrix, and analyzed by interpreting all text segments per code. Results: In total, 18 interviews were conducted. From the framework analysis, 6 codes and 12 sub-codes emerged. Overall, despite citing specific issues pertaining to its implementation, the interviewees considered multi-stakeholder and multi-disciplinary prospective risk assessment to be essential. While healthcare professionals reported being aware of the importance of risk assessment, they cited insufficient knowledge and skills to be a major obstacle in everyday practice. They also reported inadequate IT support since a paper-based system is still widely in use, thereby complicating data extraction to carry out prospective risk assessment. Conclusion: While prospective risk assessment was found to be valuable, interviewees also found it to be a resource-intensive and time-consuming process. Due to resource constraints, it may not be possible or desirable to conduct prospective risk assessment for every shortage. However, for critical-essential drugs, it is crucial to have a ready-to-use substitute based on risk assessment. Moreover, potential risks of substitutes on patient health should be identified before a shortage occurs and the substitute is dispensed as an alternative.
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Affiliation(s)
- Nenad Miljković
- Hospital Pharmacy Department, Institute of Orthopaedic Surgery "Banjica", University of Belgrade, Belgrade, Serbia
| | | | - Brian Godman
- Division of Clinical Pharmacology, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden.,Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, United Kingdom.,Department of Public Health and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa
| | - Milena Kovačević
- Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade, Belgrade, Serbia
| | - Alison Anastasi
- Central Procurement and Supplies Unit, The Malta Ministry for Health, San Gwann, Malta
| | - Tomasz Bochenek
- Department of Drug Management, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Isabelle Huys
- Clinical Pharmacology and Pharmacotherapy, KU Leuven, Leuven, Belgium
| | - Branislava Miljković
- Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade, Belgrade, Serbia
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Liu HC, Zhang LJ, Ping YJ, Wang L. Failure mode and effects analysis for proactive healthcare risk evaluation: A systematic literature review. J Eval Clin Pract 2020; 26:1320-1337. [PMID: 31849153 DOI: 10.1111/jep.13317] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 10/08/2019] [Accepted: 10/28/2019] [Indexed: 12/23/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Failure mode and effects analysis (FMEA) is a valuable reliability management tool that can preemptively identify the potential failures of a system and assess their causes and effects, thereby preventing them from occurring. The use of FMEA in the healthcare setting has become increasingly popular over the last decade, being applied to a multitude of different areas. The objective of this study is to review comprehensively the literature regarding the application of FMEA for healthcare risk analysis. METHODS An extensive search was carried out in the scholarly databases of Scopus and PubMed, and we only chose the academic articles which used the FMEA technique to solve healthcare risk analysis problems. Furthermore, a bibliometric analysis was performed based on the number of citations, publication year, appeared journals, authors, and country of origin. RESULTS A total of 158 journal papers published over the period of 1998 to 2018 were extracted and reviewed. These publications were classified into four categories (ie, healthcare process, hospital management, hospital informatization, and medical equipment and production) according to the healthcare issues to be solved, and analyzed regarding the application fields and the utilized FMEA methods. CONCLUSION FMEA has high practicality for healthcare quality improvement and error reduction and has been prevalently employed to improve healthcare processes in hospitals. This research supports academics and practitioners in effectively adopting the FMEA tool to proactively reduce healthcare risks and increase patient safety, and provides an insight into its state-of-the-art.
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Affiliation(s)
- Hu-Chen Liu
- School of Economics and Management, Tongji University, Shanghai, People's Republic of China.,College of Economics and Management, China Jiliang University, Hangzhou, People'sRepublic of China
| | - Li-Jun Zhang
- School of Management, Shanghai University, Shanghai, People's Republic of China
| | - Ye-Jia Ping
- School of Management, Shanghai University, Shanghai, People's Republic of China
| | - Liang Wang
- School of Management, Shanghai University, Shanghai, People's Republic of China
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8
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Stanfield L. Improvement of Door-to-Electrocardiogram Time Using the First-Nurse Role in the ED Setting. J Emerg Nurs 2018; 44:466-471. [DOI: 10.1016/j.jen.2017.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/29/2017] [Accepted: 12/23/2017] [Indexed: 01/07/2023]
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Nasim F, Poterucha JT, Daniels LM, Park JG, Seelhammer TG, Bohman JK, Friedrich TP, Blau CL, Elmer JL, Schears GJ. Practical Implementation of Failure Mode and Effects Analysis for Extracorporeal Membrane Oxygenation Activation. Am J Med Qual 2018; 33:523-529. [PMID: 29366330 DOI: 10.1177/1062860618754703] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is used to treat severe hypoxemic respiratory failure and as a rescue therapy for patients with cardiopulmonary arrest within a narrow window of time. A failure modes and effects analysis (FMEA) was conducted to analyze the clinical and operational processes leading to delays in initiating ECMO. FMEA determined these highest-risk failure modes that were contributing to process failure: (1) ECMO candidacy not determined in time, (2) no or incomplete evaluation for ECMO prior to consult or arrest, (3) ECMO team not immediately available, and (4) cannulation not completed in time. When implemented collectively, a total of 4 interventions addressed more than 95% of the system failures. These interventions were (1) ECMO response pager held by a team required for decision, (2) distribution of institutionally defined inclusion/exclusion criteria, (3) educational training for clinicians consulting the ECMO team, and (4) establishment of a mobile ECMO insertion cart.
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Prabhakaran S, Khorzad R, Brown A, Nannicelli AP, Khare R, Holl JL. Academic-Community Hospital Comparison of Vulnerabilities in Door-to-Needle Process for Acute Ischemic Stroke. CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES 2016; 8:S148-54. [PMID: 26515203 DOI: 10.1161/circoutcomes.115.002085] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although best practices have been developed for achieving door-to-needle (DTN) times ≤60 minutes for stroke thrombolysis, critical DTN process failures persist. We sought to compare these failures in the Emergency Department at an academic medical center and a community hospital. METHODS AND RESULTS Failure modes effects and criticality analysis was used to identify system and process failures. Multidisciplinary teams involved in DTN care participated in moderated sessions at each site. As a result, DTN process maps were created and potential failures and their causes, frequency, severity, and existing safeguards were identified. For each failure, a risk priority number and criticality score were calculated; failures were then ranked, with the highest scores representing the most critical failures and targets for intervention. We detected a total of 70 failures in 50 process steps and 76 failures in 42 process steps at the community hospital and academic medical center, respectively. At the community hospital, critical failures included (1) delay in registration because of Emergency Department overcrowding, (2) incorrect triage diagnosis among walk-in patients, and (3) delay in obtaining consent for thrombolytic treatment. At the academic medical center, critical failures included (1) incorrect triage diagnosis among walk-in patients, (2) delay in stroke team activation, and (3) delay in obtaining computed tomographic imaging. CONCLUSIONS Although the identification of common critical failures suggests opportunities for a generalizable process redesign, differences in the criticality and nature of failures must be addressed at the individual hospital level, to develop robust and sustainable solutions to reduce DTN time.
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Affiliation(s)
- Shyam Prabhakaran
- From the Division of Neurology (S.P.), Center for Healthcare Studies (S.P., R.K., A.B., A.P.N., J.L.H.), Feinberg School of Medicine, Northwestern University, Chicago, IL; and Private Practice, Chicago, IL (R.K.).
| | - Rebeca Khorzad
- From the Division of Neurology (S.P.), Center for Healthcare Studies (S.P., R.K., A.B., A.P.N., J.L.H.), Feinberg School of Medicine, Northwestern University, Chicago, IL; and Private Practice, Chicago, IL (R.K.)
| | - Alexandra Brown
- From the Division of Neurology (S.P.), Center for Healthcare Studies (S.P., R.K., A.B., A.P.N., J.L.H.), Feinberg School of Medicine, Northwestern University, Chicago, IL; and Private Practice, Chicago, IL (R.K.)
| | - Anna P Nannicelli
- From the Division of Neurology (S.P.), Center for Healthcare Studies (S.P., R.K., A.B., A.P.N., J.L.H.), Feinberg School of Medicine, Northwestern University, Chicago, IL; and Private Practice, Chicago, IL (R.K.)
| | - Rahul Khare
- From the Division of Neurology (S.P.), Center for Healthcare Studies (S.P., R.K., A.B., A.P.N., J.L.H.), Feinberg School of Medicine, Northwestern University, Chicago, IL; and Private Practice, Chicago, IL (R.K.)
| | - Jane L Holl
- From the Division of Neurology (S.P.), Center for Healthcare Studies (S.P., R.K., A.B., A.P.N., J.L.H.), Feinberg School of Medicine, Northwestern University, Chicago, IL; and Private Practice, Chicago, IL (R.K.)
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12
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McElroy LM, Khorzad R, Nannicelli AP, Brown AR, Ladner DP, Holl JL. Failure mode and effects analysis: a comparison of two common risk prioritisation methods. BMJ Qual Saf 2015; 25:329-36. [PMID: 26170336 DOI: 10.1136/bmjqs-2015-004130] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 06/21/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND Failure mode and effects analysis (FMEA) is a method of risk assessment increasingly used in healthcare over the past decade. The traditional method, however, can require substantial time and training resources. The goal of this study is to compare a simplified scoring method with the traditional scoring method to determine the degree of congruence in identifying high-risk failures. METHODS An FMEA of the operating room (OR) to intensive care unit (ICU) handoff was conducted. Failures were scored and ranked using both the traditional risk priority number (RPN) and criticality-based method, and a simplified method, which designates failures as 'high', 'medium' or 'low' risk. The degree of congruence was determined by first identifying those failures determined to be critical by the traditional method (RPN≥300), and then calculating the per cent congruence with those failures designated critical by the simplified methods (high risk). RESULTS In total, 79 process failures among 37 individual steps in the OR to ICU handoff process were identified. The traditional method yielded Criticality Indices (CIs) ranging from 18 to 72 and RPNs ranging from 80 to 504. The simplified method ranked 11 failures as 'low risk', 30 as medium risk and 22 as high risk. The traditional method yielded 24 failures with an RPN ≥300, of which 22 were identified as high risk by the simplified method (92% agreement). The top 20% of CI (≥60) included 12 failures, of which six were designated as high risk by the simplified method (50% agreement). CONCLUSIONS These results suggest that the simplified method of scoring and ranking failures identified by an FMEA can be a useful tool for healthcare organisations with limited access to FMEA expertise. However, the simplified method does not result in the same degree of discrimination in the ranking of failures offered by the traditional method.
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Affiliation(s)
- Lisa M McElroy
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois, USA Northwestern University Transplant Outcomes Research Collaborative, Northwestern University, Chicago, Illinois, USA
| | - Rebeca Khorzad
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois, USA Northwestern University Transplant Outcomes Research Collaborative, Northwestern University, Chicago, Illinois, USA
| | - Anna P Nannicelli
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois, USA
| | - Alexandra R Brown
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois, USA
| | - Daniela P Ladner
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois, USA Northwestern University Transplant Outcomes Research Collaborative, Northwestern University, Chicago, Illinois, USA
| | - Jane L Holl
- Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University, Chicago, Illinois, USA Northwestern University Transplant Outcomes Research Collaborative, Northwestern University, Chicago, Illinois, USA
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13
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McElroy LM, Collins KM, Koller FL, Khorzad R, Abecassis MM, Holl JL, Ladner DP. Operating room to intensive care unit handoffs and the risks of patient harm. Surgery 2015; 158:588-94. [PMID: 26067459 DOI: 10.1016/j.surg.2015.03.061] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 03/24/2015] [Accepted: 03/25/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND The goal of this study was to assess systems and processes involved in the operating room (OR) to intensive care unit (ICU) handoff in an attempt to understand the criticality of specific steps of the handoff. METHODS We performed a failure modes, effects, and criticality analysis (FMECA) of the OR to ICU handoff of deceased donor liver transplant recipients using in-person observations and descriptions of the handoff process from a multidisciplinary group of clinicians. For each step in the process, failures were identified along with frequency of occurrence, causes, potential effects and safeguards. A Risk Priority Number (RPN) was calculated for each failure (frequency × potential effect × safeguard; range 1-least risk to 1,000-most risk). RESULTS Using FMECA, we identified 37 individual steps in the OR to ICU handoff process. In total, 81 process failures were identified, 22 of which were determined to be critical and 36 of which relied on weak safeguards such as informal human verification. Process failures with the greatest risk of harm were lack of preliminary OR to ICU communication (RPN 504), team member absence during handoff communication (RPN 480), and transport equipment malfunction (Risk Priority Number 448). CONCLUSION Based on the analysis, recommendations were made to reduce potential for patient harm during OR to ICU handoffs. These included automated transfer of OR data to ICU clinicians, enhanced ICU team member notification processes and revision of the postoperative order sets. The FMECA revealed steps in the OR to ICU handoff that are high risk for patient harm and are currently being targeted for process improvement.
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Affiliation(s)
- Lisa M McElroy
- Center for Healthcare Studies and Center for Education in Health Sciences, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Kelly M Collins
- Section of Transplantation, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Felicitas L Koller
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Rebeca Khorzad
- Center for Healthcare Studies and Center for Education in Health Sciences, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Michael M Abecassis
- Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jane L Holl
- Center for Healthcare Studies and Center for Education in Health Sciences, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Daniela P Ladner
- Center for Healthcare Studies and Center for Education in Health Sciences, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL
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14
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Powell ES, O'Connor LM, Nannicelli AP, Barker LT, Khare RK, Seivert NP, Holl JL, Vozenilek JA. Failure mode effects and criticality analysis: innovative risk assessment to identify critical areas for improvement in emergency department sepsis resuscitation. ACTA ACUST UNITED AC 2014. [PMID: 29539994 DOI: 10.1515/dx-2014-0007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Sepsis is an increasing problem in the practice of emergency medicine as the prevalence is increasing and optimal care to reduce mortality requires significant resources and time. Evidence-based septic shock resuscitation strategies exist, and rely on appropriate recognition and diagnosis, but variation in adherence to the recommendations and therefore outcomes remains. Our objective was to perform a multi-institutional prospective risk-assessment, using failure mode effects and criticality analysis (FMECA), to identify high-risk failures in ED sepsis resuscitation. METHODS We conducted a FMECA, which prospectively identifies critical areas for improvement in systems and processes of care, across three diverse hospitals. A multidisciplinary group of participants described the process of emergency department (ED) sepsis resuscitation to then create a comprehensive map and table listing all process steps and identified process failures. High-risk failures in sepsis resuscitation from each of the institutions were compiled to identify common high-risk failures. RESULTS Common high-risk failures included limited availability of equipment to place the central venous catheter and conduct invasive monitoring, and cognitive overload leading to errors in decision-making. Additionally, we identified great variability in care processes across institutions. DISCUSSION Several common high-risk failures in sepsis care exist: a disparity in resources available across hospitals, a lack of adherence to the invasive components of care, and cognitive barriers that affect expert clinicians' decision-making capabilities. Future work may concentrate on dissemination of non-invasive alternatives and overcoming cognitive barriers in diagnosis and knowledge translation.
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Affiliation(s)
- Emilie S Powell
- 1Northwestern University, Department of Emergency Medicine, Feinberg School of Medicine, Chicago, IL, USA2Northwestern University, Center for Healthcare Studies, Institute for Public Health in Medicine, Feinberg School of Medicine, Chicago, IL, USA
| | - Lanty M O'Connor
- 3Northwestern University, Center for Education in Health Sciences, Institute for Public Health in Medicine, Feinberg School of Medicine, Chicago, IL, USA
| | - Anna P Nannicelli
- 2Northwestern University, Center for Healthcare Studies, Institute for Public Health in Medicine, Feinberg School of Medicine, Chicago, IL, USA
| | - Lisa T Barker
- 4University of Illinois College of Medicine at Peoria/OSF St. Francis Medical Center, Jump Trading Simulation and Education Center, Peoria, IL, USA
| | - Rahul K Khare
- 1Northwestern University, Department of Emergency Medicine, Feinberg School of Medicine, Chicago, IL, USA2Northwestern University, Center for Healthcare Studies, Institute for Public Health in Medicine, Feinberg School of Medicine, Chicago, IL, USA
| | - Nicholas P Seivert
- 2Northwestern University, Center for Healthcare Studies, Institute for Public Health in Medicine, Feinberg School of Medicine, Chicago, IL, USA
| | - Jane L Holl
- 2Northwestern University, Center for Healthcare Studies, Institute for Public Health in Medicine, Feinberg School of Medicine, Chicago, IL, USA
| | - John A Vozenilek
- 4University of Illinois College of Medicine at Peoria/OSF St. Francis Medical Center, Jump Trading Simulation and Education Center, Peoria, IL, USA
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15
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Loh JP, Satler LF, Pendyala LK, Minha S, Frohna WJ, Torguson R, Chen F, Suddath WO, Pichard AD, Waksman R. Use of emergency medical services expedites in-hospital care processes in patients presenting with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2014; 15:219-25. [PMID: 24952684 DOI: 10.1016/j.carrev.2014.03.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 03/20/2014] [Indexed: 11/28/2022]
Abstract
To determine whether door-to-balloon (DTB) times of patients presenting with ST-elevation myocardial infarction (STEMI) were reduced in patients transported by emergency medical services (EMS) compared to those who were self-transported. DTB time is an important measure of hospital care processes in STEMI. Use of EMS may expedite in-hospital processing and reduce DTB times. A total of 309 consecutive STEMI patients who underwent primary percutaneous coronary intervention in our institution were analyzed. Excluded were patients who received fibrinolytics, presented in cardiac arrest, were intubated, or were transferred from another hospital. EMS-transported patients (n=83) were compared to self-transported patients (n=226). The primary outcome measure was DTB time and its component time intervals. Secondary end points included symptom-to-door and symptom-to-balloon times, and correlates for DTB >90 minutes. A higher percentage of EMS-transported patients reached the time goal of DTB <90 minutes compared to self-transported patients (83.1 versus 54.3%; p<0.001). EMS-transported patients had shorter DTB times [median (IQR) minutes, 65 (50-86) versus 85 (61-126); p<0.001] due to a reduction of emergency department processing (door-to-call) time, whereas catheterization laboratory processing (call-to-balloon) times were similar in both groups. EMS-transported patients had shorter symptom-to-door [median (IQR) hours, 1.2 (0.8-3.5) versus 2.3 (1.2-7.5); p<0.001] and symptom-to-balloon [median (IQR) hours, 2.5 (1.9-4.7) versus 4.3 (2.6-9.1); p<0.001]. Independent correlates of DTB times >90 minutes were self-transport (odds ratio 5.32, 95% CI 2.65-10.70; p<0.001) and off-hours presentation (odds ratio 2.89, 95% CI 1.60-5.22; p<0.001). Use of EMS transport in STEMI patients significantly shortens time to reperfusion, primarily by expediting emergency department processes. Community education efforts should focus not only on the importance of recognizing symptoms of myocardial infarction, but also taking early action by calling the EMS.
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Affiliation(s)
- Joshua P Loh
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Lowell F Satler
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | | | - Sa'ar Minha
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - William J Frohna
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC
| | - Rebecca Torguson
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Fang Chen
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - William O Suddath
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Augusto D Pichard
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Ron Waksman
- Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC.
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