Failure modes and effect analysis to develop transfer protocols in the management of COVID-19 patients

Use of Failure Mode and Effect Analysis to Reduce Admission of Asymptomatic COVID-19 Patients to the Adult Emergency Department: An Institutional Experience

BACKGROUND

Failure mode and effect analysis is an important tool to identify failures in a system with its possible cause, effect, and set actions to be implemented proactively before the occurrence of problems. This study tries to identify common failure modes with its possible causes and effect to the health service and to plot actions to be implemented to reduce COVID-19 transmission to clients, staff, and subsequent service compromise from asymptomatic COVID-19 patients visiting the adult emergency department of SPHMMC (non-COVID-19 setup).

METHOD AND STUDY DESIGN

A multidisciplinary team, representing different divisions of the adult emergency department at St. Paul's Hospital Millennium Medical College (SPHMMC), was chosen. This team was trained on failure mode and effect analysis and basics of COVID-19, to identify possible causes of failures and their potential effects, to calculate a risk priority number (RPN) for each failure, and plan changes in practice.

RESULTS

A total of 22 failure modes and 89 associated causes and effects were identified. Many of these failure modes (12 out of 22) were found in all steps of patient flow and were associated with either due to lack of or failure to apply standard and transmission-based precautions. This suggests the presence of common targets for improvement, particularly in enhancing the safety of staff and clients. As a result of this FMEA, 23 general improvement actions were proposed.

CONCLUSION

FMEA can be used as a useful tool for anticipating potential failures in the process and proposing improvement actions that could help in reducing secondary transmissions during the pandemic.

HFE at the frontiers of COVID-19. Human factors/ergonomics to support the communication for safer care in Italy during the COVID-19 pandemic

Italy was the first country after China to be affected by COVID-19. The wave of the emergency found our country unprepared to cope with the surge of patients going to first aid departments to seek assistance in the almost complete paralysis of community health. Human factors and ergonomics (HFE) can effectively contribute to, and improve the effectiveness of, a pandemic response working on several key areas: training, adapting workflows and processes, restructuring teams and tasks, effective mechanisms and tools for communication, engaging patients and families and learning from failures and successes. In Italy, HFE expertise has been able to provide our healthcare systems with some easy-to-realize solutions (particularly dedicated to improving communication, team work and situational awareness) in order to cope with the need for rapid adaptations to new and unknown scenarios: ensuring information and communication continuity in the different levels of the healthcare system; identifying hazard opportunity through risk management tool; providing training through simulation; organizing regular briefing and debriefing; enhancing the reporting and learning system as an informal way of communicating adverse events and supporting information campaign and education initiatives for the public.

Failure modes and effects analysis to assess COVID-19 protocols in the management of obstetric emergencies

The Royal Free Hospital is one of four High Consequence Infectious Disease centres in England and as of the end of May 2020, seven women were confirmed COVID-19 peri-delivery. We developed a standard operating procedure (SOP) for suspected and confirmed COVID-19 women undergoing operative delivery. This was revised in response to our ongoing clinical experience and changes in guidance from medical and public health organisations. Following 10 weeks of clinical practice, we formally tested the SOP using point-of-care simulation to enable optimisation for a potential second surge. Our high-fidelity simulation of a COVID-19-positive parturient requiring an emergency caesarean was facilitated by the simulation team in our obstetric unit. It was designed to test the performance and safety of our SOP as well as staff performance. We used the Failure Modes and Effect Analysis tool (a systematic, prospective method of process mapping) to identify how a complex task might fail and assess the relative impact of different failures. The decision-to-delivery was 17 minutes, which we considered to be successful. However, a number of operational deficiencies were identified. The main failures related to lack of situational awareness, ill-fitting personal protective equipment and difficulties communicating between theatre and the neonatal teams located outside, posing serious potential risks to safe neonatal care. Subsequently, we have modified our SOP to include a communication check, implemented communication training for the neonatal team and organised further simulation training for theatre staff unfamiliar with COVID-19 considerations.

Development of Rapid Response Capabilities in a Large COVID-19 Alternate Care Site Using Failure Modes and Effect Analysis with In Situ Simulation

Preparedness measures for the anticipated surge of coronavirus disease 2019 (COVID-19) cases within eastern Massachusetts included the establishment of alternate care sites (field hospitals). Boston Hope hospital was set up within the Boston Convention and Exhibition Center to provide low-acuity care for COVID-19 patients and to support local healthcare systems. However, early recognition of the need to provide higher levels of care, or critical care for the potential deterioration of patients recovering from COVID-19, prompted the development of a hybrid acute care-intensive care unit. We describe our experience of implementing rapid response capabilities of this innovative ad hoc unit. Combining quality improvement tools for hazards detection and testing through in situ simulation successfully identified several operational hurdles. Through rapid continuous analysis and iterative change, we implemented appropriate mitigation strategies and established rapid response and rescue capabilities. This study provides a framework for future planning of high-acuity services within a unique field hospital setting.