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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References
James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9:122–8.
Kitch BT, Cooper JB, Zapol WM, et al. Handoffs causing patient harm: a survey of medical and surgical house staff. Jt Comm J Qual Patient Saf. 2008;34:563–70.
Holland CM, McClure EW, Howard BM, Samuels OB, Barrow DL. Interhospital transfer of neurosurgical patients to a high-volume tertiary care center: opportunities for improvement. Neurosurgery. 2015;77:200–6 discussion 6-7.
Mohorek M, Webb TP. Establishing a conceptual framework for handoffs using communication theory. J Surg Educ. 2015;72:402–9.
Byrne RW, Bagan BT, Slavin KV, Curry D, Koski TR, Origitano TC. Neurosurgical emergency transfers to academic centers in cook county a prospective multicenter study. Neurosurgery. 2008;62:709–16.
Minami CA, Sheils CR, Bilimoria KY, et al. Process improvement in surgery. Curr Probl Surg. 2016;53:62–96.
Braaksma AJJMAJ, Klingenberg W, Hicks C. A quantitative method for failure mode and effects analysis. Int J Prod Res. 2012;50:6904–17.
Bertsche SA, Pickard K. Reliability in automotive and mechanical engineering determination of component and system reliability, vol. 4. Berlin: Springer; 2008. p. 98–159.
Khare RK, Nannicelli AP, Powell ES, Seivert NP, Adams JG, Holl JL. Use of risk assessment analysis by failure mode, effects, and criticality to reduce door-to-balloon time. Ann Emerg Med. 2013;62(388–98):e12.
Rosen MA, Lee BH, Sampson JB, et al. Failure mode and effects analysis applied to the maintenance and repair of anesthetic equipment in an austere medical environment. Int J Qual Health Care. 2014;26:404–10.
Scorsetti M, Signori C, Lattuada P, et al. Applying failure mode effects and criticality analysis in radiotherapy: lessons learned and perspectives of enhancement. Radiother Oncol. 2010;94:367–74.
Viejo Moreno R, Sanchez-Izquierdo Riera JA, Molano Alvarez E, et al. Improvement of the safety of a clinical process using failure mode and effects analysis: prevention of venous thromboembolic disease in critical patients. Med Intensiv. 2016;40:483–90.
Commission AJ. Comprehensive accreditation manual, CAMH for Hospitals; 2017.
Herrigel DJ, Carroll M, Fanning C, Steinberg MB, Parikh A, Usher M. Interhospital transfer handoff practices among US tertiary care centers: a descriptive survey. J Hosp Med. 2016;11:413–7.
Chiozza ML, Ponzetti C. FMEA: a model for reducing medical errors. Clin Chim Acta. 2009;404:75–8.
Thornton E, Brook OR, Mendiratta-Lala M, Hallett DT, Kruskal JB. Application of failure mode and effect analysis in a radiology department. Radiographics. 2011;31:281–93.
Yousefinezhadi T, Jannesar Nobari FA, Behzadi Goodari F, Arab M. A case study on improving Intensive Care Unit (ICU) services reliability: by using process failure mode and effects analysis (PFMEA). Glob J Health Sci. 2016;8:52635.
DeRosier J, Stalhandske E, Bagian JP, Nudell T. Using health care failure mode and effect analysis™: the VA national center for patient safety’s prospective risk analysis system. Jt Comm J Qual Improv. 2002;28:248–67.
Littauer R, Sather J, Rothenberg C, Finn EB, Yip M, Matouk C, Pham L, Sheth KN, Ulrich A, Parwani Y, Venkatesh AK. 57 Improving the safety and quality of inter-hospital transfer for nontraumatic intracerebral and subarachnoid hemorrhage. Ann Emerg Med. 2018;72:S25–6.
Damush TM, Miller KK, Plue L, et al. National implementation of acute stroke care centers in the Veterans Health Administration (VHA): formative evaluation of the field response. J Gen Intern Med. 2014;29(Suppl 4):845–52.
Samuels O, Webb A, Culler S, Martin K, Barrow D. Impact of a dedicated neurocritical care team in treating patients with aneurysmal subarachnoid hemorrhage. Neurocrit Care. 2011;14:334–40.
Knopf L, Staff I, Gomes J, McCullough L. Impact of a neurointensivist on outcomes in critically ill stroke patients. Neurocrit Care. 2012;16:63–71.
Orlando A, Levy AS, Carrick MM, Tanner A, Mains CW, Bar-Or D. Epidemiology of mild traumatic brain injury with intracranial hemorrhage: focusing predictive models for neurosurgical intervention. World Neurosurg. 2017;107:94–102.
Badrick T, Gay S, Mackay M, Sikaris K. The key incident monitoring and management system - history and role in quality improvement. Clin Chem Lab Med. 2018;56:264–72.
Ofek F, Magnezi R, Kurzweil Y, Gazit I, Berkovitch S, Tal O. Introducing a change in hospital policy using FMEA methodology as a tool to reduce patient hazards. Isr J Health Policy Res. 2016;5:30.
Acknowledgements
We acknowledge Judy Petersen for her support in developing and presenting process maps as a technical consultant for this work.
Funding
Funding was provided by Agency for Healthcare Research and Quality (Grant No. P30HS023554), National Institutes of Health (Grant No. P30AG021342), National Center for Advancing Translational Sciences (Grant No. KL2 TR000140).
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AKV and SC obtained funding for this project. AKV, EF, and JS designed the study and lead the project team. KS, CM, LP, AU, VP, and MD contributed to the collection of data and analysis of study data. PC leads the drafting of the initial manuscript with critical review by all authors. AKV takes ownership for all data and writing in this manuscript.
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Dr. Sheth reports grants from Novartis, grants from NIH, during the conduct of the study. Dr. Chaudhry reports and Dr. Chaudhry serves as a reviewer for the CVS Caremark State of Connecticut Clinical Program. Dr. Venkatesh reports grants from Agency for Healthcare Research and Quality, grants from NIH/NIA, grants from NIH—National Center for Advancing Translational Science, during the conduct of the study. Dr. Matouk has nothing to disclose. Dr. Chilakamarri, Dr. Finn, Dr. Sather, Dr. Parwani, Dr. Ulrich, Dr. Davis, Dr. Pham, and Dr. Chilakamarri have nothing to disclose.
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This manuscript adheres to ethical guidelines and was approved by the Yale Institutional Review Board.
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Chilakamarri, P., Finn, E.B., Sather, J. et al. Failure Mode and Effect Analysis: Engineering Safer Neurocritical Care Transitions. Neurocrit Care 35, 232–240 (2021). https://doi.org/10.1007/s12028-020-01160-6
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DOI: https://doi.org/10.1007/s12028-020-01160-6