Risk Assessment of the Door‐In‐Door‐Out Process at Primary Stroke Centers for Patients With Acute Stroke Requiring Transfer to Comprehensive Stroke Centers

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.

Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis

“…documented each described role, task, activity, or communication and cognitive step on the chat board of the video conferencing platform and, then, iteratively, with feedback from LC participants, reordered them to represent the sequence of steps of the acute stroke diagnostic process from the perspective of all participants. The research team leveraged a previously developed process map, focused on interhospital transfer processes for acute stroke patients 15 and incorporated the information from the LC sessions to create a preliminary acute stroke diagnostic process map (Microsoft Visio 2019). Additional brief videoconference sessions were held with select participants for map clarifications.…”

“…Retrospective chart reviews and malpractice claims data have primarily been used to understand the ED diagnostic processes for acute stroke 11,12 . A failure modes, effects, and criticality analysis (FMECA), an engineering method, used initially in high‐risk industries such as aerospace and nuclear power, but increasingly applied to health care, involves engaging stakeholders to describe the steps and workflows of a process and to identify the vulnerabilities or failures of each step and then to characterize their underlying causes, frequency, potential harm to the patient, and any existing safeguard(s) to mitigate or eliminate, using standardized scores 9,13–15 . Unlike other process improvement approaches, FMECAs help to counter most organizations’ common temptation to focus on the most evident and visible failures, which may not be the most high‐risk ones 16 .…”

“…11,12 A failure modes, effects, and criticality analysis (FMECA), an engineering method, used initially in high-risk industries such as aerospace and nuclear power, but increasingly applied to health care, involves engaging stakeholders to describe the steps and workflows of a process and to identify the vulnerabilities or failures of each step and then to characterize their underlying causes, frequency, potential harm to the patient, and any existing safeguard(s) to mitigate or eliminate, using standardized scores. 9,[13][14][15] Unlike other process improvement approaches, FMECAs help to counter most organizations' common temptation to focus on the most evident and visible failures, which may not be the most high-risk ones. 16 In this study, we conducted an FMECA of the acute stroke diagnostic process in the ED at three diverse health systems in Chicago, IL, to identify, characterize, and rank order opportunities for system redesign to improve acute stroke diagnostic accuracy and timeliness.…”

Strengthening the stroke chain of survival in community emergency departments

“… 21 For patients requiring transfer to higher levels of stroke care for acute therapy, time is a premium, and current processes for reducing door‐in‐door‐out times of interfacility transfers are typically prolonged. 22 , 23 These delays can be minimized through collaborative processes within networks with established transfer protocols. 24 Future innovations in times of high inpatient census at CSCs may even look to models where patients receive advanced hyperacute therapies, such as EVT, but complete the remainder of their inpatient hospitalization at a PSC in the patient's local community.…”

“…Leveraging hospital networks of care, or “hub‐and‐spoke” collaborative care models between institutions, can lead to efficient regionalization of resources, facilitating patients being treated at the level of stroke center that is most appropriate for their type of stroke 21 . For patients requiring transfer to higher levels of stroke care for acute therapy, time is a premium, and current processes for reducing door‐in‐door‐out times of interfacility transfers are typically prolonged 22,23 . These delays can be minimized through collaborative processes within networks with established transfer protocols 24 .…”