Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.
Veteran Affairs Connecticut Healthcare System, West Haven, CT, USA.
Neurocrit Care. 2021 Aug;35(1):232-240. doi: 10.1007/s12028-020-01160-6. Epub 2021 Jan 5.
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.
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.
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).
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.
背景/目的：由于急性治疗的区域化增加，包括中风和脑出血，神经重症监护的院内患者转运会越来越常见。由于涉及多个提供者、来自多个学科、位于不同机构的多次交接，转运会出现独特的错误和风险。我们提出失效模式和影响分析（FMEA）作为一种系统工程方法，可应用于神经重症监护交接，以减少沟通中的故障并提高患者安全性。具体来说，我们描述了我们当地实施 FMEA 的情况，以改善颅内和蛛网膜下腔出血患者的院内转院安全性，以此作为成功的证据。
我们描述了 FMEA 过程的每个正式步骤的概念基础和具体用例示例。我们组建了一个多学科团队，制定了成功转院所需的所有流程图，并确定了妨碍每个子流程完成的“失效模式”或错误。对每种失效模式进行了风险或危害分析，并确定了对患者安全和结果影响最大的模式，并将其确定为优先级，以实施干预措施。然后制定并实施干预措施，以重新设计流程。重要的是，建立了全面的评估方法来监测结果并重新实施干预措施，以提供持续改进。
这种干预措施与急诊科（ED）吞吐量的显著减少相关（ED 停留时间从 300 分钟减少到 149 分钟，（p < .01），并且改善了跨学科沟通（从干预前（10%）增加到（64%），在神经重症监护病房和 ED 主治医生在患者到达之前讨论了患者的护理）。
应用 FMEA 方法为有神经重症监护需求的患者带来了有意义且持续的流程变化。将 FMEA 用作质量改进的变更工具，是那些希望改善及时沟通、资源利用、最终提高患者安全性的计划的有力工具。
