Abstract WP365: Reducing Door-in-Door-out Times by Applying Failure Modes Effects and Criticality Analysis

Abstract

Introduction: Given the time-critical nature of acute stroke, reducing door-in-door-out (DIDO) times at primary stroke centers (PSC) prior to transfer to comprehensive stroke centers (CSC) is a priority. We applied Failure Modes Effects and Criticality Analysis (FMECA) to the DIDO process at a PSC, an engineering methodology widely used in other industries, to understand the most critical areas negatively impacting DIDO time. Methods: We collected data during 2 in-person and 5 virtual Learning Collaborative (LC) meetings, enhanced by electronic surveys. The LC team consisted of 18 clinicians affiliated with 6 different healthcare systems including 3 PSCs and 3 CSCs, 2 participants from EMS agencies, and 5 patients and caregivers. The LC team created a DIDO process map with individual steps. For each step, we asked LC members to identify ways in which the process could be performed incorrectly, incompletely, skipped or delayed (failures) along with the clinical impact, their causes, frequency and existing safeguards. Each clinical impact, frequency and safeguard was scored from 1-10 (lowest to highest). Frequency, severity, and safeguards scores were multiplied to calculate a criticality score to rank the top DIDO process failures. Results: Among 61 DIDO process steps, the top 12 steps with the highest criticality score represented 40.4% of the sum of criticalities (Figure). Among these, the highest criticality scores were for: 1) Delay in the decision to obtain CTA; 2) Delay in stroke recognition by the EMS team; 3) Delay in stroke identification at triage. Conclusion: We identified opportunities to re-design the DIDO process for acute stroke. Existing safeguards for the identified “high” criticality failures rely on human factors (e.g., multiple visual inspections, provider’s experience). There is a need to develop better stroke identification tools and automatic triggers within the DIDO process to increase timely stroke transfers from PSC to CSCs.