Risk assessment of the hospital discharge process of high-risk patients with diabetes

Failure Mode Effects Analysis of Re-triage of Injured Patients to Receiving High-Level Illinois Trauma Centers

OBJECTIVE

This study identified failures in emergency inter-hospital transfer, or re-triage, at high-level trauma centers receiving severely injured patients.

SUMMARY BACKGROUND DATA

The re-triage process averages four hours despite the fact timely re-triage within two hours mitigates injury-associated mortality. Non-trauma and low-level trauma centers reported most critical failures were in finding an accepting high-level trauma center. Critical failures at high-level trauma centers have not been assessed.

METHODS

This was an observational cross-sectional study at nine high-level adult trauma centers and three high-level pediatric trauma centers. Failure Modes Effects Analysis (FMEA) of the re-triage process was conducted in four phases. Phase 1 purposively sampled trauma coordinators followed by snowball sampling of clinicians, operations, and leadership to ensure representative participation. Phase 2 mapped each re-triage step. Phase 3 identified failures at each step. Phase 4 scored each failure on impact, frequency, and safeguards for detection. Standardized rubrics were used in Phase 4 to rate each failure's impact (I), frequency (F), and safeguard for detection (S) to calculate their Risk Priority Number (RPN) (I x F x S). Failures were rank ordered for criticality.

RESULTS

A total of 64 trauma coordinators, surgeons, emergency medicine physicians, nurses, operations and quality managers across twelve high-level trauma centers participated. There were 178failures identified at adult and pediatric high-level trauma centers. The most critical failures were: Insufficient trained transport staff (RPN=648); Issues transmitting imaging from sending to receiving centers (RPN=400); Incomplete exchange of clinical information(RPN=384).

CONCLUSIONS

The most critical failures were limited transportation and incomplete exchange of clinical, radiological and arrival timing information. Further investigation of these failures that includes several regions is needed to determine the reproducibility of these findings.

Development and acceptability of a culturally competent skills and knowledge assessment tool for patients with diabetes mellitus

Background

Patients newly diagnosed with type 2 diabetes mellitus (DM) and newly prescribed insulin need to learn essential self-care and management skills quickly. To optimize teaching, clinicians need to assess a patient's basic understanding of DM and their skills. While DM patient assessments exist, this study reports the development of an assessment of patient DM management skills and knowledge, using feedback from DM clinicians, patients, and caregivers.

Research Design and Methods

A systematic search of Pubmed/Medline and Scopus (1980-2017) of DM knowledge assessments was performed. Twenty-four studies were identified. Content from the existing assessments was adapted to create a 12 item DM-Skills Knowledge Assessment (SKA) to assess a patient's DM management skills and knowledge. To assess cultural humility, modified cognitive interviews were conducted in individual user sessions and semi-structured focus groups. Audio-transcripts of the interviews/focus groups were independently coded, and codes were grouped into key themes. Participant demographic characteristics were assessed.

Results

Five focus groups and eleven key informant interviews were conducted, including 10 DM clinicians, 12 patients/caregivers, and 15 laypersons. All 10 clinicians reported that the DM-SKA addresses the key domains of DM education deemed to be of highest importance during the transition from hospital to home and that their patients would be willing to complete the assessment. More than half of the patient/caregiver/layperson participants self-reported race/ethnicity other than non-Hispanic white and performed similarly to non-Hispanic white participants in understanding each item, willingness to complete the DM-SKA, and perception that family or community members would be willing to complete the DM-SKA. The DM-SKA has a baseline Flesch reading score of 81.3, indicating low complexity language.

Conclusion

DM clinicians agreed that the DM-SKA assesses all essential DM management skills. For patients/caregivers, it has acceptable literacy, cognitive validity, and culturally acceptable for racial/ethnic minority populations in the study, including elderly persons.

Defining obstacles to emergency transfer of trauma patients: An evaluation of retriage processes from nontrauma and lower-level Illinois trauma centers

BACKGROUND

Retriage is the emergency transfer of severely injured patients from nontrauma and lower-level trauma centers to higher-level trauma centers. We identified the barriers to retriage at sending centers in a single health system.

METHODS

We conducted a failure modes effects and criticality analysis at 4 nontrauma centers and 5 lower-level trauma centers in a single health system. Clinicians from each center described the steps in the trauma assessment and retriage process to create a process map. We used standardized scoring to characterize each failure based on frequency, impact on retriage, and prevention safeguards. We ranked each failure using the scores to calculate a risk priority number.

RESULTS

We identified 26 steps and 93 failures. The highest-risk failure was refusal by higher-level trauma centers (receiving hospitals) to accept a patient. The most critical failures in the retriage process based on total risk, frequency, and safeguard scores were (1) refusal from a receiving higher-level trauma center to accept a patient (risk priority number = 191), (2) delay in a sending center's consultant examination of a patient in the emergency department (risk priority number = 177), and (3) delay in receiving hospital's consultant calling back (risk priority number = 177).

CONCLUSION

We identified (1) addressing obstacles to determining clinical indications for retriage and (2) identifying receiving level I trauma centers who would accept the patient as opportunities to increase timely retriage. Establishing clear clinical indications for retriage that sending and receiving hospitals agree on represents an opportunity for intervention that could improve the retriage of injured patients.

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

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.

Reliability of RT-PCR tests to detect SARS-CoV-2: risk analysis

The rapid escalation of the number of COVID-19 (Coronavirus Disease 2019) cases has forced countries around the world to implement systems for the widest possible testing of their populations. The World Health Organization (WHO) has in fact urged all countries to carry out as many tests as they can. Clinical laboratories have had to respond urgently to numerous and rising demands for diagnostic tests for SARS-CoV-2. The majority of laboratories have had to implement the RT-PCR (Reverse Transcriptase − Polymerase Chain Reaction) test method without the benefit of adequate experimental feedback. It is hoped that this article will make a useful contribution in the form of a methodology for the risk analysis of SARS-CoV-2 testing by RT-PCR and at the same time result reliability analysis of diagnostic tests, via an approach based on a combination of Fishbone Diagram and FMECA (Failure Mode, Effects, and Criticality Analysis) methods. The risk analysis is based on lessons learned from the actual experience of a real laboratory, which enabled the authors to pinpoint the principal risks that impact the reliability of RT-PCR test results. The probability of obtaining erroneous results (false positives or negatives) is implicit in the criticality assessment obtained via FMECA. In other words, the higher the criticality, the higher the risk of obtaining an erroneous result. These risks must therefore be controlled as a priority. The principal risks are studied for the following process stages: nucleic acid extraction, preparation of the mix and validation of results. For the extraction of nucleic acids, highly critical risks (exceeding the threshold set from experimentation) are the risk of error when depositing samples on the extraction plate and sample non-conformity. For the preparation of the mix the highest risks are a non-homogenous mix and, predominantly, errors when depositing samples on the amplification plate. For the validation of results, criticality can reach the maximum severity rating: here, the risks that require particular attention concern the interpretation of raw test data, poor IQC (Internal Quality Control) management and the manual entry of results and/or file numbers. Recommendations are therefore made with regard to human factor influences, internal contamination within the laboratory, management of reagents, other consumables and critical equipment, and the effect of sample quality. This article demonstrates the necessity to monitor, both internally and externally, the performance of the test process within a clinical laboratory in terms of quality and reliability.

Failure mode and effects analysis for proactive healthcare risk evaluation: A systematic literature review

RATIONALE, AIMS, AND OBJECTIVES

Failure mode and effects analysis (FMEA) is a valuable reliability management tool that can preemptively identify the potential failures of a system and assess their causes and effects, thereby preventing them from occurring. The use of FMEA in the healthcare setting has become increasingly popular over the last decade, being applied to a multitude of different areas. The objective of this study is to review comprehensively the literature regarding the application of FMEA for healthcare risk analysis.

METHODS

An extensive search was carried out in the scholarly databases of Scopus and PubMed, and we only chose the academic articles which used the FMEA technique to solve healthcare risk analysis problems. Furthermore, a bibliometric analysis was performed based on the number of citations, publication year, appeared journals, authors, and country of origin.

RESULTS

A total of 158 journal papers published over the period of 1998 to 2018 were extracted and reviewed. These publications were classified into four categories (ie, healthcare process, hospital management, hospital informatization, and medical equipment and production) according to the healthcare issues to be solved, and analyzed regarding the application fields and the utilized FMEA methods.

CONCLUSION

FMEA has high practicality for healthcare quality improvement and error reduction and has been prevalently employed to improve healthcare processes in hospitals. This research supports academics and practitioners in effectively adopting the FMEA tool to proactively reduce healthcare risks and increase patient safety, and provides an insight into its state-of-the-art.

Improving the quality of insulin prescribing for people with diabetes being discharged from hospital

Medication errors involving insulin in hospital are common, and may be particularly problematic at the point of transfer of care. Our aim was to improve the safety of insulin prescribing on discharge from hospital using a continuous improvement methodology involving cycles of iterative change. A multidisciplinary project team formulated locally tailored insulin discharge prescribing guidance. After baseline data collection, three 'plan-do-study-act' cycles were undertaken over a 3-week period (September/October 2018) to introduce the guidelines and improve the quality of discharge prescriptions from one diabetes ward at the hospital. Discharge prescriptions involving insulin from the ward during Monday to Friday of each week were examined, and their adherence to the guidance measured. After the introduction of the guidelines in the form of a poster, and later a checklist, the adherence to guidelines rose from an average of 50% to 99%. Qualitative data suggested that although it took pharmacists slightly longer to clinically verify discharge prescriptions, the interventions resulted in a clear and helpful reminder to help improve discharge quality for the benefit of patient safety. This project highlights that small iterative changes made by a multidisciplinary project team can result in improvement of insulin discharge prescription quality. The sustainability and scale of the intervention may be improved by its integration into the electronic prescribing system so that all users may access and refer to the guidance when prescribing insulin for patients at the point of discharge.

Validity and Reliability of a (Brief) Diabetes “Survival Skills” Knowledge Test: KNOW Diabetes

Purpose

The purpose of this study was to determine the validity and reliability of the KNOW Diabetes test, a survival skills knowledge test, in identifying essential self-care knowledge deficits in adults with type 2 diabetes mellitus (T2DM).

Methods

The study was conducted in 3 United States cities among adults with T2DM. A pilot feasibility phase was followed by a validation phase. Both traditional and item response theory (IRT)–based analyses were conducted. Test items were scored against an answer key. Descriptive statistics, internal consistency evaluation using Cronbach’s alpha, IRT, reliability assessment using test-retest correlation, and construct validity analyses were conducted.

Results

Consented adults (n = 280) with T2DM completed the study. In phase 1 (n = 53), the feasibility of implementation was demonstrated and resulted in a 15-question survey. In phase 2, participants (n = 227) completed the survey, with a subgroup (n = 54) completing it in a test-retest fashion. The test showed acceptable psychometric properties including unidimensionality, local independence, and differential item functioning. Concurrent validity testing showed that patients who are older, have a lower level of education, have Medicare or Medicaid, and have foot pain or numbness scored significantly lower than patients who did not. Divergent validity was assessed by testing differences between other comorbidities and revealed all tests to be nonsignificant.

Conclusions

The KNOW Diabetes test is appropriate for identifying knowledge deficits in diabetes self-management survival skills.