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

Abstract

Introduction:To date, many emergency department (ED)-based quality improvement studies and interventions for acute stroke patients have focused on expediting timesensitive treatments, particularly reducing door-to-needle time. However, prior to treatment, a diagnosis of stroke must be reached. The ED-based stroke diagnostic process has been understudied despite its importance in assuring high-quality and safe care. Methods:We used a learning collaborative to conduct a failure modes, effects, and criticality analysis (FMECA) of the acute stroke diagnostic process at three health systems in Chicago, IL. Our FMECA was designed to prospectively identify, characterize, and rank order failures in the systems and processes of care that offer opportunities for redesign to improve stroke diagnostic accuracy. Multidisciplinary teams involved in stroke care at five different sites participated in moderated sessions to create an acute stroke diagnostic process map as well as identify failures and existing safeguards. For each failure, a risk priority number and criticality score were calculated.Failures were then ranked, with the highest scores representing the most critical failures to be targeted for redesign.Results: A total of 28 steps were identified in the acute stroke diagnostic process.Iterative steps in the process include information gathering, clinical examination, interpretation of diagnostic test results, and reassessment. We found that failure to use existing screening scales to identify patients with large-vessel occlusions early on in their ED course ranked highest. Failure to obtain an accurate history of the index event, failure to suspect acute stroke in triage, and failure to use established stroke screening tools at ED arrival to identify potential stroke patients were also highly ranked. Conclusions:Our study results highlight the critical importance of upstream steps in the acute stroke diagnostic process, particularly the use of existing tools to identify stroke patients who may be eligible for time-sensitive treatments.

Delayed Diagnosis in Cerebral Venous Thrombosis: Associated Factors and Clinical Outcomes

“…Whether or not sources of delay in CVT are similar to previously identified sources of delay in detecting acute stroke (eg, failure to use screening tools, incomplete neurologic examination, and too narrow a differential diagnosis) requires further study. 21 , 22 , 23 To understand current and ideal clinical pathways for CVT detection, methods other than retrospective chart review are likely warranted. 24 Fourth, the mRS score might not be sensitive enough to study CVT‐specific clinical disability.…”

Cost‐Effectiveness of Increased Use of Dual Antiplatelet Therapy After High‐Risk Transient Ischemic Attack or Minor Stroke

“… 15 We conceptualized our QI intervention as potentially including screening tools for TIA/minor stroke, clinical decision support to help determine patients eligible for DAPT, and medication order sets to ensure correct medication administration in collaboration with pharmacy based on recent research on sources of DAPT undertreatment. 16 , 17 , 18 Health care delivery interventions frequently have substantial start‐up costs to design, train, and implement, followed by lower costs to sustain the changes made. 19 We envisioned our intervention as ED‐based because DAPT is currently indicated only within 24 hours of TIAMIS symptom onset.…”