title: Academic-Community Hospital Comparison of Vulnerabilities in Door-to-Needle Process for Acute Ischemic Stroke.
abstract: BACKGROUND
  Although best practices have been developed for achieving door-to-needle (DTN) times ≤60 minutes for stroke thrombolysis, critical DTN process failures persist. We sought to compare these failures in the Emergency Department at an academic medical center and a community hospital.
  
  
  RESULTS
  Failure modes effects and criticality analysis was used to identify system and process failures. Multidisciplinary teams involved in DTN care participated in moderated sessions at each site. As a result, DTN process maps were created and potential failures and their causes, frequency, severity, and existing safeguards were identified. 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 and targets for intervention. We detected a total of 70 failures in 50 process steps and 76 failures in 42 process steps at the community hospital and academic medical center, respectively. At the community hospital, critical failures included (1) delay in registration because of Emergency Department overcrowding, (2) incorrect triage diagnosis among walk-in patients, and (3) delay in obtaining consent for thrombolytic treatment. At the academic medical center, critical failures included (1) incorrect triage diagnosis among walk-in patients, (2) delay in stroke team activation, and (3) delay in obtaining computed tomographic imaging.
  
  
  CONCLUSIONS
  Although the identification of common critical failures suggests opportunities for a generalizable process redesign, differences in the criticality and nature of failures must be addressed at the individual hospital level, to develop robust and sustainable solutions to reduce DTN time.
authors.affiliation: From the Division of Neurology (S.P.), Center for Healthcare Studies (S.P., R.K., A.B., A.P.N., J.L.H.), Feinberg School of Medicine, Northwestern University, Chicago, IL; and Private Practice, Chicago, IL (R.K.). sprabhak@nm.org.
authors.forename: Shyam
authors.initials: S
authors.lastname: Prabhakaran
authors.affiliation: From the Division of Neurology (S.P.), Center for Healthcare Studies (S.P., R.K., A.B., A.P.N., J.L.H.), Feinberg School of Medicine, Northwestern University, Chicago, IL; and Private Practice, Chicago, IL (R.K.).
authors.forename: Rebeca
authors.initials: R
authors.lastname: Khorzad
authors.affiliation: From the Division of Neurology (S.P.), Center for Healthcare Studies (S.P., R.K., A.B., A.P.N., J.L.H.), Feinberg School of Medicine, Northwestern University, Chicago, IL; and Private Practice, Chicago, IL (R.K.).
authors.forename: Alexandra
authors.initials: A
authors.lastname: Brown
authors.affiliation: From the Division of Neurology (S.P.), Center for Healthcare Studies (S.P., R.K., A.B., A.P.N., J.L.H.), Feinberg School of Medicine, Northwestern University, Chicago, IL; and Private Practice, Chicago, IL (R.K.).
authors.forename: Anna P
authors.initials: AP
authors.lastname: Nannicelli
authors.affiliation: From the Division of Neurology (S.P.), Center for Healthcare Studies (S.P., R.K., A.B., A.P.N., J.L.H.), Feinberg School of Medicine, Northwestern University, Chicago, IL; and Private Practice, Chicago, IL (R.K.).
authors.forename: Rahul
authors.initials: R
authors.lastname: Khare
authors.affiliation: From the Division of Neurology (S.P.), Center for Healthcare Studies (S.P., R.K., A.B., A.P.N., J.L.H.), Feinberg School of Medicine, Northwestern University, Chicago, IL; and Private Practice, Chicago, IL (R.K.).
authors.forename: Jane L
authors.initials: JL
authors.lastname: Holl
mesh_terms: D000046:Academic Medical Centers / Q000706:statistics & numerical data*; D000208:Acute Disease; D003951:Diagnostic Errors; D003952:Diagnostic Imaging; D004636:Emergency Service, Hospital; D006764:Hospitals, Community / Q000706:statistics & numerical data*; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology*; D058996:Quality Improvement; D020521:Stroke / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology*; D015912:Thrombolytic Therapy; D061665:Time-to-Treatment; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D016896:Treatment Outcome; D014218:Triage
chemical_list: D010959:Tissue Plasminogen Activator
keywords: academic medical center; community hospitals; patient safety; quality improvement; stroke