Taking their cue from the auto industry, a team of physicians applied a process to eliminate inefficiencies in the care of stroke patients that shortened the time-dependent treatment while increasing the percentage of patients who received timely care.
The American Heart Association’s Get With the Guidelines stroke program calls for delivery of tissue plasminogen activator (tPA) to patients with acute ischemic stroke within 60 minutes of the patient’s arrival at the hospital. Swift treatment using reperfusion therapy has been shown to improve outcomes. But guidelines provide no guidance on how hospitals might achieve that door-to-needle goal, wrote Andria L. Ford, MD, of the neurology department at Washington University School of Medicine in St. Louis, and colleagues, in an Oct. 18 rapid access report in Stroke.
Ford and colleagues turned to the auto industry for inspiration, noting that the lean manufacturing processes pioneered by Toyota helped the automaker streamline production by weeding out inefficiencies. The researchers first put together a multidisciplinary team that included a lean engineer, emergency department (ED) physicians and nurses, neurologists, a pharmacist and radiology and patient care technicians. The team analyzed the protocols used in the ED for treating ischemic stroke patients with tPA, identified which steps were wasteful and which created value and then developed an action plan to streamline the process. They also incorporated a feedback mechanism to facilitate greater improvement.
“The VSA [value stream analysis] identified several barriers preventing rapid tPA treatment including: (1) inefficient patient flow, requiring a patient to be routed by emergency medical services to the trauma bay, then to CT, then back to the room; (2) serial processing of multiple tasks and inefficient use of available staff; and (3) delays in laboratory processing in patients suspected of being on anticoagulation,” Ford and colleagues wrote.
In their streamlined protocol, they had patients taken directly to the CT by emergency staff and then transferred to the trauma bay; they clarified roles for staff and had them work in parallel; brought in a pharmacist and a social worker to help determine time of onset and tPA dose; and added point-of-care testing to obtain an international normalized ratio reading.
To test the effectiveness of their new protocol, researchers designed a study that compared patients treated before and after the protocol was introduced. The pre-VSA group included 132 patients admitted to the ED between Jan. 1, 2009 and Feb. 28, 2011 and a post-VSA group of 87 patients admitted between March 1, 2011 and March 1, 2012. All patients were treated with intravenous tPA. Group arrival characteristics were similar.
They found that the new protocol trimmed the average door-to-needle time by 21 minutes and increased the percentage of patients treated within 60 minutes by 26 percentage points. The researchers credited the shorter door-to-CT time in part for the efficiencies gained.
An analysis by quarter showed that the benefits were sustained over the year. The researchers also compared clinical outcomes and found no adverse effects from implementing the lean protocol.
Under the new protocol, 78 percent of the patients received tPA treatment within 60 minutes, the authors highlighted. “Post-VSA, the tPA frequency distribution shifted left on the time axis and became more narrowly distributed with few outliers, suggesting not only shorter treatment times, but also less variability in treatment times,” they added.
The authors cautioned that the protocol was implemented in only one center and used a small study sample size. They recommended future studies to ascertain if the protocol added efficiencies and reduced door-to-needle times in other hospital settings.