Background: In late 2015, we assembled a multi-disciplinary team to analyze current emergency department (ED) processes and identify improvement opportunities in the current “brain attack” (BA) protocol. Using lean process engineering tools, including time study analysis, gemba walks, and cause and effect diagrams, we mapped our baseline state and identified delaying activities that did not add value to the BA process. We defined a new BA process (see Figure 1) to eliminate waste and improve team communication, including 3 Time Outs to ensure that increased speed didn’t decrease safety.
Methods: To determine the effect of our intervention, we retrospectively reviewed patients who were admitted to our ED as a BA for evaluation of possible acute ischemic stroke and had a CT brain after ED arrival between April 2015 and August 2016. ED arrival was defined as the time that patients physically arrived at the ED and “time to CT” was the time from ED arrival to the first time stamp of the CT brain. The time from ED arrival to tPA bolus was also measured for "door to needle" time. The time to CT and door to needle times were compared between BA patients before and after lean process improvements using Student’s T-test.
Results: Our cohort included 239 patients who presented to the ED as a BA. We included 116 BA patients from before the intervention and 123 from afterwards. The mean±SD time to CT prior to the intervention was 19.0±13.9 minutes. After our lean process improvements the time to CT was 14.2±15.6 minutes. The delta of 4.8 minutes resulted in a significant reduction in time to CT, p = 0.012. There were 14 patients who received tPA prior to the intervention and 9 afterwards, for a total of 23 door to needle times (10% of cohort). Door to needle time was significantly shortened post-intervention (46±13 minutes versus 32±12 minutes, p=0.013).
Conclusions: Lean process improvement methodology significantly reduces door to CT and door to needle times, supporting current AHA Target: Stroke goals and allowing faster treatment of patients with acute ischemic stroke. Incorporating time-outs into standardized processes that aim to deliver care more quickly may improve patient safety without substantially slowing down DTN times. Further investigation is required to determine whether the new process improved safety and clinical outcomes.