Background and Purpose: One minute of brain ischemia can kill 2 million nerve cells and 14 billion synapses. The more time that elapses before IV thrombolysis or mechanical reperfusion, the slimmer the odds of a successful outcome. Early in fiscal year 2015, the Door-To- Needle (DTN) and Door-To-Reperfusion (DTR) times at our comprehensive stroke center rose to 78 min and 165 min, respectively. Also, the rate of IV tPA administration within 60 min decreased to 17%. In January 2015, lean methodology, specifically, Teams Refocus Imagine Measure (TRIM) was used to reduce DTN and DTR times. The purpose was to achieve: DTN < 60 min, DTR < 120 min, and rate of IV tPA given within 60 min > 75%.
Methods: The TRIM and the Plan-Do-Check-Act methods were used to improve outcomes. Components included value stream mapping, A3 problem solving, and real-time observations to identify barriers, duplications and wasted time. The team consisted of Neurology, Neurosurgery, Nursing, Emergency Medicine, Emergency Medical Systems (EMS), Interventional Services (IVS), Radiology, Pharmacy, Anesthesia, Laboratory, Registration, Social Work, Risk Management, Transfer Center, Research, and Performance Improvement. Median and average times and percent compliance were calculated for pre-TRIM and post-TRIM data. Some interventions included:
• Designated ED trauma room for all strokes
• Early entry of acute stroke orders
• Use glucose and EKG from EMS for acute evaluation
• One-call stroke alert
• Advance tPA mixing
• Advance CTA contrast preparation
• Notification of parking lot arrival by on-call IVS Team
• Advance anesthesia consent
• Early discussion with patient and family regarding tPA
• Timely communication of turnaround times for each stroke alert
Results: In the first two weeks after implementing changes, 23 min was reduced from the stroke alert response. In five months, DTN decreased to 51 min and 63 min was eliminated from DTR.
Conclusion: Through an organized multidisciplinary team approach using standardized process improvement methods, identified best practices, and out-of-the-box thinking, improved stroke turnaround times were achieved to provide quality patient care and improve patient outcomes.