Background and Issues: In 2014, the University of Utah Hospital successfully treated >50% of acute ischemic stroke (AIS) tPA-eligible patients within 60 minutes. Target: Stroke phase II added the goal to treat 50% within 45 minutes, providing an opportunity for improvement.
Purpose: The purpose of this project was to improve door-to-needle (DTN) times by streamlining IV tPA protocols.
Methods: 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 Fig) to decrease waste and improve team communication. Key changes included: 1) definition of key team member roles; 2) a straight-to-CT plan; and 3) three planned time-outs with checklists to ensure maintenance of patient safety.
Results: From May-July 2015: mean Door-to-CT was 19 minutes and DTN was <45 minutes in 27% of eligible patients. In the two quarters following process change implementation, mean door-to-CT time was 15 minutes and DTN was <45 minutes in 60% of eligible patients. There was no observable increase in adverse events with the decreased treatment times.
Conclusions: Lean process improvement methodology can expedite DTN times, supporting current Target: Stroke goals. 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 BA process improved safety and added value by improving patient outcomes and decreasing institution cost.