The team had a median door-to-needle time of 55-65 minutes for patients receiving tPA in 2010. But they wanted to cut that to a median time of 30 minutes.
By applying “Lean” principles, first developed by Japanese car manufacturers to maximize value to customers and reduce waste, the team worked to revamp the process and meet their goal, says Jennifer Williams, RN, MSN, emergency department clinical nurse specialist.
“This was an evidence-based challenge,” says Williams. Data correlate faster door-to-needle times with better outcomes, and the team found that tPA is routinely given within 30 minutes at neurological centers in Europe.
The BJH emergency department’s previous success using Lean to reduce door-to-balloon time for STEMI heart attack patients indicated that Lean process improvement is hardwired into the department now, Williams says.
In January, 14 people, including stroke clinicians and frontline emergency department personnel, met for a three-day rapid improvement event (RIE). After first mapping out each discrete step of the current acute stroke process, the team broke into smaller groups to identify what the process would have to look like to meet the 30-minute deadline.
Significant changes included involving emergency transport personnel in the process by having them take patients directly to the CT scanner and bringing a witness to the stroke symptoms along to the hospital.
Moving CT to the front of the process would immediately identify whether a patient is a candidate for tPA or not, Williams says.
Another major change would have the care team, including EMS, huddling in the CT area to exchange information, making sure everyone has a clear picture of the patient’s condition and history, Williams says.
After mapping out the new process, the group presented it to the emergency department staff, EMS personnel and other stroke clinicians, who adopted the changes almost immediately.
“They basically changed a major process overnight,” Williams says. “And everyone is closely monitoring, so that patient safety isn’t sacrificed for speed.”
As a result, the median door-to-needle time at BJH, less than three months after the rapid improvement event, was 30 minutes.
“The significance of this process change is truly remarkable, particularly if you think about the degree of collaboration among nursing, neurology, emergency medicine, radiology, laboratory services, social work, EMS and patient registration,” says Peter Panagos, MD, co-director of the Washington University acute stroke care team. “Now, we are providing some of the fastest time critical care for stroke patients anywhere. This can only lead to improved stroke outcomes.”