Abstract NS 5: Lean Manufacturing Process Improvement Techniques Applied to Improve Treatment for Acute Ischemic Stroke in the ED
Background: Identification and treatment of acute ischemic stroke (AIS) in the emergency department (ED) requires coordinated efforts between all members of the healthcare team. In an ED that historically treats 4-10 patients a month as potential AIS, the mean door to treatment time was 60 minutes (N=132). The ED Acute Stroke Committee (EDASC) identified the opportunity to improve the existing process through the use of lean methodology, setting a goal of door to treatment time of 30 minutes for AIS patients in a large, urban teaching hospital.
Methods: Lean methodologies were chosen as a process improvement strategy. Used historically by automobile manufacturers, lean was employed by our healthcare organization to improve a process by identifying and eliminating waste. Frontline team members met to standardize the process, provide clear visual cues to steps in the process in order to identify deviations immediately and return the process to optimal performance. The EDASC invited emergency nurses, physicians, technicians, radiology staff, neurology physicians and nurses, social workers and EMS providers to a 2.5 day event in January 2011. After reviewing the current process from screening through treatment, identifying all steps that were not value added. Based on the identified inefficiencies, the team created the ideal process. Two key nursing changes were identified: (1) the use of a specific nursing screening template to ensure critical screening and assessment questions were asked by every nurse for both walk-in and EMS patients and (2) standardization of mixing and administration of tPA when ordered by the treating physician.
Results: Protocol changes were implemented March 1, 2011. For improvement in screening, new computerized documentation templates guided the nurse in specific screening questions at triage and with EMS providers when calls were received from the field. The enhanced screening documentation led to decreased likelihood of activation for non-stroke patients while increasing the number of actual AIS patient evaluations. After initial implementation, review of each stroke activation for a one week period refined the screening tool and allow for immediate modification. For expediting tPA preparation and delivery, use of computerized templates for the mixing and administration of tPA ensured consistency of process. Overall, the protocol changes applied from the lean process led to a decrease in time from patient arrival to tPA treatment from 60 minutes before the protocol change to a median of 37 minutes (N=37) after the protocol changes.
Conclusions: Rapid process improvement using lean tools creates opportunities to radically alter a process of care in a short implementation period. Standardized screening for ischemic stroke by nursing staff at patient arrival can eliminate delays in care and expedite tPA administration.
- © 2012 by American Heart Association, Inc.