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Lean Manufacturing Process Improvement Techniques Applied to ...

Lean Manufacturing Process Improvement

Techniques Applied to Improve Treatment

for Acute Ischemic Stroke in the ED

Jennifer Williams, RN, MSN, ACNS-BC, CEN, CCRN

Clinical Nurse Specialist

Emergency Services

Barnes-Jewish Hospital


Current Process for Acute Ischemic Stroke

Treatment

Patient Develops

symptoms and

EMS is activated

to scene

Patient develops

symptoms and is

brought to the ED

triage area

EMS arrives,

performs any

procedures in field

and transports to

BJH

RN triages patient

and calls comm

RN to activate

pager

ED Acute Stroke Process- Current State 1-11

EMS crew calls

comm center with

information on

patient

Patient is

transported to

room

Comm RN

activates stroke

pager and

identifies room for

patient

Patient arrives in

room and is

entered into

HMED

Neurology

Resident at

bedside for eval

12 lead ECG and

blood glucose

completed.

Lab specimens

drawn and sent via

code runner

Stroke protocol

used for orders

including CT

Patient to CT scan

CT completed.

Neurology reads

CT

Patient returned to

room

Neurology getting

time of onset

information from

witness.

Awaiting lab

results

Neurology

Resident makes

decision in

consultation with

chief/attending

Time out with ED

RN, neuro

resident, EM

physician: Time of

onset, dose, pt

weight

RN mixes tPA and

preps tubing

tPA bolus

administered


Problem #1: Inconsistent Screening and

Activation of Stroke Process

• Volume of Patients Presenting

• 250-300 patients present daily

• 130 RN staff involved in triage

• Cincinnati Stroke Scale as broad screen

• EMS Report Information Varied

• Patient Assessment

• History- inconsistent information obtained

• Identification of witness- often not brought with patients

• Time of onset/last normal- inconsistent information


Problem #2: Overwhelming number of tasks to

complete in 60 min

• Admitting

• Patient identification

• Registration

• Room assign

• EMS

• Delivers patient to room

• Reports to nursing

• Nursing

• IV placement

• Monitor hook-up

• Vital sign monitoring

• Blood glucose

• Lab draw

• Weight estimate of patient

• Clinical Assessment

• History

• Medications/allergies

• Identification of witness

• Time of onset/last normal

• Clinical Assessment (cont.)

• NIHSS

• Neurological Exam

• Labs

• PT/PTT, CBC, Creatinine

• Emergent transport of bloods to lab

• Imaging

• Disconnect from monitor

• Transport patient to CT

• CT scan

• Transport from CT to room

• Reconnect to monitoring

• Drug Preparation

• Order tPA

• Calculate tPA dose

• Prepare tPA

• Bolus and infuse tPA


Problem #3: Inefficient choreography

Triage Area

Emergent Unit 1

1

EMS Room

Ambulance Bay

Nursing Station

Trauma Critical Care

CT

CT

6

2 3 4 5


Problem #4: Labs take too long

• Labs needed for tPA

• Platelets

• INR (PT/PTT)

• Blood glucose

• On average, in 2010, it took 33 min to get

results after ordering labs


Ideal State

Barnes-Jewish Hospital and

Washington University Physicians

Implementation 3-1-2011


Solution # 1: Clear Screening

• Screening Tool

• CSS for all

patients

• Specific

screening for

patients with

positive CSS

• Applies to EMS

calls prior to

arrival and to

walk in patients


Solution # 1: Clear Screening

• Pager Activation

• If patient had

sudden onset of

symptoms listed in

last 6 hours,

activate the pager

• Communication

Center in the ED

notifies stroke team

and all clinical staff

in the ED treatment

area- includes

Nursing,

Physicians,

Radiology, Social

Work, Registration


Admitting

Patient ID

Registration

Room assign

Solution #2: Parallel Processing

CT

Tech

Nurse

#1

Nurse

#2

CT scan IV placement

Monitor hook-up

Vital sign monitoring

Blood glucose

Lab draw

Weight estimate

Code Stroke

ED

resident

History

Meds/allergie

s

Order tPA

Neurology

resident

NIHSS

Neuro Exam

Decision

Social

Worker

ID witness

Time of onset

Bolus & Infuse tPA

ED

Tech

Emergent

Transport of

Bloods to lab

Pharmacist

Calculate tPA

dose

Prepare tPA


Solution #3: Streamlined choreography

Triage Area

Emergent Unit 1

1

EMS Room

Ambulance Bay

Nursing Station

Trauma Critical Care

CT

CT

6

2 3 4 5


Solution #4: Point of care labs

• Identified INR as

rate-limiting lab

• Initiated POC for

both INR and blood

glucose

• Platelets obtained as

“hemogram” rather

than CBC.


Implementation

Results

Barnes-Jewish Hospital and

Washington University Physicians


Baseline Characteristics

Baseline Characteristics

Pre-Intervention

1/1/09-2/28/11

N=132

Age, years 70 [53, 81] §

Post-Intervention

3/1/11-10/17/11

N=53

P-value *

63 [55, 75] 0.23

Gender, Female 52% 68% 0.51

Race, African American* 45% 64% 0.022

Baseline NIHSS 9 [5, 19] 8 [4, 17] 0.39

Hypertension* 62% 88% 0.0003

Diabetes 25% 33% 0.36

Coronary Artery Disease 23% 27% 0.70

Congestive Heart Failure 15% 14% 1.0

Prior Stroke / TIA 20% 31% 0.18

Dyslipidemia 33% 38% 0.49

Tobacco Use 25% 33% 0.36

* Wilcoxon Rank Sum Test was used for continuous data and Fisher’s Exact Test was used for binary outcomes; p


Time Interval (min)

Number of Patients

80

70

60

50

40

30

20

10

0

25

20

15

10

5

0

tPA Metrics

Quarter

Intervention

Q1 Q2 Q3 Q4 Q5 Q6

Q1 Q2 Q3 Q4 Q5 Q6

Door-to-Needle

Door-to-CT


Discharge Outcomes

Discharge Outcomes

Pre-

Intervention

1/1/09-2/28/11

N=132

Post-

Intervention

3/1/11-10/17/11

N=53

P-value *

Favorable Discharge Location + 76% 79% 0.70

Symptomatic ICH ++ 3.0% 3.8% 0.68

Stroke Mimic +++ 6.8% 9.6% 0.54

* Wilcoxon Rank Sum Test was used for continuous data and Fisher’s Exact Test was used for binary outcomes; p


Other Published Rapid Treatment Protocols

Authors Year Country n DTN time

Kohrmann et al 2007-9 Germany 246 29 min

Tveiten et al 2007 Norway 14 38 min

Lindsberg et al 2004 Finland 50 50 min

Mehdiratta et al 2001 Canada 47 82 min


Summary

• Consistent Identification and initiation of process

increases efficacy

• Parallel processing results in earlier treatment

with IV tPA

• Rapid treatment protocols can safely accelerate

acute stroke thrombolysis, but require

maintenance and frequent monitoring

• Sustained treatment efficiency can be maintained

despite an increase in treatment numbers


Further Information

• BarnesJewish.org/ISC2012

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