By applying the principles of Toyota’s “lean” manufacturing process, doctors are reducing the average time between stroke patient arrival and treatment, known as door-to-needle time, from 60 to 39 minutes.
The researchers say the improvement results from applying a key component of lean manufacturing to patient care: getting input from all team members to identify inefficient steps in the process.
“We sought suggestions from everyone involved, from the paramedics who bring in patients, to admitting clerks, radiology technologists, nurses and physicians,” says senior author Jin-Moo Lee, MD, PhD, Washington University neurologist at Barnes-Jewish Hospital and director of the Department of Neurology’s cerebrovascular disease section. “Once the inefficient steps were identified, we developed a completely new protocol that eliminated them. This new treatment protocol helped us achieve one of the fastest door-to-needle times in the country.”
In an average year, Washington University physicians treat 1,300 stroke patients at Barnes-Jewish. The hospital has a dedicated stroke team capable of quickly evaluating and treating patients with the clot-dissolving drug tissue plasminogen activator (tPA). The earlier it is given, the more effective tPA is at preventing permanent brain damage from stroke. Ideally, to reduce the risk of dangerous bleeding, the drug must be given within 60 minutes after a stroke begins, a period known as the “golden hour.”
Improving door-to-needle time
“We already had very good door-to-needle times, but we thought that we could do better,” says first author Andria Ford, MD, Washington University neurologist at Barnes-Jewish. “So we put all of our team members in a room for two days and asked them to evaluate each step in the door-to-needle process.”
“Identifying steps that are wasteful and do not add value is a primary goal of lean manufacturing,” says Washington University surgeon David Jaques, MD, vice president of Surgical Services at Barnes-Jewish Hospital. “Lean has made it possible to speed the delivery of medication or blood, improve teamwork and communication and ensure that those caring for patients always have easy access to supplies and equipment.”
One problem identified by the group was repeatedly moving patients from one location to another. The staff decided it would be more efficient for paramedics to bring patients directly to the emergency department’s CT scanner for evaluation rather than to a patient examination room.
The group also made changes to the collaborative, multidisciplinary health care team required for stroke care, says co-author Peter Panagos, MD, a Washington University emergency physician at Barnes-Jewish Hospital. “For example, we asked social workers to help identify people who were with the patient when the suspected stroke began. While they talk with family members or co-workers, we can begin the initial assessment. This has the potential of saving us precious minutes,” he says.
They also found that some aspects of patient care currently performed in sequence instead could be carried out simultaneously with the addition of extra staff. In addition, they reduced time spent waiting for lab results by instituting lab tests that could be performed at the bedside, Lee says.
The new treatment procedures, implemented in March 2011, lowered average door-to-needle times by nearly 40 percent and increased the percent of patients treated within “the golden hour” from 52 to 78 percent.