Using LEAN methodology to expedite the treatment of acute ischemic stroke in the emergency room

Introduction

Stroke is the fifth leading cause of death and the leading cause of long-term disability in the United States. ¹ The most important determinant of patient outcome following an ischemic stroke, which accounts for 87% of strokes, is timely treatment with tissue plasminogen activator (alteplase). ² It is accepted that the faster a stroke victim receives alteplase, the better their outcome. Kingwood Medical Center successfully achieved greater than the national administration time using LEAN methodology. This article discusses this successful journey.

Background

Kingwood Medical Center is a 411-bed tertiary care hospital serving the north Houston area and the northeast Texas corridor. Kingwood Medical Center is affiliated with the Hospital Corporation of America (HCA), the largest for-profit hospital system in the United States and a national leader in quality patient care. Kingwood Medical Center is a comprehensive stroke center and certified chest pain center, and its busy emergency rooms see over 90,000 patients per year.

The timely administration of alteplase requires coordination of multiple departments and services in the hospital. After first obtaining its stroke center designation, Kingwood Medical Center’s “Door to Needle” (D2N) time averaged almost 80 minutes. The national goal for alteplase administration, D2N, is 60 minutes; the rapid administration of alteplase has been shown to improve clinical outcomes and reduce the burden of disease for patients. ³ It was therefore our goal to reduce the D2N time at Kingwood Medical Center to meet the national goal.

A “Code Neuro” is an emergency code that, like all other hospital emergency codes, is utilized to assemble the required stakeholders and resources to treat a medical emergency (in this case an acute neurological event). As a comprehensive stroke center, Kingwood Medical Center had a “Code Neuro” process in place; however, the process was not well defined, roles and responsibilities were not clearly delineated, and expectations among not only stakeholders but also among leaders were unclear. The end result is that despite utilizing “Code Neuro” to expedite the diagnosis and subsequent treatment of acute ischemic stroke, there were many process failures that ultimately caused delays in this time-sensitive treatment.

Methodology

The first step in meeting the goal was to create a sense of urgency and commitment to change; this was led by our Chief Medical Officer Dr. Mujtaba Ali-Khan. The team realized that in order to identify opportunities for improvement, all team members needed to have a full understanding and appreciation of the complex interrelationships and dependencies of each hospital service in the timely diagnosis and treatment of acute ischemic strokes.

An interdisciplinary team was assembled in early April 2017 to perform a process improvement project utilizing LEAN methodology. Facilitated by the Director of Emergency Services, the team began by conducting a current state value stream analysis to fully understand the patient’s trajectory from the time of stroke symptom onset to receiving alteplase.

A value stream map is an LEAN tool that details the process steps in a workflow and facilitates the identification of unnecessary steps, also known as non-value-added activities, from start to finish. ⁴ Outlining all the steps in a process, regardless of how inconsequential they may seem at the time, allows members of the care team to identify opportunities for improvement. These small steps, even if they only account for minutes, are of particular importance in stroke care because for every minute a stroke is left untreated, 1.9 million neurons are lost. ⁵ While the presentation of stroke symptoms and deficits vary from person to person and depend on, among other things, the location of the brain affected by the stroke and neurons affected by a stroke do not rejuvenate; once they die, they are not replaced and so damage is permanent.

Members of the process improvement team included representatives from the emergency room, laboratory, imaging services, pharmacy, endovascular procedure laboratory, critical care services, quality, and Emergency Medical Services (EMS) partners. The active involvement of EMS in this process improvement project allowed a more in-depth analysis and understanding of the pre-hospital phase of care, which in turn allowed for more targeted interventions to further streamline the D2N process.

After completing the current state value stream analysis, the team was taken aback at the multiple opportunities that existed to streamline the alteplase administration process and reduce the time it took to initiate treatment. The team began by creating a future state value stream analysis and developed a targeted action plan to address the numerous opportunities to simplify the process found in the current state analysis. These included the following:

Pre-alert communication from EMS to activate the “Code Neuro” process before the patient arrives in the emergency room;

Results

Figures 1 and 2 show the value stream maps that the team developed for the current state (blue post-it notes) and future state (yellow post-it notes); the pink post-it notes in the current state value stream map represent the process improvement opportunities identified by the team that formed the basis of the action plan developed to reduce D2N times. As illustrated in the value stream maps, the process improvement team was able to significantly reduce the number of process steps when caring for a patient suffering from an acute ischemic stroke.

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Figure 1.

Current state value stream map.

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Figure 2.

Future state value stream map.

As shown in Figure 3, which trends the average D2N times by month, the results of the new Code Neuro process were impressive. As shown in Figure 4, baseline D2N time was 76 minutes (January to April 2017). Following the implementation of the future state value stream map, the D2N time dropped significantly to 50 minutes (May 2017). The average D2N time for the remainder of 2017 was 50 minutes, and our D2N time for 2018 is 40.5 minutes.

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Figure 3.

Alteplase D2N time, average by month. D2N indicates door to needle.

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Figure 4.

Impact of process improvement initiative on D2N times. D2N indicates door to needle.

The tactic implemented as a result of the process improvement initiative that had the greatest impact on D2N time was activating the “Code Neuro” process based on pre-alert notification received from EMS while still in the field. By activating the “Code Neuro” team prior to the patient’s arrival, all of the required hospital services were able to mobilize the required resources before the patient’s arrival, allowing for a more seamless transition of care to the hospital. This would not have been possible without the active engagement of EMS in the process improvement process.

It is important to note that D2N reporting incorporates all patient cases; there are no cases excluded as with other quality outcome measures. Kingwood Medical Center has a robust quality management process for the review of all alteplase administrations. alteplase D2N outliers were found to be due to the patients’ clinical conditions upon arrival (eg, severe hypertension, cardiac arrest) where the immediate administration of alteplase would be contraindicated. Throughout 2018, there have been no process-related delays in alteplase administration.

Thanks to the LEAN process improvement activity the team conducted and the resultant change in practice, we reduced the D2N time by 36 minutes, suggests the conservation of mean of 68.4 million neurons per patient, and thus provided a large number of patients with a better prognosis. This improved prognosis is thanks to the neurons saved through the timelier administration of alteplase that would have otherwise been lost. The use of LEAN methodology permitted the team to not only identify opportunities to improve patient care but also created ownership and personal accountability for change among all caregivers and departments involved in the care of these patients. This sense of ownership significantly facilitated the change management process required to successfully implement the changes.

Lessons learned

Like all new initiatives, the success of the revised alteplase administration process was largely dependent on effective change management and leadership. The most important factor in the success of any initiative is leadership support; thankfully support from the executive team down was a boon to facilitating the implementation of this new process. Another important factor in successful change management is communication. In order to effectively communicate the changes that were coming, an elevator speech was developed and the entire process improvement team took ownership in spreading the message. Communication also occurred by e-mail, text, and traditional mail to both internal and external stakeholders. A lesson learned was to ensure that there be a single contact person for any questions or comments so that clarifications were consistent. Furthermore, a clearer delineation of roles and responsibilities for communication and messaging would have avoided some of the confusion and frustration that is inherent in any new initiative. Lastly, we would recommend formal continuous improvement analyses at more regular intervals. The process improvement team has scheduled a process review, called “LEAN Code Neuro 2.0,” to occur this year, however, this is almost 2 years after the initial process improvement team met. The authors will be making recommendations to our newly formed Clinical Excellence Steering Committee that all clinical process improvement initiatives that were developed using LEAN methodology be reviewed at least annually.

Conclusions

The LEAN methodology is a powerful performance improvement tool whose effectiveness is best realized through the engagement of content experts and the use of visual cues to highlight performance improvement opportunities. For instance, the visual nature of the value stream map allows for the rapid identification of process steps and facilitates the identification of opportunities to reduce steps or even simply utilize concurrent as opposed to consecutive task performance, removing non-value-added time. By utilizing LEAN methodology to reduce the D2N time for patients suffering from acute ischemic strokes, the process improvement team was able to ensure that all patients received timely access to this time-sensitive treatment, thus improving their health outcomes. Says Dr. Ali-Khan, “Creating a culture of ‘no-excuses!’ is critical when it comes to delivering highest quality, safest and most efficient care. I believe under the ED medical and nursing leadership, who systematically identified opportunities and strategically implemented solutions, this culture is now ‘hard-wired’ in the frontline staff.” LEAN methodology truly supported us in living the mission of HCA: “Above all else, we are committed to the care and improvement of human life.”