Applying Toyota Lean Manufacturing Principles to Stroke Care: Accelerating Door-to-Needle Times

Transcription

1 Applying Toyota Lean Manufacturing Principles to Stroke Care: Accelerating Door-to-Needle Times Peter Panagos, Andria Ford, Jennifer Williams, Naim Khoury, Tomoko Sampson, Craig McCammon, Jin-Moo Lee Washington University School of Medicine Barnes-Jewish Hospital St Louis, Missouri Department of Emergency Medicine and NeurologyPet Panagos, MD, FAHA, FACEP

2 Background BAC PSC Recommendations DTN < 60 minutes in 80% pts AHA/ASA Target Stroke 50% AIS treated < 60 minutes US GWTG data only 33% < 60 minutes Golden Hour treated patients had less inhospital mortality and ICH (Circulation.2011;123:750-58) European (Findland) Centers 20 minutes DTN (Median)! NINDS Reverse Site Visit: February 15, 2006

3 Time is Brain Time NNT for one Absolute risk interval good reduction Time NNT outcome for one Absolute risk interval good reduction 0-90 min outcome 5 20% min % 20% min % 11% Combined data from ECASS I-III, EPITHET, NINDS, ATLANTIS; Lees et al, Lancet 375: , 2010

4 Acute Stroke In St Louis Stroke Care

5 How well do we do? Locally Resident based Acute Stroke Protocol is Expeditious and Safe. Stroke. 2009;40:

6 Lean Process: What is it? Lean Process Improvement First developed by Toyota to improve manufacturing processes Involvement of workers at all levels with input to improvement process performance and eliminate inefficiencies Evaluate Current State Develop Ideal State Develop metrics to track improvement Apply Lean Methodology to Stroke Care

7 LEAN Principles 1. Right process producing the right result 2. Developing people and partners 3. Solving problems drives organization learning 4. Generate value for customers, society and the economy NINDS Reverse Site Visit: February 15, 2006

8 Applying Lean to Stroke Care Evaluate process flow (ED stroke response) Assemble multi-disciplinary team Value Stream Map Map patient and process flow Identify problems with processes (inefficiencies) Prioritize problem-solving based on: Impact Ease of problem solving Initiate projects to eliminate inefficiencies

9 Value Stream Mapping (VSM) What is a VSM? A map depicting all work required in a process, showing information & patient flow How does it help? Highlights complexities and barriers to throughput (exposes problems) The process of mapping is just as important as the map (map is the communication tool)

10 Example of RIE: BJH Acute Stroke Protocol Assembly of team Representation from all areas of care (ED attendings and residents, Neurology attendings and residents, ED nurses, NICU nurses, patient care techs, radiology, lab medicine) Lean Coaching Facilitator Current State Evaluation of process and flow Identification of inefficiencies Hurdles to accomplishing goals Future State Ideal processes based on simplicity Elimination of inefficiencies Processes needed to reach ideal state Identification of relevant metrics to evaluate improvement

11 Lean: ED IV tpa Process Chart Step 1 Prep meeting, to properly scope and plan project Step 2 Introduce / Communicate plans to Faculty and all affected parties Step 3 Focused RIE to develop new process, requires participation from key process stakeholders RIE = Rapid Improvement Event Step 4 Communicate proposed changes to all affected parties Step 7 Original RIE team reconvenes for postimplementation summary, process adjustments made if necessary Step 6 Collect data, evaluate effectiveness of new process (1-2 weeks of data) Step 5 Implement new process NINDS Reverse Site Visit: February 15, 2006

12 Current State

13 Problem #1: Overwhelming # 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 Witnesses difficult to locate 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

14 Problem #2: Inefficient choreography Emergent Unit 1 CT CT 1 Nursing Station Trauma Critical Care Ambulance Bay

15 Problem #3: 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 Q1 Q2 Q3 Q4 All labs INR plt glc

16 Ideal State

17 Solution #1: Parallel Processing Code Stroke Admitting CT Tech Nurse #1 Nurse #2 ED resident Neurology resident Social Worker ED Tech Pharmacist Patient ID Registration Room assign CT scan IV placement Monitor hook-up Vital sign monitoring Blood glucose Lab draw Weight estimate History Meds/allergies Order tpa NIHSS Neuro Exam ID witness Time of onset Emergent Transport of Bloods to lab Calculate tpa dose Prepare tpa Decision Bolus & Infuse tpa

18 Solution #2:Streamlined choreography Emergent Unit 1 CT CT 1 Nursing Station Trauma Critical Care Ambulance Bay

19 Solution #3: 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.

20 Implementation

21 Protocol Metrics: Before and After VSA Stroke Protocol Metrics Pre-Intervention 1/1/09-2/28/11 N=132 Post- Intervention 3/1/11-1/3/12 N=70 P-value * Door-to-Needle Time* 60 [46, 73] 39 [27, 55] < Onset-to-Needle Time* 131 [105, 165] 111 [72, 158] Onset-to-Arrival Time 62 [43, 93] 67 [37, 96] 0.71 % Patients with DTN < 60 52% 79% Door-to- Head CT Time* 16 [10, 22] 1 [0, 4] < Door-to-CBC (non-poc) T 22 [16,29] 24 [16,33] 0.37 Door-to-PTT (non-poc), T 34 [29,42] 40 [31,48] 0.27 * Wilcoxon Rank Sum Test was used for continuous data and Fisher s Exact Test was used for binary outcomes; p<0.05 required for significance. For continuous data, results are presented as Median [25 th quartile, 75 th quartile].

22 Percent of Patients Treated Relative Frequency of DTN Times Before and After Streamlines Protocol Pre-VSA Post-VSA Door-to-Needle Time, Minutes

23 Discharge Outcomes Discharge Outcomes Pre- Intervention 1/1/09-2/28/11 N=132 Post- Intervention 3/1/11-1/3/12 N=70 P-value * Favorable Discharge Location + 76% 82% 0.83 Symptomatic ICH % 5.4% 0.61 Stroke Mimic % 10.8% 0.48 * Wilcoxon Rank Sum Test was used for continuous data and Fisher s Exact Test was used for binary outcomes; p<0.05 required for significance. + Favorable discharge location was defined as discharge to home or inpatient rehabilitation (compared to the remainder of patients who had unfavorable discharge location defined as discharge to nursing home or in-hospital death). ++ Symptomatic ICH was defined as any worsening in neurological status within 36 hrs of onset associated with hemorrhage on head CT. +++ Stroke mimic was defined as a discharge diagnosis other than stroke.. NIHSS=National Institutes of Health Stroke Scale; TIA = transient ischemic attack; min=minutes; CT=computed tomography; ICH=intracerebral hemorrhage.

24 Summary Lean management tools effectively improve acute stroke clinical care Earlier treatment with IV tpa increases efficacy Rapid treatment protocols safely accelerate acute stroke thrombolysis, BUT require maintenance and frequent monitoring Sustained treatment efficiency can be maintained despite an increase in treatment numbers (e.g to 2011 = 60% increase) Lean process develops enduring relationships

25 ED Nursing Jennifer Williams, RN Nicki Meyer, RN Elizabeth Kellet, RN Gina Seltzer, RN Kimberly Waltrip, RN Darryl Williams, RN Bev Neulist, RN ED Physicians Peter Panagos, MD David Tan, MD Brian Froekle, MD Time is Brain The Lean Team Lean Engineer Vikas Ghayal ED Pharmacy Craig McCammon, PharmD Neuroscience Nursing Jennifer Wedner, RN Neurology Andria Ford, MD Tomoko Sampson, MD Jill Newgent, RN Jin-Moo Lee, MD, PhD Available Online at: medicine.wustl.edu/isc2012