Abstract 162: Sustained Improvement of Door-to-Needle Times Using Toyota's LEAN Manufacturing Principles: The Washington University Experience 2003-15

Abstract

Background and Purpose: Earlier tissue-type plasminogen activator (tPA) treatment for acute ischemic stroke (AIS), demonstrated by fast door-to-needle times (DNTs), leads to improved patient outcomes. Discrete interventions can improve DNTs, but often this improvement is not sustained over the long term. Hypothesis: LEAN quality improvement methodology can sustain and improve DNTs over a course of decade. Methods: Since 2003, a multidisciplinary quality improvement team has been continually monitoring and modifying the tPA protocol to eliminate inefficiencies using LEAN tools such as value stream analysis or rapid improvement events. We report our quality metrics (DNT, onset-to-treatment time (ONT), NIHSS, symptomatic intracranial hemorrhage (sICH) and favorable discharge clinical outcomes) as they relate to specific LEAN events. Results: Over a 10-year period, process improvement events have dramatically accelerated DTN times for AIS patients in a single hospital ED. The first event in 2004 (resident-based protocol) led to 25% improved DNT (81 vs. 60, P<0.001). In 2011, a new protocol (routing patients directly to CT, using parallel process workflow, and point-of-care labs) improved DNTs 35% (60 vs. 39 minutes, P<0.0001). Finally, in 2014 a treat-in-CT protocol was adopted and lowered DNTs 24% (38 vs. 29 min, P=0.002), for overall 58% improvement in DTN since 2004 (P<0.0001). To ensure efficiency gained was not at the expense of patient safety, sICH, favorable discharge location and percentage of stroke mimics (available only since 2011) were compared and did not differ over time. Conclusions: Application of LEAN and ongoing process improvement measures led to sustained improvement in DNTs for over a decade without compromising safety.