Abstract TP336: Sustaining Excellence in Alteplase Administration in the Emergency Department: Staying Lean

Abstract

Background: Identification and treatment of acute ischemic stroke (AIS) patients in the emergency department (ED) was reorganized in January 2011 using Lean Methodologies. The team achieved initial success post implementation in March 2011 of median time to treatment of 34 minutes. Sustaining the improvements required a shift in paradigm of the ED Acute Stroke Committee (EDASC) and the front line staff caring for the patients. Pre-Lean door to treatment time was 60 minutes (N=132). Methods: Lean methodologies were chosen as a process improvement strategy. Initial implementation demonstrated immediate success of reaching 34 minutes; however in the first quarter following the implementation, the team identified drift in the process and increased numbers of stroke activation evaluations. Individual case review at monthly meetings demonstrated intermittent role confusion, complex patient presentations, inconsistency in process for alteplase preparation and patient preparation. While the team historically discussed these issues, the expectations had been raised to sustain the critical changes. Identification of individuals in each case for role clarification, general nursing education regarding alteplase preparation, reinforcement of bolus administration as a priority and the addition of point of care testing to decrease barriers enabled the front line staff to receive timely feedback and rapid practice corrections. Results: The initial protocol changes were implemented in March 2011. Team reviews with rapid (less than 48 hour) feedback were implemented in April 2011. Point of care testing was implemented in September 2011 for PT/INR testing. Median time to treatment increased to 51 and 48 minutes in April and May 2011. Through drill down review, communication of expectations and progress, and addition of point of care testing the post implementation median time is currently 39 minutes (N=120) for 2011 and 2012. Conclusions: Rapid process improvement using lean tools creates opportunities to radically alter a process of care. Sustaining the changes requires rapid attention to process defects, identification of additional opportunities for improvement and individual accountability to the process.