Implementing ERT practice guidelines in a dual site academic medical center: A transformational and lean approach

Purpose:
The aim of this abstract is to discuss the performance improvement journey to reduce door, or failed treatment, to groin access of patients that suffer ischemic strokes and require ERT in a dual site academic medical center.

Significance:
As practice guidelines are developed for acute ischemic stroke patients requiring endovascular revascularization therapy (ERT), physician experts recommend door-to-groin puncture times of 60 minutes. Stroke centers must survey resources and develop strategic plans to meet practice recommendations.

Strategy and Implementation:
Using transformational leadership and lean thinking as the framework and a goal of door-to-groin access of 60 minutes, the organization assembled a multidisciplinary task force to scrutinize each step of the process. The mission of was to add value, eliminate waste, and improve patient outcomes. The group met biweekly to map out the current process and identify areas of redundancy. Then, the group assembled future state maps with revisions. Suggestions were presented to primary Stroke Committee for approval and implementation. Prior to the initiative, patients were sent to one of three nursing units. Physicians and staff wasted time locating and evaluating patients. One of the key strategies was to send all stroke patients to a central area, preoperative holding. The multidisiplinary team descended on the patient in this area, evaluations were complete, and a plan of care determined. Preoperative holding is located adjacent to the cath labs which allowed for swift tranfer.

Evaluation:
In 2012, the mean door-to-puncture was 104.5 minutes. For 2013, the mean is 72 minutes but is a smaller sample. Preliminary results suggest delays are attributed to overall awareness of time benchmark, arrival times for on call staff, and the need for additional work up or imaging.

Implications for Practice:
Strokes are the forth leading cause of death and disability in United States. Using the concept, time is brain, expeditious throughput of patients suffering from acute ischemic strokes is crucial. Mulitdisciplinary teams must work in unison for optimal patient outcomes.