1
|
Cegłowska U, Zawada A, Zielińska M, Hermanowski T, Buczacki A. Using a lean management approach in acute ischemic stroke management: a systematic review. POSTEPY PSYCHIATRII NEUROLOGII 2024; 33:67-79. [PMID: 39119549 PMCID: PMC11304223 DOI: 10.5114/ppn.2024.141056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/14/2024] [Indexed: 08/10/2024]
Abstract
Purpose Stroke is the second leading cause of death worldwide with an annual mortality rate of 6.55 million, which accounts for 11.6% of the total number of deaths. Early diagnosis is crucial for improving treatment outcomes. Lean management is an approach originating in the car manufacturing process derived from the Toyota Production System, which healthcare providers have recently adapted. The objective is to examine the use of lean practices in managing AIS in hospital settings. Methods A systematic literature search was performed using MEDLINE and SCOPUS databases, including publications from 1st January 2000 to 20th September 2022. Results A total of 13 studies fulfilled the predefined inclusion criteria. The recombinant tissue plasminogen activator (rtPA) was used in 11 studies, in 2 studies in combination with mechanical thrombectomy (MT). MT alone was used in the other 2 studies. The value stream mapping was used in all included studies to analyze workflow in acute ischemic stroke (AIS) treatment. Outcome measures include mostly door-to-needle (DTN) time for rtPA treatment and door-to-puncture (DTP) time for mechanical thrombectomy. DTN time was assessed in nine studies and reached statistically significant results in five. DTP was examined in three studies; in two, statistically significant decreases in DTP were observed. Conclusions Lean management can be a useful method for achieving key performance indicators in AIS, consistent with current guidelines. The results of this systematic literature review show that value stream mapping may improve the process of AIS treatment by reducing in-hospital delays. The field of research that focuses on implementing lean management tools in healthcare is increasing, with more publications appearing in recent years.
Collapse
Affiliation(s)
- Urszula Cegłowska
- Department of Applied Pharmacy, Faculty of Pharmacy, Medical University of Warsaw, Poland
| | - Anna Zawada
- Department of Applied Pharmacy, Faculty of Pharmacy, Medical University of Warsaw, Poland
| | - Magdalena Zielińska
- Department of Biochemistry and Pharmacogenomics, Faculty of Pharmacy, Medical University of Warsaw, Poland
| | - Tomasz Hermanowski
- Department of Applied Pharmacy, Faculty of Pharmacy, Medical University of Warsaw, Poland
| | - Aleksander Buczacki
- Institute of Production Systems Organisation, Faculty of Production Engineering, Warsaw University of Technology, Poland
| |
Collapse
|
2
|
Klu M, de Souza AC, Carbonera LA, Secchi TL, Pille A, Rodrigues M, Brondani R, de Almeida AG, Dal Pizzol A, Camelo DMF, Mantovani GP, Oldoni C, Tessari MS, Nasi LA, Martins SCO. Improving door-to-reperfusion time in acute ischemic stroke during the COVID-19 pandemic: experience from a public comprehensive stroke center in Brazil. Front Neurol 2023; 14:1155931. [PMID: 37492852 PMCID: PMC10365273 DOI: 10.3389/fneur.2023.1155931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/13/2023] [Indexed: 07/27/2023] Open
Abstract
Background The global COVID-19 pandemic has had a devastating effect on global health, resulting in a strain on healthcare services worldwide. The faster a patient with acute ischemic stroke (AIS) receives reperfusion treatment, the greater the odds of a good functional outcome. To maintain the time-dependent processes in acute stroke care, strategies to reorganize infrastructure and optimize human and medical resources were needed. Methods Data from AIS patients who received thrombolytic therapy were prospectively assessed in the emergency department (ED) of Hospital de Clínicas de Porto Alegre from 2019 to 2021. Treatment times for each stage were measured, and the reasons for a delay in receiving thrombolytic therapy were evaluated. Results A total of 256 patients received thrombolytic therapy during this period. Patients who arrived by the emergency medical service (EMS) had a lower median door-to-needle time (DNT). In the multivariable analysis, the independent predictors of DNT >60 min were previous atrial fibrillation (OR 7) and receiving thrombolysis in the ED (OR 9). The majority of patients had more than one reason for treatment delay. The main reasons were as follows: delay in starting the CT scan, delay in the decision-making process after the CT scan, and delay in reducing blood pressure. Several actions were implemented during the study period. The most important factor that contributed to a decrease in DNT was starting the bolus and continuous infusion of tPA on the CT scan table (decreased the median DNT from 74 to 52, DNT ≤ 60 min in 67% of patients treated at radiology service vs. 24% of patients treated in the ED). The DNT decreased from 78 min to 66 min in 2020 and 57 min in 2021 (p = 0.01). Conclusion Acute stroke care continued to be a priority despite the COVID-19 pandemic. The implementation of a thrombolytic bolus and the start of continuous infusion on the CT scan table was the main factor that contributed to the reduction of DNT. Continuous monitoring of service times is essential for improving the quality of the stroke center and achieving better functional outcomes for patients.
Collapse
Affiliation(s)
- Marcelo Klu
- Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Ana Claudia de Souza
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Leonardo Augusto Carbonera
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Thais Leite Secchi
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Arthur Pille
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Marcio Rodrigues
- Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Rosane Brondani
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Andrea Garcia de Almeida
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Angélica Dal Pizzol
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Daniel Monte Freire Camelo
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Gabriel Paulo Mantovani
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Carolina Oldoni
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Marcelo Somma Tessari
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Luiz Antonio Nasi
- Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Sheila Cristina Ouriques Martins
- Neurology Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil
| |
Collapse
|
3
|
Rawson J, Petrone A, Adcock A. Single-step Optimization in Triaging Large Vessel Occlusion Strokes: Identifying Factors to Improve Door-to-groin Time for Endovascular Therapy. West J Emerg Med 2023; 24:737-742. [PMID: 37527384 PMCID: PMC10393444 DOI: 10.5811/westjem.59770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/27/2023] [Indexed: 08/03/2023] Open
Abstract
INTRODUCTION Although acute stroke endovascular therapy (EVT) has dramatically improved outcomes in acute ischemic stroke (AIS) patients with large vessel occlusions (LVO), access to EVT-capable centers remains limited, particularly in rural areas. Therefore, it is essential to optimize triage systems for EVT-eligible patients. One strategy may be the use of a telestroke network that typically consists of multiple spoke sites that receive a consultation to determine appropriateness of patient transfer to an EVT-capable hub site. Standardization of AIS protocols may be necessary to achieve target door-to-groin (DTG) times of less than 60 minutes in EVT-eligible patients upon hub arrival. Specifically, the decision to obtain vascular imaging at the transferring hub site vs delaying until arrival at the hub is controversial. The purpose of this study was to identify factors associated with reduced DTG time in LVO-AIS patients. METHODS We performed a retrospective chart review for all patients treated over a 3.5-year period at our home hub institution. Patients were classified as telestroke transfers, non-telestroke transfers, and direct-to-hub presentations. We recorded demographic information, DTG time, reperfusion status, length of stay (LOS), functional status at discharge, seven-day mortality, and the site where vascular imaging- computed tomography angiography (CTA)-was obtained. We performed binary logistic regression to identify factors associated with DTG <60 minutes. RESULTS In the sample of EVT-eligible patients (n = 383), CTA was performed at the spoke site prior to transfer to the hub institution in 53% of cases. Further, 59% of telestroke transfer cases received a CTA prior to transfer compared to only 40% of non-telestroke transfers (59 vs 40%, P = 0.01). A Door-to-groin time <60 minutes was achieved in 67% of transfer patients who received pre-transfer CTA compared to only 22% of transfer patients who received CTA upon hub arrival and 17% of patients who presented directly to the hub. Ultimately, transfer patients who received CTA prior to transfer were 7.2 times more likely to have a DTG <60 minutes compared to those who did not (OR 7.2, 95% confidence interval 3.5-14.7; P < 0.001). CONCLUSION Pre-transfer computed tomography angiography was the only significant predictor of achieving target door-to-groin times of less than 60 minutes. Because DTG time has been well established as a predictor of clinical outcomes, including pre-transfer CTA in a standardized acute ischemic stroke protocol may prove beneficial. Our findings also illustrate the need to optimize direct-to-hub stroke alerts and telestroke relationships to minimize workflow disruptions, which became more apparent during the pandemic.
Collapse
Affiliation(s)
- Joshua Rawson
- West Virginia University School of Medicine, Morgantown, West Virginia
| | - Ashley Petrone
- West Virginia University, Department of Pathology, Morgantown, West Virginia
| | - Amelia Adcock
- West Virginia University, Department of Neurology; Cerebrovascular Division, Morgantown, West Virginia
| |
Collapse
|
4
|
Liberman AL, Holl JL, Romo E, Maas M, Song S, Prabhakaran S. Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis. Acad Emerg Med 2023; 30:187-195. [PMID: 36565234 DOI: 10.1111/acem.14648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/03/2022] [Accepted: 12/21/2022] [Indexed: 12/25/2022]
Abstract
INTRODUCTION To date, many emergency department (ED)-based quality improvement studies and interventions for acute stroke patients have focused on expediting time-sensitive treatments, particularly reducing door-to-needle time. However, prior to treatment, a diagnosis of stroke must be reached. The ED-based stroke diagnostic process has been understudied despite its importance in assuring high-quality and safe care. METHODS We used a learning collaborative to conduct a failure modes, effects, and criticality analysis (FMECA) of the acute stroke diagnostic process at three health systems in Chicago, IL. Our FMECA was designed to prospectively identify, characterize, and rank order failures in the systems and processes of care that offer opportunities for redesign to improve stroke diagnostic accuracy. Multidisciplinary teams involved in stroke care at five different sites participated in moderated sessions to create an acute stroke diagnostic process map as well as identify failures and existing safeguards. For each failure, a risk priority number and criticality score were calculated. Failures were then ranked, with the highest scores representing the most critical failures to be targeted for redesign. RESULTS A total of 28 steps were identified in the acute stroke diagnostic process. Iterative steps in the process include information gathering, clinical examination, interpretation of diagnostic test results, and reassessment. We found that failure to use existing screening scales to identify patients with large-vessel occlusions early on in their ED course ranked highest. Failure to obtain an accurate history of the index event, failure to suspect acute stroke in triage, and failure to use established stroke screening tools at ED arrival to identify potential stroke patients were also highly ranked. CONCLUSIONS Our study results highlight the critical importance of upstream steps in the acute stroke diagnostic process, particularly the use of existing tools to identify stroke patients who may be eligible for time-sensitive treatments.
Collapse
Affiliation(s)
- Ava L Liberman
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Jane L Holl
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Elida Romo
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Matthew Maas
- Department of Neurology, Northwestern University, Chicago, Illinois, USA
| | - Sarah Song
- Department of Neurology, Rush University, Chicago, Illinois, USA
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| |
Collapse
|
5
|
Leite KFDS, Faria MGBFD, Andrade RLDP, Sousa KDLD, Santos SRD, Ferreira KS, Rezende CEMD, Neto OMP, Monroe AA. Effect of implementing care protocols on acute ischemic stroke outcomes: a systematic review. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:173-185. [PMID: 36948202 PMCID: PMC10033200 DOI: 10.1055/s-0042-1759578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 01/13/2022] [Indexed: 03/24/2023]
Abstract
BACKGROUND Implementing stroke care protocols has intended to provide better care quality, favor early functional recovery, and achieving long-term results for the rehabilitation of the patient. OBJECTIVE To analyze the effect of implementing care protocols on the outcomes of acute ischemic stroke. METHODS Primary studies published from 2011 to 2020 and which met the following criteria were included: population should be people with acute ischemic stroke; studies should present results on the outcomes of using protocols in the therapeutic approach to acute ischemic stroke. The bibliographic search was carried out in June 2020 in 7 databases. The article selection was conducted by two independent reviewers and the results were narratively synthesized. RESULTS A total of 11,226 publications were retrieved in the databases, of which 30 were included in the study. After implementing the protocol, 70.8% of the publications found an increase in the rate of performing reperfusion therapy, such as thrombolysis and thrombectomy; 45.5% identified an improvement in the clinical prognosis of the patient; and 25.0% of the studies identified a decrease in the length of hospital stay. Out of 19 studies that addressed the rate of symptomatic intracranial hemorrhage, 2 (10.5%) identified a decrease. A decrease in mortality was mentioned in 3 (25.0%) articles out of 12 that evaluated this outcome. CONCLUSIONS We have identified the importance of implementing protocols in increasing the performance of reperfusion therapies, and a good functional outcome with improved prognosis after discharge. However, there is still a need to invest in reducing post-thrombolysis complications and mortality.
Collapse
Affiliation(s)
- Karina Fonseca de Souza Leite
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil.
| | - Mariana Gaspar Botelho Funari de Faria
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil.
| | - Rubia Laine de Paula Andrade
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil.
| | - Keila Diane Lima de Sousa
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil.
| | - Samuel Ribeiro dos Santos
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil.
| | - Kamila Santos Ferreira
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Hospital das Clínicas, Ribeirão Preto SP, Brazil.
| | - Carlos Eduardo Menezes de Rezende
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil.
- Ministério da Saúde, Agência Nacional de Saúde Suplementar, Brasília DF, Brazil.
| | - Octavio Marques Pontes Neto
- Universidade de São Paulo, Faculdade de Medicina de Ribeirao Preto, Departamento de Neurociências e Ciências do Comportamento, Ribeirão Preto SP, Brazil.
| | - Aline Aparecida Monroe
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil.
| |
Collapse
|
6
|
Thakur V, Akerele OA, Randell E. Lean and Six Sigma as continuous quality improvement frameworks in the clinical diagnostic laboratory. Crit Rev Clin Lab Sci 2023; 60:63-81. [PMID: 35978530 DOI: 10.1080/10408363.2022.2106544] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Processes to enhance customer-related services in healthcare organizations are complex and it can be difficult to achieve efficient patient-focused services. Laboratories make an integral part of the healthcare service industry where healthcare providers deal with critical patient results. Errors in these processes may cost a human life, create a negative impact on an organization's reputation, cause revenue loss, and open doors for expensive lawsuits. To overcome these complexities, healthcare organizations must implement an approach that helps healthcare service providers to reduce waste, variation, and work imbalance in the service processes. Lean and Six Sigma are used as continuous process improvement frameworks in laboratory medicine. Six Sigma uses an approach that involves problem-solving, continuous improvement and quantitative statistical process control. Six Sigma is a technique based on the DMAIC process (Define, Measure, Analyze, Improve, and Control) to improve quality performance. Application of DMAIC in a healthcare organization provides guidance on how to handle quality that is directed toward patient satisfaction in a healthcare service industry. The Lean process is a technique for process management in which waste reduction is the primary purpose; this is accomplished by implementing waste mitigation practices and methodologies for quality improvement. Overall, this article outlines the frameworks for continuous quality and process improvement in healthcare organizations, with a focus on the impacts of Lean and Six Sigma on the performance and quality service delivery system in clinical laboratories. It also examines the role of utilization management and challenges that impact the implementation of Lean and Six Sigma in clinical laboratories.
Collapse
Affiliation(s)
- Vinita Thakur
- Department of Laboratory Medicine, Health Sciences Center, Eastern Health Authority, St. John's, Canada.,Faculty of Medicine, Memorial University of Newfoundland, St. John's, Canada
| | - Olatunji Anthony Akerele
- Department of Laboratory Medicine, Health Sciences Center, Eastern Health Authority, St. John's, Canada
| | - Edward Randell
- Department of Laboratory Medicine, Health Sciences Center, Eastern Health Authority, St. John's, Canada.,Faculty of Medicine, Memorial University of Newfoundland, St. John's, Canada
| |
Collapse
|
7
|
Hwong WY, Ng SW, Tong SF, Ab Rahman N, Law WC, Kaman Z, Wong SK, Puvanarajah SD, Sivasampu S. Stroke thrombolysis in a middle-income country: A case study exploring the determinants of its implementation. Front Neurol 2022; 13:1048807. [PMID: 36504666 PMCID: PMC9729841 DOI: 10.3389/fneur.2022.1048807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/07/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Translation of evidence into clinical practice for use of intravenous thrombolysis in acute stroke care has been slow, especially across low- and middle-income countries. In Malaysia where the average national uptake was poor among the public hospitals in 2018, one hospital intriguingly showed comparable thrombolysis rates to high-income countries. This study aimed to explore and provide in-depth understanding of factors and explanations for the high rates of intravenous stroke thrombolysis in this hospital. Methods This single case study sourced data using a multimethod approach: (1) semi-structured in-depth interviews and focus group discussions, (2) surveys, and (3) review of medical records. The Tailored Implementation of Chronic Diseases (TICD) framework was used as a guide to understand the determinants of implementation. Twenty-nine participants comprising the Hospital Director, neurologists, emergency physicians, radiologists, pharmacists, nurses and medical assistants (MAs) were included. Thematic analyses were conducted inductively before triangulated with quantitative analyses and document reviews. Results Favorable factors contributing to the uptake included: (1) cohesiveness of team members which comprised of positive interprofessional team dynamics, shared personal beliefs and values, and passionate leadership, and (2) facilitative work process through simplification of workflow and understanding the rationale of the sense of urgency. Patient factors was a limiting factor. Almost two third of ischemic stroke patients arrived at the hospital outside the therapeutic window time, attributing patients' delayed presentation as a main barrier to the uptake of intravenous stroke thrombolysis. One other barrier was the availability of resources, although this was innovatively optimized to minimize its impact on the uptake of the therapy. As such, potential in-hospital delays accounted for only 3.8% of patients who missed the opportunity to receive thrombolysis. Conclusions Despite the ongoing challenges, the success in implementing intravenous stroke thrombolysis as standard of care was attributed to the cohesiveness of team members and having facilitative work processes. For countries of similar settings, plans to improve the uptake of intravenous stroke thrombolysis should consider the inclusion of interventions targeting on these modifiable factors.
Collapse
Affiliation(s)
- Wen Yea Hwong
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, Selangor, Malaysia,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands,*Correspondence: Wen Yea Hwong ;
| | - Sock Wen Ng
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, Selangor, Malaysia
| | - Seng Fah Tong
- Department of Family Medicine, Universiti Kebangsaan Malaysia, Selangor, Malaysia
| | - Norazida Ab Rahman
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, Selangor, Malaysia
| | - Wan Chung Law
- Neurology Unit, Department of Medicine, Sarawak General Hospital, Ministry of Health Malaysia, Kuching, Malaysia
| | - Zurainah Kaman
- Neurology Unit, Department of Medicine, Sarawak General Hospital, Ministry of Health Malaysia, Kuching, Malaysia
| | - Sing Keat Wong
- Department of Neurology, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Santhi Datuk Puvanarajah
- Department of Neurology, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Sheamini Sivasampu
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, Selangor, Malaysia
| |
Collapse
|
8
|
Santos ACDSGD, Reis ADC, Souza CGD, Santos IL, Ferreira LAF, Senna P. Measuring the current state-of-the-art in lean healthcare literature from the lenses of bibliometric indicators. BENCHMARKING-AN INTERNATIONAL JOURNAL 2022. [DOI: 10.1108/bij-10-2021-0580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeLean healthcare (LHC) applies lean philosophy in the healthcare sector to promote a culture of continuous improvement through the elimination of non-value-added activities. Studies on the subject can be classified as conceptual (theoretical) or analytical (applied). Therefore, this research compares bibliometric indicators between conceptual and analytical articles on LHC.Design/methodology/approachFor data collection, the PRISMA Protocol was employed, and 488 articles published from 2009 to 2021, indexed in the Scopus and WoS databases, were retrieved.FindingsThis study reveals how conceptual and analytical LHC studies are organized in terms of the most relevant journals, articles, institutions, countries, the total number of citations, collaboration networks (co-authorship, international collaboration network and institutional collaboration network) and main co-words.Originality/valueOnly four papers conducting bibliometric analysis on LHC studies were identified in the Scopus and Web of Science databases. In addition, none of these papers compared conceptual and analytical bibliometric indicators to reveal the evolution, organization and trends of each category. Therefore, this work is not only the first to make this comparison but also the first to analyze the collaboration between authors, institutions and countries in relation to studies on LHC. The analyses performed in this work allow one new possible understanding, by researchers and health professionals, of the literature behavior in this field of study.
Collapse
|
9
|
Leite KFDS, dos Santos SR, Andrade RLDP, de Faria MGBF, Saita NM, Arcêncio RA, Isaac ISDS, de Rezende CEM, Villa TCS, Pontes Neto OM, Monroe AA. Reducing care time after implementing protocols for acute ischemic stroke: a systematic review. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:725-740. [PMID: 36254446 PMCID: PMC9685828 DOI: 10.1055/s-0042-1755194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Abstract
Background The treatment of acute ischemic stroke with cerebral reperfusion therapy requires rapid care and recognition of symptoms.
Objective To analyze the effectiveness of implementing protocols for acute ischemic stroke in reducing care time.
Methods Systematic review, which was performed with primary studies in Portuguese, English, and Spanish published between 2011 and 2020. Inclusion criteria: study population should comprise people with acute ischemic stroke and studies should present results on the effectiveness of using urgent care protocols in reducing care time. The bibliographic search was conducted in June 2020 in the LILACS, MEDLINE, Embase, Scopus, CINAHL, Academic Search Premier, and SocINDEX databases. The articles were selected, and data were extracted by two independent reviewers; the synthesis of the results was performed narratively. The methodological quality of articles was evaluated through specific instruments proposed by the Joanna Briggs Institute.
Results A total of 11,226 publications were found, of which 35 were included in the study. Only one study reported improvement in the symptoms-onset-to-door time after protocol implementation. The effectiveness of the therapeutic approach protocols for ischemic stroke was identified in improving door-to-image, image-to-needle, door-to-needle and symptoms-onset-to-needle times. The main limitation found in the articles concerned the lack of clarity in relation to the study population.
Conclusions Several advances have been identified in in-hospital care with protocol implementation; however, it is necessary to improve the recognition time of stroke symptoms among those who have the first contact with the person affected by the stroke and among the professionals involved with the prehospital care.
Collapse
Affiliation(s)
- Karina Fonseca de Souza Leite
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Samuel Ribeiro dos Santos
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Rubia Laine de Paula Andrade
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Mariana Gaspar Botelho Funari de Faria
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Nanci Michele Saita
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Ricardo Alexandre Arcêncio
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Igor Simões da Silva Isaac
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Carlos Eduardo Menezes de Rezende
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
- Ministério da Saúde, Agência Nacional de Saúde Suplementar, Brasília DF, Brazil
| | - Tereza Cristina Scatena Villa
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| | - Octavio Marques Pontes Neto
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Neurociências e Ciências do Comportamento, Ribeirão Preto SP, Brazil
| | - Aline Aparecida Monroe
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Materno-Infantil e Saúde Pública, Ribeirão Preto SP, Brazil
| |
Collapse
|
10
|
Bao H, Zhang S, Hao J, Zuo L, Xu X, Yang Y, Jiang H, Li G. Improving the Prehospital Identification and Acute Care of Acute Stroke Patients: A Quality Improvement Project. Emerg Med Int 2022; 2022:3456144. [PMID: 35186333 PMCID: PMC8850070 DOI: 10.1155/2022/3456144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 12/28/2021] [Accepted: 01/03/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There are a large number of stroke patients in China, and there is currently a lack of prehospital acute stroke care training programs. AIM To develop a prehospital emergency medical service (PEMS) training program to improve the prehospital identification and acute care of acute stroke. METHODS Forty prehospital emergency doctors whose service stations are located within a 10 km radius from Shanghai Pudong New Area Medical Emergency Service Center took this course on November 13, 2014. A questionnaire was designed to evaluate the PEMS personnel's knowledge in stroke and acute stroke care and was conducted before and after training as an assessment of the effectiveness of training. The patient population in this study included a baseline cohort before training and a prospective cohort after training, each composed of patients who were sent to Shanghai East Hospital South Stoke Center within one year. The transit time, final diagnosis, administration of thrombolysis, and door-to-needle time (DNT) were collected and analyzed. RESULTS After the training, 100% of the PEMS personnel were competent to identify stroke cases using the Cincinnati prehospital stroke scale (CPSS). All participants realized that intravenous thrombolysis therapy in a time-sensitive manner is the most effective way to treat acute ischemic stroke. Although there was no difference in first-aid transit time before and after training, the stroke diagnosis rate improved by 6.5% after training (P=0.03). The thrombolysis rate increased to 29.6% from 24.3% but did not reach statistical significance. Compared to 84.0 minutes (standard deviation: 23.1 minutes) before the training, the average DNT after training was 53 minutes (standard deviation: 15.0 minutes), demonstrating a remarkable reduction (P < 0.01). CONCLUSION The training program effectively improved the PEMS personnel's knowledge in stroke and stroke acute care.
Collapse
Affiliation(s)
- Huan Bao
- Department of Neurology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Sumian Zhang
- Department of ICU, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Junjie Hao
- Department of Neurology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Lian Zuo
- Department of Neurology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Xiahong Xu
- Department of Neurology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Yumei Yang
- Department of Neurology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Hua Jiang
- Department of Medical Education, Shanghai Pudong Medical Emergency Center, Shanghai 201206, China
| | - Gang Li
- Department of Neurology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| |
Collapse
|
11
|
Shahjouei S, Li J, Koza E, Abedi V, Sadr AV, Chen Q, Mowla A, Griffin P, Ranta A, Zand R. Risk of Subsequent Stroke Among Patients Receiving Outpatient vs Inpatient Care for Transient Ischemic Attack: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2136644. [PMID: 34985520 PMCID: PMC8733831 DOI: 10.1001/jamanetworkopen.2021.36644] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
IMPORTANCE Transient ischemic attack (TIA) often indicates a high risk of subsequent cerebral ischemic events. Timely preventive measures improve the outcome. OBJECTIVE To estimate and compare the risk of subsequent ischemic stroke among patients with TIA or minor ischemic stroke (mIS) by care setting. DATA SOURCES MEDLINE, Web of Science, Scopus, Embase, International Clinical Trials Registry Platform, ClinicalTrials.gov, Trip Medical Database, CINAHL, and all Evidence-Based Medicine review series were searched from the inception of each database until October 1, 2020. STUDY SELECTION Studies evaluating the occurrence of ischemic stroke after TIA or mIS were included. Cohorts without data on evaluation time for reporting subsequent stroke, with retrospective diagnosis of the index event after stroke occurrence, and with a report of outcomes that were not limited to patients with TIA or mIS were excluded. Two authors independently screened the titles and abstracts and provided the list of candidate studies for full-text review; discrepancies and disagreements in all steps of the review were addressed by input from a third reviewer. DATA EXTRACTION AND SYNTHESIS The study was prepared and reported following the Preferred Reporting Items for Systematic Reviews and Meta-analyses, Meta-analysis of Observational Studies in Epidemiology, Methodological Expectations of Cochrane Intervention Reviews, and Enhancing the Quality and Transparency of Health Research guidelines. The Risk of Bias in Nonrandomized Studies-of Exposures (ROBINS-E) tool was used for critical appraisal of cohorts, and funnel plots, Begg-Mazumdar rank correlation, Kendall τ2, and the Egger bias test were used for evaluating the publication bias. All meta-analyses were conducted under random-effects models. MAIN OUTCOMES AND MEASURES Risk of subsequent ischemic stroke among patients with TIA or mIS who received care at rapid-access TIA or neurology clinics, inpatient units, emergency departments (EDs), and unspecified or multiple settings within 4 evaluation intervals (ie, 2, 7, 30, and 90 days). RESULTS The analysis included 226 683 patients from 71 articles recruited between 1981 and 2018; 5636 patients received care at TIA clinics (mean [SD] age, 65.7 [3.9] years; 2291 of 4513 [50.8%] men), 130 139 as inpatients (mean [SD] age, 78.3 [4.0] years; 49 458 of 128 745 [38.4%] men), 3605 at EDs (mean [SD] age, 68.9 [3.9] years; 1596 of 3046 [52.4%] men), and 87 303 patients received care in an unspecified setting (mean [SD] age, 70.8 [3.8] years, 43 495 of 87 303 [49.8%] men). Among the patients who were treated at a TIA clinic, the risk of subsequent stroke following a TIA or mIS was 0.3% (95% CI, 0.0%-1.2%) within 2 days, 1.0% (95% CI, 0.3%-2.0%) within 7 days, 1.3% (95% CI, 0.4%-2.6%) within 30 days, and 2.1% (95% CI, 1.4%-2.8%) within 90 days. Among the patients who were treated as inpatients, the risk of subsequent stroke was to 0.5% (95% CI, 0.1%-1.1%) within 2 days, 1.2% (95% CI, 0.4%-2.2%) within 7 days, 1.6% (95% CI, 0.6%-3.1%) within 30 days, and 2.8% (95% CI, 2.1%-3.5%) within 90 days. The risk of stroke among patients treated at TIA clinics was not significantly different from those hospitalized. Compared with the inpatient cohort, TIA clinic patients were younger and had had lower ABCD2 (age, blood pressure, clinical features, duration of TIA, diabetes) scores (inpatients with ABCD2 score >3, 1101 of 1806 [61.0%]; TIA clinic patients with ABCD2 score >3, 1933 of 3703 [52.2%]). CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis, the risk of subsequent stroke among patients who were evaluated in a TIA clinic was not higher than those hospitalized. Patients who received treatment in EDs without further follow-up had a higher risk of subsequent stroke. These findings suggest that TIA clinics can be an effective component of the TIA care component pathway.
Collapse
Affiliation(s)
- Shima Shahjouei
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
| | - Jiang Li
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, Pennsylvania
| | - Eric Koza
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania
| | - Vida Abedi
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, Pennsylvania
- Biocomplexity Institute, Virginia Tech, Blacksburg, Virginia
| | - Alireza Vafaei Sadr
- Department de Physique Theorique and Center for Astroparticle Physics, University Geneva, Geneva, Switzerland
| | - Qiushi Chen
- Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles
| | - Paul Griffin
- Department of Industrial and Manufacturing Engineering, Pennsylvania State University, University Park
| | - Annemarei Ranta
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Ramin Zand
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania
| |
Collapse
|
12
|
Bulmer T, Volders D, Blake J, Kamal N. Discrete-Event Simulation to Model the Thrombolysis Process for Acute Ischemic Stroke Patients at Urban and Rural Hospitals. Front Neurol 2021; 12:746404. [PMID: 34777215 PMCID: PMC8586711 DOI: 10.3389/fneur.2021.746404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/30/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Effective treatment with tissue plasminogen activator (tPA) critically relies on rapid treatment. Door-to-needle time (DNT) is a key measure of hospital efficiency linked to patient outcomes. Numerous changes can reduce DNT, but they are difficult to trial and implement. Discrete-event simulation (DES) provides a way to model and determine the impact of process improvements. Methods: A conceptual framework was developed to illustrate the thrombolysis process; allowing for treatment processes to be replicated using a DES model developed in ARENA. Activity time duration distributions from three sites (one urban and two rural) were used. Five scenarios, three process changes, and two reductions in activity durations, were simulated and tested. Scenarios were tested individually and in combinations. The primary outcome measure is median DNT. The study goal is to determine the largest improvement in DNT at each site. Results: Administration of tPA in the imaging area resulted in the largest median DNT reduction for Site 1 and Site 2 for individual test scenarios (12.6%, 95% CI 12.4–12.8%, and 8.2%, 95% CI 7.5–9.0%, respectively). Ensuring that patients arriving via emergency medical services (EMS) remain on the EMS stretcher to imaging resulted in the largest median DNT improvement for Site 3 (9.2%, 95% CI 7.9–10.5%). Reducing both the treatment decision time and tPA preparation time by 35% resulted in a 11.0% (95% CI 10.0–12.0%) maximum reduction in median DNT. The lowest median and 90th percentile DNTs were achieved by combining all test scenarios, with a maximum reduction of 26.7% (95% CI 24.5–28.9%) and 17.1% (95% CI 12.5–21.7%), respectively. Conclusions: The detailed conceptual framework clarifies the intra-hospital logistics of the thrombolysis process. The most significant median DNT improvement at rural hospitals resulted from ensuring patients arriving via EMS remain on the EMS stretcher to imaging, while urban sites benefit more from administering tPA in the imaging area. Reducing the durations of activities on the critical path will provide further DNT improvements. Significant DNT improvements are achievable in urban and rural settings by combining process changes with reducing activity durations.
Collapse
Affiliation(s)
- Tessa Bulmer
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
| | - David Volders
- Interventional and Diagnostic Neuroradiology, QEII Health Sciences Centre, Nova Scotia Health, Halifax, NS, Canada.,Department of Radiology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - John Blake
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
| |
Collapse
|
13
|
Holl JL, Khorzad R, Zobel R, Barnard A, Hillman M, Vargas A, Richards C, Mendelson S, Prabhakaran S. Risk Assessment of the Door-In-Door-Out Process at Primary Stroke Centers for Patients With Acute Stroke Requiring Transfer to Comprehensive Stroke Centers. J Am Heart Assoc 2021; 10:e021803. [PMID: 34533049 PMCID: PMC8649509 DOI: 10.1161/jaha.121.021803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Patients with acute stroke at non- or primary stroke centers (PSCs) are transferred to comprehensive stroke centers for advanced treatments that reduce disability but experience significant delays in treatment and increased adjusted mortality. This study reports the results of a proactive, systematic, risk assessment of the door-in-door-out process and its application to solution design. Methods and Results A learning collaborative (clinicians, patients, and caregivers) at 2 PSCs and 3 comprehensive stroke centers in Chicago, Illinois participated in a failure modes, effects, and criticality analysis to identify steps in the process; failures of each step, underlying causes; and to characterize each failure's frequency, impact, and safeguards using standardized scores to calculate risk priority and criticality numbers for ranking. Targets for solution design were selected among the highest-ranked failures. The failure modes, effects, and criticality analysis process map and risk table were completed during in-person and virtual sessions. Failure to detect severe stroke/large-vessel occlusion on arrival at the PSC is the highest-ranked failure and can lead to a 45-minute door-in-door-out delay caused by failure to obtain a head computed tomography and computed tomography angiogram together. Lower risk failures include communication problems and delays within the PSC team and across the PSC comprehensive stroke center and paramedic teams. Seven solution prototypes were iteratively designed and address 4 of the 10 highest-ranked failures. Conclusions The failure modes, effects, and criticality analysis identified and characterized previously unrecognized failures of the door-in-door-out process. Use of a risk-informed approach for solution design is novel for stroke and should mitigate or eliminate the failures.
Collapse
Affiliation(s)
- Jane L Holl
- Department of Neurology Biological Sciences Division University of Chicago Chicago IL
| | | | | | - Amy Barnard
- Northwestern Medicine Lake Forest Hospital Lake Forest IL
| | | | | | - Christopher Richards
- Department of Emergency Medicine University of Cincinnati College of Medicine Cincinnati OH
| | - Scott Mendelson
- Department of Neurology Biological Sciences Division University of Chicago Chicago IL
| | - Shyam Prabhakaran
- Department of Neurology Biological Sciences Division University of Chicago Chicago IL
| |
Collapse
|
14
|
Chiu LQ, Quek DYJ, Salihan RB, Ng WM, Othman RB, Lee CH, Oh DCT. ACT-FAST: a quality improvement project to increase the percentage of acute stroke patients receiving intravenous thrombolysis within 60 minutes of arrival at the emergency department. Singapore Med J 2021; 62:476-481. [PMID: 32227791 DOI: 10.11622/smedj.2020040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Stroke is a leading cause of death and disability, with the administration of recombinant transcriptase-plasminogen activator (rtPA) improving outcomes in a time-dependent manner. Only 52.3% of eligible stroke patients at our institution received rtPA within 60 minutes of arrival. We aimed to improve the percentage of acute stroke patients receiving rtPA within 60 minutes of arrival at the emergency department (ED). METHODS This study presents results from the first year of a clinical practice improvement project that implemented quality improvement interventions. The primary outcome measure was percentage of acute ischaemic stroke patients receiving rtPA within 60 minutes of arrival at the ED. Secondary outcome measures included components of total door-to-needle (DTN) time and factors for delay to thrombolysis. Interventions were establishment of standardised acute stroke activation guidelines, screening question at ED registration, prehospital notification of stroke activation, public education, scripting for thrombolysis consent and easy access to equipment. RESULTS The percentage of patients thrombolysed within 60 minutes increased to 60.6% (p = 0.27), and DTN time decreased from 59 minutes to 54.5 minutes (p = 0.15). This was attributable to reduced door-to-physician time, door-to-imaging time and decision time, although the results were not significant. There was no significant increase in symptomatic intracranial haemorrhage or mortality secondary to stroke. Length of stay was significantly reduced by 1.5 days (p < 0.048). CONCLUSION The interventions resulted in an increasing but non-significant trend of acute stroke patients receiving thrombolysis within 60 minutes. Outcomes will be monitored for a longer duration to demonstrate trends and sustainability.
Collapse
Affiliation(s)
- Li Qi Chiu
- Department of Emergency Medicine, Tan Tock Seng Hospital, Singapore
| | | | | | - Wai May Ng
- Department of Neuroradiology, National Neuroscience Institute, Singapore
| | | | - Chiao-Hao Lee
- Department of Emergency Medicine, Tan Tock Seng Hospital, Singapore
| | | |
Collapse
|
15
|
Holodinsky JK, Onaemo VN, Whelan R, Hunter G, Graham BR, Hamilton J, Schwartz L, Latta L, Peeling L, Kelly ME. Implementation of a provincial acute stroke pathway and its impact on access to advanced stroke care in Saskatchewan. BMJ Open Qual 2021; 10:bmjoq-2020-001214. [PMID: 34385186 PMCID: PMC8362703 DOI: 10.1136/bmjoq-2020-001214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 07/27/2021] [Indexed: 11/04/2022] Open
Abstract
Background For ischaemic stroke, outcome severity is heavily time dependent. Systems of care need to be in place to ensure that patients with stroke are treated quickly and appropriately across entire health regions. Prior to this study, the province of Saskatchewan, Canada did not have a provincial stroke strategy in place. Methods A quality improvement project was undertaken to create and evaluate a provincial stroke strategy. The Saskatchewan Acute Stroke Pathway was created using a multidisciplinary team of experts, piloted at five stroke centres and then implemented provincially. The number of stroke alerts, door-to-imaging, door-to-needle, door-to-groin puncture times and treatment rates were collected at all centres. Improvements over time were analysed using run charts and individuals control charts. Results The number of stroke alerts province-wide trended upwards in the last 6 months of the study. There were no clear trends or shifts in the proportion of stroke alerts treated with alteplase or endovascular therapy. Across the province, the weighted mean door-to-imaging time decreased from 21 to 15 min, the weighted mean door-to-needle time decreased from 62 to 47 min and the mean door-to-groin puncture time decreased from 83 to 70 min. There was high variability in the degree of improvement from centre to centre. Conclusions The implementation of a province wide acute stroke pathway has led to improvement in stroke care on a provincial basis. Further work addressing intercentre variability is ongoing.
Collapse
Affiliation(s)
- Jessalyn K Holodinsky
- Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Vivian N Onaemo
- Ministry of Health, Government of Saskatchewan, Regina, Saskatchewan, Canada
| | - Ruth Whelan
- Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Gary Hunter
- Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Brett R Graham
- Division of Neurology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Jessica Hamilton
- Saskatchewan Health Quality Council, Saskatoon, Saskatchewan, Canada
| | - Laura Schwartz
- Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Lori Latta
- Ministry of Health, Government of Saskatchewan, Regina, Saskatchewan, Canada
| | - Lissa Peeling
- Division of Neurosurgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Michael E Kelly
- Division of Neurosurgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| |
Collapse
|
16
|
Sung SF, Hung LC, Hu YH. Developing a stroke alert trigger for clinical decision support at emergency triage using machine learning. Int J Med Inform 2021; 152:104505. [PMID: 34030088 DOI: 10.1016/j.ijmedinf.2021.104505] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/01/2021] [Accepted: 05/17/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Acute stroke is an urgent medical condition that requires immediate assessment and treatment. Prompt identification of patients with suspected stroke at emergency department (ED) triage followed by timely activation of code stroke systems is the key to successful management of stroke. While false negative detection of stroke may prevent patients from receiving optimal treatment, excessive false positive alarms will substantially burden stroke neurologists. This study aimed to develop a stroke-alert trigger to identify patients with suspected stroke at ED triage. METHODS Patients who arrived at the ED within 12 h of symptom onset and were suspected of a stroke or transient ischemic attack or triaged with a stroke-related symptom were included. Clinical features at ED triage were collected, including the presenting complaint, triage level, self-reported medical history (hypertension, diabetes, hyperlipidemia, heart disease, and prior stroke), vital signs, and presence of atrial fibrillation. Three rule-based algorithms, ie, Face Arm Speech Test (FAST) and two flavors of Balance, Eyes, FAST (BE-FAST), and six machine learning (ML) techniques with various resampling methods were used to build classifiers for identification of patients with suspected stroke. Logistic regression (LR) was used to find important features. RESULTS The study population consisted of 1361 patients. The values of area under the precision-recall curve (AUPRC) were 0.737, 0.710, and 0.562 for the FAST, BE-FAST-1, and BE-FAST-2 models, respectively. The values of AUPRC for the top three ML models were 0.787 for classification and regression tree with undersampling, 0.783 for LR with synthetic minority oversampling technique (SMOTE), and 0.782 for LR with class weighting. Among the ML models, logistic regression and random forest models in general achieved higher values of AUPRC, in particular in those with class weighting or SMOTE to handle class imbalance problem. In addition to the presenting complaint and triage level, age, diastolic blood pressure, body temperature, and pulse rate, were also important features for developing a stroke-alert trigger. CONCLUSIONS ML techniques significantly improved the performance of prediction models for identification of patients with suspected stroke. Such ML models can be embedded in the electronic triage system for clinical decision support at ED triage.
Collapse
Affiliation(s)
- Sheng-Feng Sung
- Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan; Department of Information Management and Institute of Healthcare Information Management, National Chung Cheng University, Chiayi County, Taiwan; Department of Nursing, Min-Hwei Junior College of Health Care Management, Tainan, Taiwan
| | - Ling-Chien Hung
- Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan
| | - Ya-Han Hu
- Department of Information Management, National Central University, Taoyuan City, Taiwan.
| |
Collapse
|
17
|
Zhou MH, Kansagra AP. Changes in Patient Volumes and Outcomes After Adding Thrombectomy Capability. Stroke 2021; 52:2143-2149. [PMID: 33866819 DOI: 10.1161/strokeaha.120.032389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE With the rising demand for endovascular thrombectomy (EVT) and introduction of thrombectomy-capable stroke centers (TSC), there is interest among existing stroke hospitals to add EVT capability to attract and retain stroke patient referrals. In this work, we quantify changes in patient volumes and outcomes when adding EVT capability to an existing stroke center. METHODS In MATLAB 2017a Simulink, we simulate a 3-center system comprising an EVT-capable comprehensive stroke center, an EVT-incapable primary stroke center, and an EVT-incapable primary stroke center that gains EVT capability (TSC). We model these changes in 2 geographic settings (urban and rural) using 2 routing paradigms (Nearest Center and Bypass). In Nearest Center, patients are sent to the nearest center regardless of EVT capability. In Bypass, patients with severe strokes are sent to the nearest EVT-capable center, and all others are sent to the nearest center. Probability of good clinical outcome is determined by type and timing of treatment using outcomes reported in clinical trials. RESULTS Adding EVT capability in the Bypass model produced an absolute increase of 40.1% in total volume of patients with stroke and 31.2% to 31.9% in total volume of acute stroke treatments at the TSC. In the Nearest Center model, the total volume of patients with stroke did not change, but total volume of acute stroke treatment at the TSC had an absolute increase of 9.3% to 9.5%. Good clinical outcomes saw an absolute increase of 0.2% to 0.6% in the whole population and 0.3% to 1.8% in the TSC population. CONCLUSIONS Adding EVT capability shifts patient and treatment volume to the TSC. However, these changes produce modest improvement in overall population health. Health systems should weigh relative hospital and patient benefits when considering adding EVT capability.
Collapse
Affiliation(s)
- Minerva H Zhou
- School of Medicine (M.H.Z.), Washington University, St. Louis, MO
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology (A.P.K.), Washington University, St. Louis, MO.,Department of Neurological Surgery (A.P.K.), Washington University, St. Louis, MO.,Department of Neurology (A.P.K.), Washington University, St. Louis, MO
| |
Collapse
|
18
|
Assessing the relationship of the human resource, finance, and information technology functions on reported performance in hospitals using the Lean management system. Health Care Manage Rev 2021; 46:145-152. [PMID: 33630506 DOI: 10.1097/hmr.0000000000000253] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Given pressures to control costs and improve quality of care, one of the most prevalent transformational performance improvement approaches in health care is Lean management. However, the roles of support functions such as human resource (HR), finance, and information technology (IT) in Lean management and the relationships of these support functions with performance are unknown. PURPOSE The aim of this study was to examine the relationships between the HR, finance, and IT functions, overall Lean implementation, and self-reported performance improvement in hospitals that have implemented Lean. METHODOLOGY/APPROACH Data from a national survey of Lean in U.S. hospitals (N = 1,222; 847 reported using Lean) were analyzed using multivariable regression and bootstrapped mediation analysis. The extent to which HR, finance, and IT functions support Lean management was measured using indices including six, three, and six items respectively. Lean implementation was measured by the number of units doing Lean (up to 29) and by a four-level self-reported maturity scale. Performance improvement was measured using an index of self-reported achievements (ranging from 0 to 16). RESULTS There were significant positive associations between Lean HR, finance, and IT functions and self-reported performance impact (controlling for organizational and market variables). Tests of mediation indicated that the associations of HR, finance, and IT functions with self-reported performance were significantly mediated by the number of Lean units (mediated proportion ranging from 40% to 73%), and HR function was also mediated by self-reported maturity (61% mediated). There were no moderating effects. CONCLUSION HR, finance, and IT functions are positively associated with self-reported Lean impact on performance and primarily explained by the overall degree of Lean implementation. PRACTICE IMPLICATIONS Efforts to align HR, finance, and IT functions with overall Lean implementation can help to ensure that frontline caregivers and managers have the data and skills required to meet transformational improvement goals.
Collapse
|
19
|
Zhou MH, Kansagra AP. Population health impact of extended window thrombectomy in acute ischemic stroke. Interv Neuroradiol 2020; 27:516-522. [PMID: 33153379 DOI: 10.1177/1591019920972209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Recent trials support endovascular thrombectomy (EVT) in select patients beyond the conventional 6-hour window. OBJECTIVE In this work, we estimate the impact of extended window EVT on procedural volumes and population-level clinical outcomes using Monte Carlo simulation. METHODS We simulated extending EVT eligibility in a system comprising an EVT-incapable primary stroke center (PSC) and EVT-capable comprehensive stroke center (CSC) using routing paradigms that initially direct patients to (1) the nearest center, (2) the CSC, or (3) either CSC or nearest center based on stroke severity. EVT eligibility and outcomes are based on HERMES, DEFUSE-3, and DAWN studies in the 0-6, 6-16, and 16-24 hour windows, respectively. Probability of good clinical outcome is determined by type and timing of treatment using clinical trial data. RESULTS Relative increase in EVT volume in the three tested routing paradigms was 15.7-15.8%. The absolute increase in the rate of good clinical outcome 0.4% in all routing paradigms. NNT for extended window EVT was 239.9-246.4 among the entire stroke population. CONCLUSION Extended window EVT with DEFUSE-3 and DAWN criteria increases EVT volume and modestly improves population-level clinical outcomes.
Collapse
Affiliation(s)
- Minerva H Zhou
- School of Medicine, Washington University, St. Louis, MO, USA
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA.,Department of Neurological Surgery, Washington University, St. Louis, MO, USA.,Department of Neurology, Washington University, St. Louis, MO, USA
| |
Collapse
|
20
|
Dhand S, O'Connor P, Hughes C, Lin SP. Acute Ischemic Stroke: Acute Management and Selection for Endovascular Therapy. Semin Intervent Radiol 2020; 37:109-118. [PMID: 32419723 PMCID: PMC7224969 DOI: 10.1055/s-0040-1709152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Stroke is a medical emergency and expeditious treatment is critical to reducing permanent disability or death. Acute management of patients suffering from acute ischemic stroke (AIS) requires early recognition of symptoms, rapid assessment and stabilization (hyperacute workup), and appropriate selection of patients for reperfusion with intravenous alteplase and/or mechanical thrombectomy. Established stroke protocols which involve both prehospital emergency medical services and in-hospital multidisciplinary stroke teams have been shown to be crucial to reducing the long term, devastating effects of stroke.
Collapse
Affiliation(s)
- Sabeen Dhand
- Department of Radiology, Lambert Radiology Medical Group at PIH Health, Whittier, California
| | - Paul O'Connor
- Department of Radiology, Lambert Radiology Medical Group at PIH Health, Whittier, California
| | - Charles Hughes
- Department of Neuroscience, University of California Los Angeles, Los Angeles, California
| | - Shao-Pow Lin
- Department of Radiology, Lambert Radiology Medical Group at PIH Health, Whittier, California
| |
Collapse
|
21
|
Rudd AG, Bladin C, Carli P, De Silva DA, Field TS, Jauch EC, Kudenchuk P, Kurz MW, Lærdal T, Ong M, Panagos P, Ranta A, Rutan C, Sayre MR, Schonau L, Shin SD, Waters D, Lippert F. Utstein recommendation for emergency stroke care. Int J Stroke 2020; 15:555-564. [PMID: 32223543 PMCID: PMC7672780 DOI: 10.1177/1747493020915135] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Recent advances in treatment for stroke give new possibilities for optimizing
outcomes. To deliver these prehospital care needs to become more
efficient. Aim To develop a framework to support improved delivery of prehospital care. The
recommendations are aimed at clinicians involved in prehospital and
emergency health systems who will often not be stroke specialists but need
clear guidance as to how to develop and deliver safe and effective care for
acute stroke patients. Methods Building on the successful implementation program from the Global
Resuscitation Alliance and the Resuscitation Academy, the Utstein
methodology was used to define a generic chain of survival for Emergency
Stroke Care by assembling international expertise in Stroke and Emergency
Medical Services (EMS). Ten programs were identified for Acute Stroke Care
to improve survival and outcomes, with recommendations for implementation of
best practice. Conclusions Efficient prehospital systems for acute stroke will be improved through
public awareness, optimized prehospital triage and timely diagnostics, and
quick and equitable access to acute treatments. Documentation, use of
metrics and transparency will help to build a culture of excellence and
accountability.
Collapse
Affiliation(s)
- A G Rudd
- NHS England and King's College, London, England
| | - C Bladin
- Eastern Health Monash University, Melbourne, Australia
| | - P Carli
- Emergency Medical Services, Paris, France
| | - D A De Silva
- National Neuroscience Institute, Singapore General Hospital, Singapore
| | - T S Field
- University of British Columbia, Vancouver, Canada
| | - E C Jauch
- Mission Health System, Asheville, USA
| | - P Kudenchuk
- University of Washington School of Medicine, Seattle, WA, USA
| | - M W Kurz
- Stavanger University Hospital, Stavanger, Norway
| | - T Lærdal
- The Laerdal Foundation, Stavanger, Norway
| | - Meh Ong
- Singapore General Hospital and Duke-NUS Medical School, Singapore, Singapore
| | - P Panagos
- Washington University School of Medicine, St. Louis, MO, USA
| | - A Ranta
- University of Otago, Dunedin, New Zealand
| | - C Rutan
- American Heart Association, Dallas, TX, USA
| | | | - L Schonau
- Danish Resuscitation Council, Copenhagen, Denmark
| | - S D Shin
- Seoul National University College of Medicine, Seoul, South Korea
| | - D Waters
- Ambulance New Zealand, Wellington, New Zealand
| | - F Lippert
- Copenhagen Emergency Medical Services, Copenhagen, Denmark
| |
Collapse
|
22
|
Tlapa D, Zepeda-Lugo CA, Tortorella GL, Baez-Lopez YA, Limon-Romero J, Alvarado-Iniesta A, Rodriguez-Borbon MI. Effects of Lean Healthcare on Patient Flow: A Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:260-273. [PMID: 32113632 DOI: 10.1016/j.jval.2019.11.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 11/01/2019] [Accepted: 11/14/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To assess the effects of lean healthcare (LH) on patient flow in ambulatory care and determine whether waiting time and length of stay (LOS) decrease after LH interventions. METHODS A systematic review was performed with close adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We searched for studies of healthcare organizations applying LH interventions within ambulatory care published between 2002 and 2018. Six databases and grey literature sources were used. Two reviewers independently screened and assessed each study. When consensus was difficult to reach, a third reviewer intervened. Finally, a summary of findings was generated. RESULTS Out of 5627 studies, 40 were included. Regarding LOS for all patients, 19 out of 22 studies reported a decrease. LOS for discharged patients decreased in 11 out of 13 studies, whereas LOS for admitted patients was reduced in 6 out of 7 studies. Waiting time for patients before seeing a healthcare professional decreased in 24 out of 26 studies. Waiting time to treatment and waiting time for appointments were minimized in 4 and 2 studies, respectively. Patients who left without being seen by a doctor decreased in 9 out of 12 studies. Finally, patient and staff satisfaction were measured in 8 and 2 studies, respectively, with each reporting improvements. CONCLUSIONS According to our findings, LH helped to reduce waiting time and LOS in ambulatory care, mainly owing to its focus on identifying and minimizing non-value added (NVA) activities. Nevertheless, evidence of the impact of LH on patient/staff satisfaction and the translation of the obtained benefits into savings is scarce among studies.
Collapse
Affiliation(s)
- Diego Tlapa
- Universidad Autónoma de Baja California, Ensenada, Baja California, Mexico.
| | | | | | | | - Jorge Limon-Romero
- Universidad Autónoma de Baja California, Ensenada, Baja California, Mexico
| | | | | |
Collapse
|
23
|
Is Door-to-Needle Time Reduced for Emergency Medical Services Transported Stroke Patients Routed Directly to the Computed Tomography Scanner on Emergency Department Arrival? J Stroke Cerebrovasc Dis 2020; 29:104477. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104477] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 09/12/2019] [Accepted: 10/09/2019] [Indexed: 11/18/2022] Open
|
24
|
Laberge M, Côté A, Ruiz A. Clinical pathway efficiency for elective joint replacement surgeries: a case study. J Health Organ Manag 2019; 33:323-338. [PMID: 31122119 DOI: 10.1108/jhom-03-2018-0087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this paper is to define a clinical pathway for total joint replacement (TJR) surgery, estimate the effect of delays between steps of the pathway on wait time for surgery and to identify factors contributing to more efficient operations and challenges to their implementation. DESIGN/METHODOLOGY/APPROACH This is a case study with a mixed methods approach. The authors conducted interviews with hospital staff. Data collected in the interviews and through on-site observation were analyzed to map the TJR process and identify the steps of the care pathway. The authors extracted and analyzed data (time stamps) from 60 hospital patient records for each step in the pathway and ran a regression on the duration of the whole trajectory. FINDINGS There were wide variations in the delays observed between the seven steps identified. The delay between Step 1 and Step 2 was the only significant variable in predicting the total wait time to surgery. In one hospital, one delay explained 50 percent of the variation. There was misalignment between findings from the qualitative data in terms of strategies implemented to increase efficiency of the clinical pathway to the quantitative data on delays between the steps. RESEARCH LIMITATIONS/IMPLICATIONS The study identified the clinical pathway from the consultation with an orthopaedic surgeon to the surgery. However, it did not go beyond the surgery. Future research could investigate the relationship between specific processes and delays between steps of the process and patient outcomes, including length of stay, mobilization and functionality in activities of daily living, as well as potential complications from surgery, readmission and the services required after the patient was discharged. PRACTICAL IMPLICATIONS Wait times can be addressed by implementing strategies at the health system level or at the organizational level. The authors found and discuss areas where there could be efficiency gains for health care organizations. SOCIAL IMPLICATIONS Stakeholders in care processes are diverse and they each have their preferences in how they practice (in the case of providers) and how they perceive and wish to respond adequately to patients' needs in contexts that have different norms and approaches. The approach in this study enables a better understanding of the processes, the organizational culture and how these may affect each other. ORIGINALITY/VALUE Our mixed methods enabled a process mapping and the identification of factors that significantly affected the efficiency of the TJR surgery process. It combines methods from process engineering with health services and management research. To some extent, this study demonstrates that although managers can define and enforce processes, organizational culture and practices are harder to influence.
Collapse
Affiliation(s)
- Maude Laberge
- Department of Operations and Decision Systems, Universite Laval Faculte des sciences de l'administration , Quebec, Canada
| | - André Côté
- Department of Operations and Decision Systems, Universite Laval Faculte des sciences de l'administration , Quebec, Canada
| | - Angel Ruiz
- Department of Operations and Decision Systems, Universite Laval Faculte des sciences de l'administration , Quebec, Canada
| |
Collapse
|
25
|
Use of Lean and Related Transformational Performance Improvement Systems in Hospitals in the United States: Results From a National Survey. Jt Comm J Qual Patient Saf 2019; 44:574-582. [PMID: 30243359 DOI: 10.1016/j.jcjq.2018.03.002] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 03/13/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND The health care system in the United States is costly with high variance in quality. There is growing interest in transformational performance improvement initiatives, such as the Lean management system, to eliminate waste and inefficiency and improve quality of care for patients. METHODS A national survey of all 4,500 short-term acute general medical/surgical and pediatric hospitals in the United States was fielded between May and September 2017 by the Survey Data Center of the American Hospital Association. RESULTS Responses were received from 1,222 hospitals (27.3% response rate). Sixty-nine percent (69.3%) reported use Lean or related Lean plus Six Sigma or Robust Process Improvement approaches. Not-for-profit hospitals, hospitals located in metro/urban areas, those belonging to a system/network, and those with 100-399 beds were most likely to be engaged in these activities and for an average of 5.2 years. However, only 12.6% (n = 102) of hospitals reported being at a mature hospitalwide stage of implementation. The degree of maturity, leadership commitment, daily management system use, and training were each positively associated with reported positive performance outcomes. CONCLUSION A majority of hospitals have adopted Lean-based transformational performance improvement approaches but with wide variance in the degree of implementation. It takes time for Lean to gain traction. The length of time doing Lean is positively associated with implementation progress and reported positive performance impacts. The extent to which Lean has an organizationwide performance impact awaits further research that links the variables in this study with objective cost and quality measures.
Collapse
|
26
|
Rotter T, Plishka C, Lawal A, Harrison L, Sari N, Goodridge D, Flynn R, Chan J, Fiander M, Poksinska B, Willoughby K, Kinsman L. What Is Lean Management in Health Care? Development of an Operational Definition for a Cochrane Systematic Review. Eval Health Prof 2019; 42:366-390. [PMID: 29635950 PMCID: PMC6659584 DOI: 10.1177/0163278718756992] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Industrial improvement approaches such as Lean management are increasingly being adopted in health care. Synthesis is necessary to ensure these approaches are evidence based and requires operationalization of concepts to ensure all relevant studies are included. This article outlines the process utilized to develop an operational definition of Lean in health care. The literature search, screening, data extraction, and data synthesis processes followed the recommendations outlined by the Cochrane Collaboration. Development of the operational definition utilized the methods prescribed by Kinsman et al. and Wieland et al. This involved extracting characteristics of Lean, synthesizing similar components to establish an operational definition, applying this definition, and updating the definition to address shortcomings. We identified two defining characteristics of Lean health-care management: (1) Lean philosophy, consisting of Lean principles and continuous improvement, and (2) Lean activities, which include Lean assessment activities and Lean improvement activities. The resulting operational definition requires that an organization or subunit of an organization had integrated Lean philosophy into the organization's mandate, guidelines, or policies and utilized at least one Lean assessment activity or Lean improvement activity. This operational definition of Lean management in health care will act as an objective screening criterion for our systematic review. To our knowledge, this is the first evidence-based operational definition of Lean management in health care.
Collapse
Affiliation(s)
- Thomas Rotter
- Healthcare Quality Programs, School of Nursing, Queen's University,
Kingston, Canada
| | - Christopher Plishka
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon,
Canada
| | - Adegboyega Lawal
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon,
Canada
| | - Liz Harrison
- School of Rehabilitation Science, College of Medicine, University of
Saskatchewan, Saskatoon, Canada
| | - Nazmi Sari
- Department of Economics, University of Saskatchewan, Saskatoon, Canada
| | - Donna Goodridge
- College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Rachel Flynn
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - James Chan
- School of Health Sciences, University of Northern British Columbia,
Canada
| | - Michelle Fiander
- Assistant Research Professor, College of Pharmacy, Department of
Pharmacotherapy, University of Utah
| | - Bonnie Poksinska
- Department of Management and Engineering, Linköping University, Sweden
| | - Keith Willoughby
- Edwards School of Business, University of Saskatchewan, Saskatoon,
Canada
| | - Leigh Kinsman
- University of Tasmania and Tasmanian Health Service (North), Launceston,
Tasmania, Australia
| |
Collapse
|
27
|
Improving Door-to-needle Times in the Treatment of Acute Ischemic Stroke Across a Canadian Province: Methodology. Crit Pathw Cardiol 2019; 18:51-56. [PMID: 30747766 DOI: 10.1097/hpc.0000000000000173] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Alteplase is a proven medical treatment for acute ischemic stroke; however, the effectiveness of this treatment is highly time dependent. Therefore, it is imperative that hospitals treat acute ischemic stroke patients as quickly as possible. The measure, door-to-needle time, is the time from hospital arrival to when alteplase administration begins. OBJECTIVE The goal in the Canadian province of Alberta was to reduce the door-to-needle time to a median of 30 minutes and to increase the percent of patients treated within 60 minutes to 90%. OVERVIEW OF METHODOLOGY A modified version of Institute for Healthcare Improvement Breakthrough Series Collaborative was used. All stroke centers self-enrolled into the collaborative after initial contact, and sites created interdisciplinary teams to participate in the Collaborative. Leadership and faculty were highly experienced in quality improvement and acute stroke. There were 3 daylong face-to-face learning sessions that were attended by enrolled teams, which included presentation about the evidence, site presentations to promote cross-site learning, and time to plan changes with their teams. The sites were also supported by site visits, webinars, and data feedback.
Collapse
|
28
|
Kansagra AP, Wallace AN, Curfman DR, McEachern JD, Moran CJ, Cross DT, Lee JM, Ford AL, Manu SG, Panagos PD, Derdeyn CP. Streamlined triage and transfer protocols improve door-to-puncture time for endovascular thrombectomy in acute ischemic stroke. Clin Neurol Neurosurg 2019; 166:71-75. [PMID: 29408777 DOI: 10.1016/j.clineuro.2018.01.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 01/10/2018] [Accepted: 01/22/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Shorter time from symptom onset to treatment is associated with improved outcomes in patients who undergo mechanical thrombectomy for treatment of acute ischemic stroke due to emergent large vessel occlusion. In this work, we detail pre-thrombectomy process improvements in a multi-hospital network and report the effect on door-to-puncture time in patients undergoing mechanical thrombectomy. PATIENTS AND METHODS A streamlined workflow was adopted to minimize door-to-puncture time. Key features of this workflow included rapid and concurrent clinical and radiological evaluation with point-of-care image interpretation, pre-transfer IV thrombolysis and CTA for transferred patients, immediate transport to the angiography suite potentially before neurointerventional radiology team arrival, and minimalist room setup. Door-to-puncture time was measured prospectively and analyzed retrospectively for 78 consecutive patients treated between January 2015 and December 2015. Statistical analysis was performed using the F-test on individual coefficients of a linear regression model. RESULTS From quarter 1 to quarter 4, the number of thrombectomies performed increased by 173% (11 patients to 30 patients, p = 0.002), and there was a significant increase in the proportion of transferred patients that underwent pre-transfer CTA (p = 0.04). During this interval, overall median door-to-puncture time decreased by 74% (147 min to 39 min, p < 0.001); this decrease was greatest in transferred patients with pre-transfer CTA (81% decrease, 129 min to 25 min, p < 0.001) and smallest in patients presenting directly to the emergency department (52% decrease, 167 min to 87 min, p < 0.001). CONCLUSION Simple workflow improvements to streamline in-hospital triage and perform critical workup at transferring hospitals can produce reductions in door-to-puncture time.
Collapse
Affiliation(s)
- Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, United States; Department of Neurosurgery, Washington University School of Medicine, United States; Department of Neurology, Washington University School of Medicine, United States.
| | - Adam N Wallace
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, United States
| | - David R Curfman
- Department of Neurology, Washington University School of Medicine, United States
| | - James D McEachern
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, United States
| | - Christopher J Moran
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, United States; Department of Neurosurgery, Washington University School of Medicine, United States
| | - DeWitte T Cross
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, United States; Department of Neurosurgery, Washington University School of Medicine, United States
| | - Jin-Moo Lee
- Department of Neurology, Washington University School of Medicine, United States
| | - Andria L Ford
- Department of Neurology, Washington University School of Medicine, United States
| | - S Goyal Manu
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, United States
| | - Peter D Panagos
- Department of Neurology, Washington University School of Medicine, United States; Department of Emergency Medicine, Washington University School of Medicine, United States
| | - Colin P Derdeyn
- Department of Radiology, University of Iowa Hospitals and Clinics, United States
| |
Collapse
|
29
|
Zhou MH, Kansagra AP. Effect of routing paradigm on patient centered outcomes in acute ischemic stroke. J Neurointerv Surg 2019; 11:762-767. [DOI: 10.1136/neurintsurg-2018-014537] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 11/28/2018] [Accepted: 12/06/2018] [Indexed: 11/04/2022]
Abstract
BackgroundTo compare performance of routing paradigms for patients with acute ischemic stroke using clinical outcomes.MethodsWe simulated different routing paradigms in a system comprising one primary stroke center (PSC) and one comprehensive stroke center (CSC), separated by distances representative of urban, suburban, and rural environments. In the nearest center paradigm, patients are initially sent to the nearest center, while in CSC first, patients are sent to the CSC. In the Rhode Island and distributive paradigms, patients with a FAST-ED (Facial palsy, Arm weakness, Speech changes, Time, Eye deviation, and Denial/neglect) score ≥4 are sent to the CSC, while others are sent to the nearest center or PSC, respectively. Performance and efficiency were compared using rates of good clinical outcome, determined by type and timing of treatment using clinical trial data, and number needed to bypass (NNB).ResultsGood clinical outcome was achieved in 43.76% of patients in nearest center, 44.48% in CSC first, and 44.44% in Rhode Island and distributive in an urban setting; 43.38% in nearest center, 44.19% in CSC first, and 44.17% in Rhode Island in a suburban setting; and 41.10% in nearest center, 43.20% in CSC first, and 42.73% in Rhode Island in a rural setting. In all settings, NNB was generally higher for CSC first compared with Rhode Island or distributive.ConclusionRouting paradigms that allow bypass of nearer hospitals for thrombectomy capable centers improve population level patient outcomes. Differences are more pronounced with increasing distance between hospitals; therefore, paradigm choice may be most impactful in rural settings. Selective bypass, as implemented in the Rhode Island and distributive paradigms, improves system efficiency with minimal impact on outcomes.
Collapse
|
30
|
Reducing Door-to-Needle Times for Ischaemic Stroke to a Median of 30 Minutes at a Community Hospital. Can J Neurol Sci 2018; 46:51-56. [PMID: 30516454 DOI: 10.1017/cjn.2018.368] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Alteplase is an effective treatment for ischaemic stroke patients, and it is widely available at all primary stroke centres. The effectiveness of alteplase is highly time-dependent. Large tertiary centres have reported significant improvements in their door-to-needle (DTN) times. However, these same improvements have not been reported at community hospitals. METHODS Red Deer Regional Hospital Centre (RDRHC) is a community hospital of 370 beds that serves approximately 150,000 people in their acute stroke catchment area. The RDRHC participated in a provincial DTN improvement initiative, and implemented a streamlined algorithm for the treatment of stroke patients. During this intervention period, they implemented the following changes: early alert of an incoming acute stroke patient to the neurologist and care team, meeting the patient immediately upon arrival, parallel work processes, keeping the patient on the Emergency Medical Service stretcher to the CT scanner, and administering alteplase in the imaging area. Door-to-needle data were collected from July 2007 to December 2017. RESULTS A total of 289 patients were treated from July 2007 to December 2017. In the pre-intervention period, 165 patients received alteplase and the median DTN time was 77 minutes [interquartile range (IQR): 60-103 minutes]; in the post-intervention period, 104 patients received alteplase and the median DTN time was 30 minutes (IQR: 22-42 minutes) (p < 0.001). The annual number of patients that received alteplase increased from 9 to 29 in the pre-intervention period to annual numbers of 41 to 63 patients in the post-intervention period. CONCLUSION Community hospitals staffed with community neurologists can achieve median DTN times of 30 minutes or less.
Collapse
|
31
|
Munce SEP, Perrier L, Shin S, Adhihetty C, Pitzul K, Nelson MLA, Bayley MT. Impact of quality improvement strategies on the quality of life of individuals post-stroke: a systematic review. Disabil Rehabil 2018; 42:1055-1061. [DOI: 10.1080/09638288.2018.1512163] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Sarah E. P. Munce
- Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, University of Toronto, Toronto, Canada
| | - Laure Perrier
- Gerstein Science Information Centre, University of Toronto, Toronto, Canada
| | - Saeha Shin
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Chamila Adhihetty
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Kristen Pitzul
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Michelle L. A. Nelson
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Sinai Health System, Lunenfeld-Tanenbaum Research Institute, Toronto, Canada
| | - Mark T. Bayley
- Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| |
Collapse
|
32
|
Jauch EC, Holmstedt CA. Fast Protocol for Treating Acute Ischemic Stroke by Emergency Physicians: What Took So Long? Ann Emerg Med 2018; 73:113-115. [PMID: 30420233 DOI: 10.1016/j.annemergmed.2018.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Edward C Jauch
- Mission Research Institute/Mission Health System, Asheville, NC.
| | - Christine A Holmstedt
- Departments of Neurology and Emergency Medicine, MUSC Health Comprehensive Stroke Program, and MUSC Health Teleneuroscience Program, Medical University of South Carolina, Charleston, SC
| |
Collapse
|
33
|
Bhatt N, Marulanda-Londoño ET, Atchaneeyasakul K, Malik AM, Asdaghi N, Akram N, D'Amour D, Hesse K, Zhang T, Sacco RL, Romano JG. Target Stroke: Best Practice Strategies Cut Door to Thrombolysis Time to <30 Minutes in a Large Urban Academic Comprehensive Stroke Center. Neurohospitalist 2018; 9:22-25. [PMID: 30671160 DOI: 10.1177/1941874418801443] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The therapeutic window for acute ischemic stroke with intravenous recombinant tissue plasminogen activator (IV rt-PA) is brief and crucial. The American Heart Association/American Stroke Association Target: Stroke Best Practice Strategies (TSBPS) aim to improve intravenous thrombolysis door-to-needle (DTN) time. We assessed the efficacy of implementation of selected TSBPS to reduce DTN time in a large tertiary care hospital. A multidisciplinary DTN committee assessed causes of delayed DTN time and implemented focused TSBPS in our urban academic medical center. We analyzed door-to-CT time, DTN time, and CT to IV rt-PA time in consecutive patients treated with IV rt-PA over 27 months preimplementation and 13 months postimplementation. One hundred forty-eight patients were included in the preimplementation and 126 in the postimplementation group. We found no significant difference between the groups in demographics, comorbidities, anticoagulation status, prethrombolysis hypertension treatment, arrival by EMS, after-hours arrival, or in stroke etiology. After implementation, median DTN time improved from 59 (interquartile range [IQR]: 52-80) to 29 (IQR: 20-41) minutes (P < .001). Door-to-CT time decreased from 17 (14-21) to 16 (12-19) minutes (P = .016), and CT-to-IV rt-PA time improved from 43 (IQR: 31-59) to 13 (IQR: 6-23) minutes (P < .001). Rates of symptomatic intracranial hemorrhage (2.7% vs 3.2%, P = .82) and treatment of stroke mimics (9% vs 13%, P = .31) were similar in both the groups. Individualized hospital gap analysis identifies targeted interventions that lead to rapid and sustained improvement in treatment times.
Collapse
Affiliation(s)
- Nirav Bhatt
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA.,Share the first authorship for this manuscript
| | - Erika T Marulanda-Londoño
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA.,Share the first authorship for this manuscript
| | | | - Amer M Malik
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Negar Asdaghi
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Nida Akram
- Jackson Memorial Hospital, Miami, FL, USA
| | | | | | - Tony Zhang
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ralph L Sacco
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jose G Romano
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| |
Collapse
|
34
|
Han JH, Jang S, Choi MO, Yoon MJ, Lim SB, Kook JR, Kang DW, Kwon SU, Kim JS, Jeon SB. Point-of-care coagulation testing for reducing in-hospital delay in thrombolysis. HONG KONG J EMERG ME 2018. [DOI: 10.1177/1024907918799938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: The confirmation of prothrombin time international normalized ratio by a central laboratory often delays intravenous thrombolysis in patients with acute ischemic stroke. Objectives: We investigated the feasibility, reliability, and usefulness of point-of-care determination of prothrombin time international normalized ratio for stroke thrombolysis. Methods: Among 312 patients with ischemic stroke, 202 who arrived at the emergency room within 4.5 h of stroke onset were enrolled in the study. Patients with lost orders for point-of-care testing for the prothrombin time international normalized ratio or central laboratory testing for the prothrombin time international normalized ratio (n = 47) were excluded. We compared international normalized ratio values and the time interval from arrival to the report of test results (door-to-international normalized ratio time) between point-of-care testing for the prothrombin time international normalized ratio and central laboratory testing for the prothrombin time international normalized ratio. In patients who underwent thrombolysis, we compared the time interval from arrival to thrombolysis (door-to-needle time) between the current study population and historic cohort at our center. Results: In the 155 patients included in the study, the median door-to-international normalized ratio time was 9.0 min (interquartile range, 5.0–12.0 min) for point-of-care testing for the prothrombin time international normalized ratio and 46.0 min (interquartile range, 38.0–55.0 min) for central laboratory testing for the prothrombin time international normalized ratio (p < 0.001). The intraclass correlation coefficient between point-of-care testing for the prothrombin time international normalized ratio and central laboratory testing for the prothrombin time international normalized ratio was 0.975 (95% confidence interval: 0.966–0.982). Forty-nine of the 155 patients underwent intravenous thrombolysis. The door-to-needle time was significantly decreased after implementation of point-of-care testing for the prothrombin time international normalized ratio (median, 23.0 min; interquartile range, 16.0–29.8 vs median, 46.0 min; interquartile range, 33.5–50.5 min). Conclusion: Utilization of point-of-care testing for the prothrombin time international normalized ratio was feasible in the management of patients with acute ischemic stroke. Point-of-care testing for the prothrombin time international normalized ratio was quick and reliable and had a pivotal role in expediting thrombolysis.
Collapse
Affiliation(s)
- Jung Hee Han
- Department of Nursing, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seongsoo Jang
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mi-Ok Choi
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mi-Jeong Yoon
- Department of Nursing, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seung-Bok Lim
- Department of Nursing, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jeong-Ran Kook
- Department of Nursing, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong-Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sun U Kwon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong S Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Beom Jeon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
35
|
Derdeyn C. The Powerful Benefit of Endovascular Thrombectomy for Acute Ischemic Stroke: Driving Major Changes in Stroke Systems of Care and Imaging Triage. Radiology 2018; 288:527-528. [DOI: 10.1148/radiol.2018180641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Colin Derdeyn
- From the Department of Radiology, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Room 3962 JPP, Iowa City, IA 52240
| |
Collapse
|
36
|
Zhou MH, Kansagra AP. Effect of routing paradigm on patient-centered outcomes in acute ischemic stroke. J Neurointerv Surg 2018; 11:251-256. [PMID: 29970618 DOI: 10.1136/neurintsurg-2018-013994] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/04/2018] [Accepted: 06/13/2018] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To compare performance of routing paradigms for patients with acute ischemic stroke using clinical outcomes. METHODS We simulated different routing paradigms in a system comprising one primary stroke center (PSC) and onecomprehensive stroke center (CSC), separated by distances representative of urban, suburban, and rural environments. In the Nearest Center paradigm, patients are initially sent to the nearest center, while in CSC First, patients are sent to the CSC. In Rhode Island and Distributive paradigms, patients with Field Assessment Stroke Triage for Emergency Destination (FAST-ED) score ≥4 are sent to the CSC, while others are sent to the nearest center or PSC, respectively. Performance and efficiency were compared using rates of good clinical outcome determined by type and timing of treatment using clinical trial data and number needed to bypass (NNB). RESULTS Good clinical outcome was achieved in 43.67% of patients in Nearest Center and 44.62% in CSC First, Rhode Island, and Distributive in an urban setting; 42.79% in Nearest Center and 43.97% in CSC First and Rhode Island in a suburban setting; and 39.76% in Nearest Center, 41.73% in CSC First, and 41.59% in Rhode Island in a rural setting. In all settings, the NNB was considerably higher for CSC First than for Rhode Island or Distributive. CONCLUSION Routing paradigms that allow bypass of nearer hospitals for thrombectomy-capable centers improve population-level patient outcomes. Differences are more pronounced with increasing distance between hospitals; therefore, the choice of model may have greater effect in rural settings. Selective bypass, as implemented in Rhode Island and Distributive paradigms, improves system efficiency with minimal effect on outcomes.
Collapse
Affiliation(s)
- Minerva H Zhou
- School of Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri, USA.,Department of Neurological Surgery, Washington University School of Medicine, St Louis, Missouri, USA.,Department of Neurology, Washington University School of Medicine, St Louis, Missouri, USA
| |
Collapse
|
37
|
Tan BY, Ngiam NJ, Sunny S, Kong WY, Tam H, Sim TB, Leong BS, Bhartendu C, Paliwal PR, Seet RC, Chan BP, Teoh HL, Sharma VK, Yeo LL. Improvement in Door-to-Needle Time in Patients with Acute Ischemic Stroke via a Simple Stroke Activation Protocol. J Stroke Cerebrovasc Dis 2018; 27:1539-1545. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.01.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 11/30/2017] [Accepted: 01/01/2018] [Indexed: 12/26/2022] Open
|
38
|
Huang Q, Zhang JZ, Xu WD, Wu J. Generalization of the right acute stroke promotive strategies in reducing delays of intravenous thrombolysis for acute ischemic stroke: A meta-analysis. Medicine (Baltimore) 2018; 97:e11205. [PMID: 29924046 PMCID: PMC6024468 DOI: 10.1097/md.0000000000011205] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The generalization of successful efforts for reducing time delays in intravenous thrombolysis (IVT) could help facilitate its utility and benefits in acute ischemic stroke (AIS) patients.We searched the PubMed and Embase databases for articles reporting interventions to reduce time delays in IVT, published between January 1995 and September 2017. The IVT rate was chosen as the primary outcome, while the compliance rates of onset-to-door time (prehospital delay) and door-to-needle time (in-hospital delay) within the targeted time frame were the secondary outcomes. Interventions designed to reduce prehospital, in-hospital, or total time delays were quantitatively described in meta-analyses. The efficacy of postintervention improvement was illustrated as odds ratios (ORs) and 95% confidence intervals (95% CIs).In total, 86 papers (17 on prehospital, 56 on in-hospital, and 13 on total delay) encompassing 17,665 IVT cases were enrolled, including 28 American, 23 Asian, 30 European, and 5 Australian studies. The meta-analysis revealed statistically significant improvement in promoting IVT delivery after prehospital improvement interventions with an OR of 1.45 (95% CI, 1.23-1.71) for the new transportation protocol, 1.38 (95% CI, 1.11-1.73) for educational and training programs, and 1.83 (95% CI, 1.44-2.32) for comprehensive prehospital stroke code. The benefits of reducing in-hospital delay were much greater in developed western countries than in Asian countries, with ORs of 2.90 (95% CI, 2.51-3.34), 2.17 (95% CI, 1.95-2.41), and 1.89 (95% CI, 1.74-2.04) in American, European, and Asian countries, respectively. And telemedicine (OR, 2.26; 95% CI, 2.08-2.46) seemed to work better than pre-notification alone (OR, 1.94; 95% CI, 1.74-2.17) and in-hospital organizational improvement programs (OR, 2.10; 95% CI, 1.97-2.23). Mobile stroke treatment unit and use of a comprehensive stroke pathway in the pre- and in-hospital settings significantly increased IVT rates by reducing total time delay, with ORs of 2.01 (95% CI, 1.60-2.51) and 1.77 (95% CI, 1.55-2.03), respectively.Optimization of the work flow with organizational improvement or novel technology could dramatically reduce pre- and in-hospital time delays of IVT in AIS. This study provided detailed information on the net and quantitative benefits of various programs for reducing time delays to facilitate the generalization of appropriate AIS management.
Collapse
Affiliation(s)
- Qiang Huang
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University
| | - Jing-ze Zhang
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University
| | - Wen-deng Xu
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University
| | - Jian Wu
- Department of Neurology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| |
Collapse
|
39
|
Sablot D, Ion I, Khlifa K, Farouil G, Leibinger F, Gaillard N, Laverdure A, Bensalah Z, Mas J, Fadat B, Smadja P, Ferraro-Allou A, Bonnec JM, Olivier N, Dutray A, Tardieu M, Dumitrana A, Guibal A, Jurici S, Bertrand JL, Allou T, Arquizan C, Bonafe A. Target Door-to-Needle Time for Tissue Plasminogen Activator Treatment with Magnetic Resonance Imaging Screening Can Be Reduced to 45 min. Cerebrovasc Dis 2018; 45:245-251. [DOI: 10.1159/000489568] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 04/24/2018] [Indexed: 01/19/2023] Open
Abstract
Objective: The purpose of this study was to demonstrate that the median door-to-needle (DTN) time for intravenous tissue plasminogen activator (tPA) treatment can be reduced to 45 min in a primary stroke centre with MRI-based screening for acute ischaemic stroke (AIS). Methods: From February 2015 to February 2017, the stroke unit of Perpignan general hospital, France, implemented a quality-improvement (QI) process. During this period, patients who received tPA within 4.5 h after AIS onset were included in the QI cohort. Their clinical characteristics and timing metrics were compared each semester and also with those of 135 consecutive patients with AIS treated by tPA during the 1-year pre-QI period (pre-QI cohort). Results: In the QI cohort, 274 patients (92.5%) underwent MRI screening. While the demographic and baseline characteristics were not significantly different between cohorts, the median DTN time was significantly lower in the QI than in the pre-QI cohort (52 vs. 84 min; p < 0.00001). Within the QI cohort, the median DTN time for each semester decreased from 65 to 44 min (p < 0.00001) and the proportion of treated patients with a DTN time ≤45 min increased from 25 to 58.9% (p < 0.0001). Overall, DTN time improvement was associated with a better outcome at 3 months (patients with a modified Rankin Scale score between 0 and 2: 61.8% in the QI vs. 39.3% in the pre-QI cohort; p < 0.0001). Conclusions: A QI process can reduce the DTN within 45 min with MRI as a screening tool.
Collapse
|
40
|
Wu TY, Coleman E, Wright SL, Mason DF, Reimers J, Duncan R, Griffiths M, Hurrell M, Dixon D, Weaver J, Meretoja A, Fink JN. Helsinki Stroke Model Is Transferrable With "Real-World" Resources and Reduced Stroke Thrombolysis Delay to 34 min in Christchurch. Front Neurol 2018; 9:290. [PMID: 29760676 PMCID: PMC5937050 DOI: 10.3389/fneur.2018.00290] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 04/16/2018] [Indexed: 01/01/2023] Open
Abstract
Background Christchurch hospital is a tertiary hospital in New Zealand supported by five general neurologists with after-hours services provided mainly by onsite non-neurology medical residents. We assessed the transferrability and impact of the Helsinki Stroke model on stroke thrombolysis door-to-needle time (DNT) in Christchurch hospital. Methods Key components of the Helsinki Stroke model were implemented first in 2015 with introduction of patient pre-notification and thrombolysis by the computed tomography (CT) suite, followed by implementation of direct transfer to CT on ambulance stretcher in May 2017. Data from the prospective thrombolysis registry which began in 2012 were analyzed for the impact of these interventions on median DNT. Results Between May and December 2017, 46 patients were treated with alteplase, 25 (54%) patients were treated in-hours (08:00–17:00 non-public holiday weekdays) and 21 (46%) patients were treated after-hours. The in-hours, after-hours, and overall median (interquartile range) DNTs were 34 (28–43), 47 (38–60), and 40 (30–51) minutes. The corresponding times in 2012–2014 prior to interventions were 87 (68–106), 86 (72–116), and 87 (71–112) minutes, representing median DNT reduction of 53, 39, and 47 minutes, respectively (p-values <0.01). The interventions also resulted in significant reductions in the overall median door-to-CT time (from 49 to 19 min), CT-to-needle time (32 to 20 min) and onset-to-needle time (168 to 120 min). Conclusion The Helsinki stroke model is transferrable with real-world resources and reduced stroke DNT in Christchurch by over 50%.
Collapse
Affiliation(s)
- Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Erin Coleman
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Sarah L Wright
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Deborah F Mason
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Jon Reimers
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Roderick Duncan
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Mary Griffiths
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Michael Hurrell
- Department of Radiology, Christchurch Hospital, Christchurch, New Zealand
| | - David Dixon
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - James Weaver
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - John N Fink
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| |
Collapse
|
41
|
Hansen CK, Christensen A, Rodgers H, Havsteen I, Kruuse C, Christensen H. Does the Primary Imaging Modality-Computed Tomography or Magnetic Resonance Imaging-Influence Stroke Physicians' Certainty on Whether or Not to Give Thrombolysis to Randomized Acute Stroke Patients? J Stroke Cerebrovasc Dis 2017; 27:926-935. [PMID: 29198901 DOI: 10.1016/j.jstrokecerebrovasdis.2017.10.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 10/26/2017] [Accepted: 10/29/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Door-to-needle time of 20 minutes to stroke patients with intravenous tissue plasminogen activator (iv-tPA) is feasible when computed tomography (CT) is used as first-line of brain imaging. Magnetic resonance imaging (MRI)-based assessment is more time-consuming but superior in detecting acute ischemia. The certainty with which stroke physicians prescribe or refrain from giving iv-tPA treatment to CT- versus MRI-examined patients has not previously been studied. The aim of the present study was to determine the effect of a primary imaging strategy of CT or MRI on clinicians' certainty to prescribe or refrain from giving iv-tPA to patients with suspected acute stroke. METHOD Consecutive patients with suspected stroke were quasi-randomized to either CT- or MRI-based assessment before potential iv-tPA treatment. The influence of (1) the clinical findings and (2) the image findings, and (3) the certainty with which the stroke physician prescribed or refrained from giving iv-tPA treatment were assessed with visual analog scales (VAS). Predictors of treatment certainty were identified with a random-effect model. RESULTS Four-hundred forty-four consecutive patients were quasi-randomized. MRI influenced the final treatment decision more than CT (P = .002). Compared with CT-examined patients (mean VAS score 8.6, SD ±1.6) stroke physicians were significantly more certain when prescribing or refraining from giving iv-tPA to MRI-examined patients (mean VAS score 9.0, SD ±1.2) (P = .014). No differences in modified Rankin scale or mortality were detected at 3 months in CT- versus MRI-examined iv-tPA-treated patients. CONCLUSIONS Stroke physicians were significantly more certain when prescribing iv-tPA to MRI-examined stroke patients, and MRI influences the final treatment decision significantly more compared with CT, although no difference in mortality and functional outcome at 3 months was detected between CT- and MRI-examined patients treated with iv-tPA.
Collapse
Affiliation(s)
- Christine Krarup Hansen
- Department of Neurology, Bispebjerg-Frederiksberg-Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Anders Christensen
- Department of Radiology, Bispebjerg-Frederiksberg-Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Helen Rodgers
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle, United Kingdom
| | - Inger Havsteen
- Department of Radiology, Bispebjerg-Frederiksberg-Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Christina Kruuse
- Department of Neurology, Neurovascular Research Unit, Herlev-Gentofte-Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Hanne Christensen
- Department of Neurology, Bispebjerg-Frederiksberg-Hospital, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
42
|
Kamal N, Smith EE, Jeerakathil T, Hill MD. Thrombolysis: Improving door-to-needle times for ischemic stroke treatment - A narrative review. Int J Stroke 2017; 13:268-276. [PMID: 29140185 DOI: 10.1177/1747493017743060] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background The effectiveness of thrombolysis is highly time dependent. For this reason, short target times have been set to reduce time to treatment from hospital arrival, which is called door-to-needle time. Summary of review There has been considerable work done at single centers and across multiple hospitals to improve door-to-needle time. There have been reductions of 8 to 47 min when applying one or more improvement strategies at single centers, and there have been many multi-hospital initiatives. The delays to treatment have been attributed to both patient and hospital factors, and strategies to address these delays have been proven to reduce door-to-needle time. The most effective strategies include pre-notification of arrival by Emergency Medical Services (EMS), single-call activation of stroke team, rapid registration process, moving the patient to computed tomography on EMS stretcher, and administration of alteplase in the scanner. There are many exciting areas of future direction including reduction of door-to-needle time in developing countries, improving pre-hospital response times, and improving the efficiency of endovascular treatment. Conclusions There is now a broad understanding of the causes of delays to fast treatment and the strategies that can be employed to improve door-to-needle time such that most centers could achieve median door-to-needle time of 30 min.
Collapse
Affiliation(s)
- Noreen Kamal
- 1 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Eric E Smith
- 1 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,2 Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | | | - Michael D Hill
- 1 Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,2 Department of Community Health Sciences, University of Calgary, Calgary, Canada.,4 Department of Medicine, University of Calgary, Calgary, Canada.,5 Department of Radiology, University of Calgary, Calgary, Canada
| |
Collapse
|
43
|
Kamal N, Holodinsky JK, Stephenson C, Kashayp D, Demchuk AM, Hill MD, Vilneff RL, Bugbee E, Zerna C, Newcommon N, Lang E, Knox D, Smith EE. Improving Door-to-Needle Times for Acute Ischemic Stroke: Effect of Rapid Patient Registration, Moving Directly to Computed Tomography, and Giving Alteplase at the Computed Tomography Scanner. Circ Cardiovasc Qual Outcomes 2017; 10:CIRCOUTCOMES.116.003242. [PMID: 28096208 DOI: 10.1161/circoutcomes.116.003242] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 10/26/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The effectiveness of specific systems changes to reduce DTN (door-to-needle) time has not been fully evaluated. We analyzed the impact of 4 specific DTN time reduction strategies implemented prospectively in a staggered fashion. METHODS AND RESULTS The HASTE (Hurry Acute Stroke Treatment and Evaluation) project was implemented in 3 phases at a single academic medical center. In HASTE I (June 6, 2012 to June 5, 2013), baseline performance was analyzed. In HASTE II (June 6, 2013 to January 24, 2015), 3 changes were implemented: (1) a STAT stroke protocol to prenotify the stroke team about incoming stroke patients; (2) administering alteplase at the computed tomography (CT) scanner; and (3) registering the patient as unknown to allow immediate order entry. In HASTE III (January 25, 2015 to June 29, 2015), we implemented a process to bring the patient directly to CT on the emergency medical services stretcher. Log-transformed DTN time was modeled. Data from 350 consecutive alteplase-treated patients were analyzed. Multivariable regression showed the following factors to be significant: giving alteplase in the CT (32% decrease in DTN time, 95% confidence interval [CI] 38%-55%), stretcher to CT (30% decrease in DTN time, 95% CI 16%-42%), patient registered as unknown (12% decrease in DTN time, 95% CI 3%-20%), STAT stroke protocol (11% decrease in DTN time, 95% CI 1%-20%), and stroke severity (National Institutes of Health Stroke Scale score 6-8: 19% decrease in DTN time, 95% CI 6%-31%; National Institutes of Health Stroke Scale score >8: 27% decrease in DTN time, 95% CI 17%-37%). CONCLUSIONS Taking the patient to CT on the emergency medical services stretcher, registering the patient as unknown, STAT stroke protocol, and administering alteplase in CT are associated with lower DTN time.
Collapse
Affiliation(s)
- Noreen Kamal
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Jessalyn K Holodinsky
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Caroline Stephenson
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Devika Kashayp
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Andrew M Demchuk
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Michael D Hill
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Renee L Vilneff
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Erin Bugbee
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Charlotte Zerna
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Nancy Newcommon
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Eddy Lang
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Darren Knox
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada
| | - Eric E Smith
- From the Department of Clinical Neurosciences (N.K., A.M.D., M.D.H., E.E.S.) and Department of Community Health Sciences (J.K.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada; Calgary Stroke Program, Alberta Health Services (C.S., A.M.D., M.D.H., C.Z., N.N., D. Knox, E.E.S.) and Department of Emergency Medicine (D. Kashayp, E.B., E.L.), Foothills Medical Centre, Calgary, Alberta, Canada; Emergency Medical Services, Alterta Health Services, Calgary, Alberta, Canada (R.L.V.); and Hotchkiss Brain Institute (A.M.D., M.D.H., E.E.S.), University of Calgary, Calgary, Alberta, Canada.
| |
Collapse
|
44
|
Abstract
PURPOSE OF REVIEW Acute ischemic stroke (AIS) care is rapidly evolving. This review discusses current diagnostic, therapeutic, and process models that can expedite stroke treatment to achieve best outcomes. RECENT FINDINGS Use of stent retrievers after selection via advanced imaging is safe and effective, and is an important option for AIS patients with large vessel occlusion (LVO). Significant time delays occur before and during patient transfers, and upon comprehensive stroke center (CSC) arrival, and have deleterious effects on functional outcome. Removing obstacles, enhancing inter-facility communication, and creating acute stroke management processes and protocols are paramount strategies to enhance network efficiency. Inter-departmental CSC collaboration can significantly reduce door-to-treatment times. Streamlined stroke systems of care may result in higher treatment rates and better functional outcomes for AIS patients, simultaneously conserving healthcare dollars. Stroke systems of care should be structured regionally to minimize time to treatment. A proactive approach must be employed; a management plan incorporating stroke team prenotification and parallel processes between departments can save valuable time, maximize brain salvage, and reduce disability from stroke.
Collapse
|
45
|
Cichos KH, Linsky PL, Wei B, Minnich DJ, Cerfolio RJ. Cost Savings of Standardization of Thoracic Surgical Instruments: The Process of Lean. Ann Thorac Surg 2017; 104:1889-1895. [PMID: 29054303 DOI: 10.1016/j.athoracsur.2017.06.064] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 06/07/2017] [Accepted: 06/12/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Our objective is to show the effect that standardization of surgical trays has on the number of instruments sterilized and on cost. METHODS We reviewed our most commonly used surgical trays with the 3 general thoracic surgeons in our division and agreed upon the least number of surgical instruments needed for mediastinoscopy, video-assisted thoracoscopic surgery, robotic thoracic surgery, and thoracotomy. RESULTS We removed 59 of 79 instruments (75%) from the mediastinoscopy tray, 45 of 73 (62%) from the video-assisted thoracoscopic surgery tray, 51 of 84 (61%) from the robotic tray, and 50 of 113 (44%) from the thoracotomy tray. From January 2016 to December 2016, the estimated savings by procedure were video-assisted thoracoscopic surgery (n = 398) $21,890, robotic tray (n = 231) $19,400, thoracotomy (n = 163) $15,648, and mediastinoscopy (n = 162) $12,474. Estimated total savings were $69,412. The weight of the trays was reduced 70%, and the nonsteamed sterilization rate (opened trays that needed to be reprocessed) decreased from 2% to 0%. None of the surgeons requested any of the removed instruments. CONCLUSIONS Standardization of thoracic surgical trays is possible despite having multiple thoracic surgeons. This process of lean (the removal of nonvalue steps or equipment) reduces the number of instruments cleaned and carried and reduces cost. It may also reduce the incidence of "wet loads" that require the resterilization of instruments.
Collapse
Affiliation(s)
- Kyle H Cichos
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham Hospital, Birmingham, Alabama
| | - Paul L Linsky
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham Hospital, Birmingham, Alabama
| | - Benjamin Wei
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham Hospital, Birmingham, Alabama
| | - Douglas J Minnich
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham Hospital, Birmingham, Alabama
| | - Robert J Cerfolio
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham Hospital, Birmingham, Alabama.
| |
Collapse
|
46
|
Improving treatment times for patients with in-hospital stroke using a standardized protocol. J Neurol Sci 2017; 381:68-73. [DOI: 10.1016/j.jns.2017.08.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 08/15/2017] [Accepted: 08/17/2017] [Indexed: 11/17/2022]
|
47
|
Cone DC, Cooley C, Ferguson J, Harrell AJ, Luk JH, Martin-Gill C, Marquis SW, Pasichow S. Observational Multicenter Study of a Direct-to-CT Protocol for EMS-transported Patients with Suspected Stroke. PREHOSP EMERG CARE 2017; 22:1-6. [PMID: 28841085 DOI: 10.1080/10903127.2017.1356410] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE In an effort to decrease door-to-needle times for patients with acute ischemic stroke, some hospitals have begun taking stable EMS patients with suspected stroke directly from the ambulance to the CT scanner, then to an emergency department (ED) bed for evaluation. Minimal data exist regarding the potential for time savings with such a protocol. The study hypothesis was that a direct-to-CT protocol would be associated with decreases in both door-to-CT-ordered and door-to-needle times. METHODS An observational, multicenter before/after study was conducted of time/process measures at hospitals that have implemented direct-to-CT protocols for patients transported by EMS with suspected stroke. Participating hospitals submitted data on at least the last 50 "EMS stroke alert" patients before the launch of the direct-to-CT protocol, and at least the first 50 patients after. Time elements studied were arrival at the ED, time the head CT was ordered, and time tPA was started. Data were submitted in blinded fashion (patient and hospital identifiers removed); at the time of data analysis, the lead investigator was unaware of which data came from which hospital. Simple descriptive statistics were used, along with the Mann-Whitney test to compare time medians. RESULTS Seven hospitals contributed data on 1040 patients (529 "before" and 511 "after"); 512 were male, and 627 had final diagnoses of ischemic stroke, of whom 275 received tPA. The median door-to-CT-ordered time for all patients was 7 minutes in the before phase, and 4 minutes after (difference 3 minutes, p = < 0.0001); similarly, the median door-to-CT-started time was 6 minutes "before" and 10 minutes after (p < 0.0001). The median door-to-needle time for all patients given tPA was 42 minutes before, and 44 minutes after (p = 0.78). Four hospitals had modest decreases in door-to-CT-ordered time (of 2, 4, 2, and 5 minutes), and only one hospital had a decrease in door-to-needle time (32 min vs 26 min, p = 0.012). CONCLUSIONS In this sample from seven hospitals, a minimal reduction in door-to-CT-ordered and door-to-CT-started time, but no change in door-to-needle time, was found for EMS patients with suspected stroke taken directly to the CT scanner, compared to those evaluated in the ED prior to CT.
Collapse
|
48
|
Nowak M, Pfaff H, Karbach U. Does Value Stream Mapping affect the structure, process, and outcome quality in care facilities? A systematic review. Syst Rev 2017; 6:170. [PMID: 28838320 PMCID: PMC5571664 DOI: 10.1186/s13643-017-0563-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 08/14/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Quality improvement within health and social care facilities is needed and has to be evidence-based and patient-centered. Value Stream Mapping, a method of Lean management, aims to increase the patients' value and quality of care by a visualization and quantification of the care process. The aim of this research is to examine the effectiveness of Value Stream Mapping on structure, process, and outcome quality in care facilities. METHODS A systematic review is conducted. PubMed, EBSCOhost, including Business Source Complete, Academic Search Complete, PSYCInfo, PSYNDX, SocINDEX with Full Text, Web of Knowledge, and EMBASE ScienceDirect are searched in February 2016. All peer-reviewed papers evaluating Value Stream Mapping and published in English or German from January 2000 are included. For data synthesis, all study results are categorized into Donabedian's model of structure, process, and outcome quality. To assess and interpret the effectiveness of Value Stream Mapping, the frequencies of the results statistically examined are considered. RESULTS Of the 903 articles retrieved, 22 studies fulfill the inclusion criteria. Of these, 11 studies are used to answer the research question. Value Stream Mapping has positive effects on the time dimension of process and outcome quality. It seems to reduce non-value-added time (e.g., waiting time) and length of stay. All study designs are before and after studies without control, and methodologically sophisticated studies are missing. CONCLUSIONS For a final conclusion about Value Stream Mapping's effectiveness, more research with improved methodology is needed. Despite this lack of evidence, Value Stream Mapping has the potential to improve quality of care on the time dimension. The contextual influence has to be investigated to make conclusions about the relationship between different quality domains when applying Value Stream Mapping. However, for using this review's conclusion, the limitation of including heterogeneous and potentially biased results has to be considered.
Collapse
Affiliation(s)
- Marina Nowak
- Institute of Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), Faculty of Human Sciences, Faculty of Medicine, University of Cologne, Eupener Strasse 129, 50933 Cologne, Germany
| | - Holger Pfaff
- Institute of Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), Faculty of Human Sciences, Faculty of Medicine, University of Cologne, Eupener Strasse 129, 50933 Cologne, Germany
| | - Ute Karbach
- Institute of Medical Sociology, Health Services Research and Rehabilitation Science (IMVR), Faculty of Human Sciences, Faculty of Medicine, University of Cologne, Eupener Strasse 129, 50933 Cologne, Germany
| |
Collapse
|
49
|
Abstract
PURPOSE OF REVIEW We discuss the frequency of stroke misdiagnosis in the emergency department (ED), identify common diagnostic pitfalls, describe strategies to reduce diagnostic error, and detail ongoing research. RECENT FINDINGS The National Academy of Medicine has re-defined and highlighted the importance of diagnostic errors for patient safety. Recent rates of stroke under-diagnosis (false-negative cases, "stroke chameleons") range from 2-26% and 30-43% for stroke over-diagnosis (false-positive cases, "stroke mimics"). Failure to diagnosis stroke can preclude time-sensitive treatments and has been associated with poor outcomes. Strategies have been developed to improve detection of posterior circulation stroke syndromes, but ongoing work is needed to reduce under-diagnosis in other atypical stroke presentations. The published rates of harm associated with stroke over-diagnosis, particularly thrombolysis of stroke mimics, remain low. Additional strategies to improve the accuracy of stroke diagnosis should focus on rapid clinical reasoning in the time-sensitive setting of acute ischemic stroke and identifying imperfections in the healthcare system which may contribute to diagnostic error.
Collapse
Affiliation(s)
- Ava L Liberman
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Shyam Prabhakaran
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| |
Collapse
|
50
|
Abstract
Background Increasing pressure in the United Kingdom (UK) urgent care system has led to Emergency Departments (EDs) failing to meet the national requirement that 95% of patients are admitted, discharged or transferred within 4-h of arrival. Despite the target being the same for all acute hospitals, individual Trusts organise their services in different ways. The impact of this variation on patient journey time and waiting is unknown. Our study aimed to apply the Lean technique of Value Stream Mapping (VSM) to investigate care processes and delays in patient journeys at four contrasting hospitals. Methods VSM timing data were collected for patients accessing acute care at four hospitals in South West England. Data were categorised according to waits and activities, which were compared across sites to identify variations in practice from the patient viewpoint. We included Public and Patient Involvement (PPI) to fully interpret our findings; observations and initial findings were considered in a PPI workshop. Results One hundred eight patients were recruited, comprising 25,432 min of patient time containing 4098 episodes of care or waiting. The median patient journey was 223 min (3 h, 43 min); just within the 4-h target. Although total patient journey times were similar between sites, the stage where the greatest proportion of waiting occurred varied. Reasons for waiting were dominated by waits for beds, investigations or results to be available. From our sample we observed that EDs without a discharge/clinical decision area exhibited a greater proportion of waiting time following an admission or discharge decision. PPI interpretation indicated that patients who experience waits at the beginning of their journey feel more anxious because they are ‘not in the system yet’. Conclusions The novel application of VSM analysis across different hospitals, coupled with PPI interpretation, provides important insight into the impact of care provision on patient experience. Measures that could reduce patient waiting include automatic notification of test results, and the option of discharge/clinical decision areas for patients awaiting results or departure. To enhance patient experience, good communication with patients and relatives about reasons for waits is essential.
Collapse
|