Process improvement to enhance existing stroke team activity toward more timely thrombolytic treatment

Process mining framework with time perspective for understanding acute care: a case study of AIS in hospitals

Background

Acute care for critical illness requires very strict treatment timeliness. However, healthcare providers usually cannot accurately figure out the causes of low efficiency in acute care process due to the lack of effective tools. Besides, it is difficult to compare or conformance processes from different patient groups.

Methods

To solve these problems, we proposed a novel process mining framework with time perspective, which integrates four steps: standard activity construction, data extraction and filtering, iterative model discovery, and performance analysis.

Results

It can visualize the execution of actual clinical activities hierarchically, evaluate the timeliness and identify bottlenecks in the treatment process. We take the acute ischemic stroke as a case study, and retrospectively reviewed 420 patients’ data from a large hospital. Then we discovered process models with timelines, and identified the main reasons for in-hospital delay.

Conclusions

Experiment results demonstrate that the framework proposed could be a new way of drawing insights about hospitals’ clinical process, to help clinical institutions increase work efficiency and improve medical service.

Effectiveness of emergency physician determinations of the need for thrombolytic therapy in acute stroke

An increased emphasis on stroke care has led to a proliferation of specialized stroke teams despite relatively few trials demonstrating their efficacy. Our academic stroke center incorporated a unique setup allowing for the comparison between stroke teams and emergency physicians. During weekday working hours, a stroke team would respond to the emergency department for stroke activations. During all other times, the emergency physician caring for the patient would make all treatment decisions. We sought to determine whether there was any difference in treatment and outcomes between these two groups. We conducted a retrospective review of all stroke activations from January 2015 to June 2016 and compared the thrombolytic administration rates, modified Rankin Scale (mRS) at discharge, and change in National Institutes of Health Stroke Scale (NIHSS). A total of 415 stroke activations were identified. Of those, 69 of 262 patients (26.3%) seen by emergency physicians and 60 of 153 patients (39.2%) seen by neurologists received thrombolysis (P = 0.006). No significant difference was found in the discharge mRS or change in NIHSS between the two groups. Emergency physicians administered significantly less thrombolytics than did neurologists. No significant difference was observed in outcomes, including mRS and admission-to-discharge change in NIHSS.

Improvement of Endovascular Stroke Treatment: A 24-Hour Neuroradiological On-Site Service Is Not Enough

Background and Purpose

With the advent of endovascular stroke treatment (EST) with mechanical thrombectomy, stroke treatment has also become more challenging. Purpose of this study was to investigate whether a fulltime neuroradiological on-site service and workflow optimization with a structured documentation of the interdisciplinary stroke workflow resulted in improved procedural times.

Material and Methods

Procedural times of 322 consecutive patients, who received EST (1) before (n = 96) and (2) after (n = 126) establishing a 24-hour neuroradiological on-site service as well as (3) after implementation of a structured interdisciplinary workflow documentation (“Stroke Check”) (n = 100), were analysed.

Results

A fulltime neuroradiological on-site service resulted in a nonsignificant improvement of procedural times during out-of-hours admissions (p ≥ 0.204). Working hours and out-of-hours procedural times improved significantly, if additional workflow optimization was realized (p ≤ 0.026).

Conclusions

A 24-hour interventional on-site service is a major prerequisite to adequately provide modern reperfusion therapies in patients with acute ischemic stroke. However, simple measures like standardized and focused documentation that affect the entire interdisciplinary pre- and intrahospital stroke rescue chain seem to be important.

The influence of emergency department crowding on the efficiency of care for acute stroke patients

Objective

To investigate the impact of emergency department (ED) crowding (number of ED patients) and number of ED staff on the efficiency of the ED care process for acute stroke patients.

Design

Retrospective cohort study conducted from 1 May 2008 to 31 December 2013.

Setting

Largest primary stroke center (3000-bed tertiary academic hospital) in southern Taiwan.

Participants

Patients aged 18-80 years presenting to the ED with acute stroke symptoms ≤3 h from symptom onset (n = 1142).

Main Outcome Measures

Door-to-assessment time (DTA), door-to-computed tomography completion time (DTCT) and door-to-needle time (DTN).

Results

Of the 785 patients with ischemic stroke, 90 (11.46%) received thrombolysis. In the multivariate regression analysis, the number of ED patients and the number of attending physicians were significantly associated with delayed DTA and DTCT but not DTN. Initial assessment by a resident was also associated with delayed DTA and DTCT. The number of nurses was associated with delayed DTCT and DTN.

Conclusions

Although ED crowding was not associated with delayed DTN, it predicted delayed DTA and DTCT in thrombolysis-eligible stroke patients. The number of attending physicians affected initial assessment and DTCTs, whereas the number of nurses impacted thrombolytic administration times.

[Why is reperfusion therapy delayed in stroke code patients? A qualitative analysis]

BACKGROUND

Efficacy and safety of reperfusion therapy in acute ischaemic stroke is time-dependent and has a limited therapeutic window, which is, in fact, the main exclusion criterion. Initiatives to evaluate the quality of care are essential to design future interventions and ensure the shortest management times and application of such treatments.

OBJECTIVE

The aim of the study is to identify and classify potential causes of delay in the administration of reperfusion therapy in a tertiary hospital, a reference for the comprehensive treatment of acute ischaemic stroke.

MATERIAL AND METHODS

The project was developed in Hospital Universitario Virgen de la Arrixaca, Murcia, Spain. A total of 337 patients with acute ischaemic stroke treated with reperfusion therapies were evaluated. For qualitative analysis, 2 working groups were formed: an advocacy group that designed and directed the entire project, and a multidisciplinary one, which served as a source of information and a mechanism for active involvement of all professionals in the stroke-care chain. Information was collected in 3 meetings and then, both the flowcharts and the cause-effect diagram were prepared.

RESULTS

Based on the above tools, potential causes of delay were identified and classified according to an operational criterion into unmodified structures, and modifiable ones with known evidence and hypothetical repercussions. Modifiable ones are noted for their importance in the design of future improvement interventions in stroke care. Some of them are: Variability in following established protocols, lack of procedures in some parts of the stroke-care chain, etc.

CONCLUSION

Knowledge of the current situation has just been the starting point, but it has been an essential requisite for the design and implementation of a quality improvement program to shorten in-hospital stroke code times.

Comprehensive code stroke program to reduce reperfusion delay for in-hospital stroke patients

Background

Stroke may occur during hospital admission (in-hospital stroke). Although patients with in-hospital stroke are potentially good candidates for reperfusion therapy, they often do not receive treatment as rapidly as expected.

Aims

We investigated the effect of a code stroke program for in-hospital stroke, which included the use of computerized physician order entry, specific evaluation and treatment protocols for in-hospital stroke patients, and regular education of medical staffs.

Methods

We implemented the program in the cardiology and cardiovascular surgery departments/wards (target-ward group) in November 2008. We compared time intervals from symptom onset to evaluation and reperfusion treatment before and after program implementation between the target-ward and other departments/wards (other-ward group).

Results

Among 70 consecutive in-hospital stroke patients who received reperfusion therapy between July 2002 and February 2015, 28 and 42 were treated before and after program implementation, respectively. After program implementation, time intervals from symptom onset to neurology notification (50 min vs. 28 min; P = 0.033), symptom onset to brain imaging (91 min vs. 41 min; P < 0.001), and symptom recognition to notification (22 min vs. 9 min; P = 0.011) were reduced in the target-ward group. Finally, times from symptom onset to intravenous tissue plasminogen activator administration and to arterial puncture were reduced by 55 min (120 min vs. 65 min; P < 0.001) and 130 min (295 min vs. 165 min; P < 0.001), respectively. However, time reductions in the other-ward group were not significant.

Conclusions

The comprehensive program for in-hospital stroke that included the use of computerized physician order entry was effective in reducing time intervals to evaluation and reperfusion therapy.

Effective management of patients with acute ischemic stroke based on lean production on thrombolytic flow optimization

The efficacy of thrombolytic therapy for acute ischemic stroke (AIS) decreases when the administration of tissue plasminogen activator (tPA) is delayed. Derived from Toyota Production System, lean production aims to create top-quality products with high-efficiency procedures, a concept that easily applies to emergency medicine. In this study, we aimed to determine whether applying lean principles to flow optimization could hasten the initiation of thrombolysis. A multidisciplinary team (Stroke Team) was organized to implement an ongoing, continuous loop of lean production that contained the following steps: decomposition, recognition, intervention, reengineering and assessment. The door-to-needle time (DNT) and the percentage of patients with DNT ≤ 60 min before and after the adoption of lean principles were used to evaluate the efficiency of our flow optimization. Thirteen patients with AIS in the pre-lean period and 43 patients with AIS in the lean period (23 in lean period I and 20 patients in lean period II) were consecutively enrolled in our study. After flow optimization, we reduced DNT from 90 to 47 min (p < 0.001^¤). In addition, the percentage of patients treated ≤60 min after hospital arrival increased from 38.46 to 75.0 % (p = 0.015^¤). Adjusted analysis of covariance confirmed a significant influence of optimization on delay of tPA administration (p < 0.001). The patients were more likely to have a good prognosis (mRS ≤ 2 at 90 days) after the flow optimization (30.77-75.00 %, p = 0.012^¤). Our study may offer an effective approach for optimizing the thrombolytic flow in the management of AIS.