Beat the Clock: Using a Visual Tool for Process Improvement in Ischemic Stroke Care Door-to-Needle Times

Abstract

Introduction

Time is of the essence when caring for stroke patients. Early recognition and assessment can be challenging. The community hospital's Primary Stroke Center door-to-needle (DTN) time was an average of 81.5 minutes. There were several reasons for this delay, such as inability to recognize stroke symptoms and get the team activated, as well as prioritizing timely arrival in CT scan. Through the use of a visual software tool to facilitate team coordination and time tracking, it was possible to improve stroke care efficiency and significantly decrease DTN times.

Methods

The hospital implemented a process improvement with the use of Trauma Timer™ — a web-based computer program with a large digital clock and animated, color-coded stopwatch. Trauma Timer™ was used to coordinate and time the team's actions during each phase of evaluation and treatment. The results were recorded for later review to ascertain precisely which phases were responsible for the delay. The team was able to review the results in a timely manner to improve performance as well as outcomes.

Results

The average DTN time decreased from 81.5 minutes to 38.2 minutes within the first seven months and was sustained with only minor variation for the duration of the pilot.

Outcome

Using Trauma Timer™ improved efficiency and care of stroke patients as evidenced by an increased tPA administration rate and reduced DTN times by 43.3 minutes.

Introduction

Ischemic stroke remains one of the leading causes of morbidity and mortality in the United States. It is the fifth leading cause of death and the leading cause of severe life-long disability (AHA/ASA Guidelines, 2018). Ischemic stroke is a time-critical emergency in which expert diagnosis and rapid treatment is necessary to achieve positive outcomes (Ahmed, L.C., 2009). The American Heart Association's Get With The Guidelines–Stroke program has been developed to measure and improve the quality of care and outcome for patients presenting with symptoms consistent with stroke.

Recombinant tissue plasminogen activator (rtPA) must be administered within 4.5 hours of symptom onset, and hospitals have been challenged to improve door-to-needle times for its administration (Heidenreich, P., et al., 2017). Realizing that administration of this medication is only effective in improving outcomes if certain elements are met, the situation becomes even more challenging in busy emergency departments. The important elements in this timeline, which must be completed within 60 minutes of arrival at the hospital according to the GWTG-Stroke guidelines, include:

• early recognition of patients arriving with stroke symptoms
• activation of the team of experts
• completion and interpretation of non-contrast head computerized tomography (CT) scan
• physician ordering the weight-based rtPA
• preparation of the medication either by pharmacy or nursing
• administration of the intravenous medication

Background

Hospitals across the US have developed protocols to achieve the metric of door-to-needle time within one hour (Smith et al., 2015). The ED at a small community hospital in New Jersey was not unlike these other hospitals. The hospital's ED consisted of 15 bays with annual visits of approximately 34,000 patients. At the onset of the program the ED had an average DTN of 81.5 minutes with a wide range of actual times and several missed opportunities due to these delays. It became abundantly clear that a new approach was needed. There was also a reluctance on the part of the physicians when considering the administration of rtPA due to potential feared side effects.

The stroke committee began looking at each element of the time-critical segments to isolate where the barriers occurred. The analysis of the data showed a wide range of obstacles including failure of EMS to alert the hospital to a potential stroke patient, the inability of nursing staff to prioritize, delays in ordering CT, delays in facilitating patients to CT scan, and delays in obtaining CT results. To isolate the ED's obstacles and make improvements a solution was needed. Hospital-wide education was required to improve the staff's understanding, as well as a visual tool.

Process change tool implementation

Trauma Timer™ is a web-based computer program with a large digital clock and animated, color-coded stopwatch that makes it easy to read even from a distance. The clock face displays the phases of the protocol as sequential time slices and shows the time spent on each phase as the minute hand progresses. Checklists are displayed below the stopwatch to keep the entire team focused on the timely care of the stroke patient. The display can be viewed on multiple devices. Using Trauma Timer™ as a central point of reference eliminates any confusion as to the exact status of the protocol among the medical professionals involved. At the conclusion of the protocol the results are displayed on the screen and saved for later analysis. Using the secure web portal, the data were then reviewed to ascertain exactly which segment was responsible for the delay.

The process change was implemented in February 2015 and was utilized through February 2018. It was evident from the data that the areas for improvement were in getting the CT ordered and getting the patient to CT scan. Once the patient had the CT done, results were obtained quickly.

With this finding, the stroke team concentrated its efforts on hospital-wide education for staff including both nurses and physicians. With the focus on education and an increased emphasis on care of each individual stroke patient, the times for arrival to MD exam decreased significantly. Review of baseline data indicated that prior to the use of Trauma Timer™ it was unclear why arrival to CT result was so long. Post-implementation data demonstrated that the delays were with early recognition — specifically, recognition by nursing and getting the physician to the bedside.

The use of Trauma Timer™ created excitement within the department, so the entire team knew there was a potential tPA candidate present. Physicians were in friendly competition with each other to get the best DTN time.

Reviewing each stroke patient in real time assisted the staff to see exactly where the delays occurred. The process improvement involved a multi-department approach with collaboration amongst the different departments. The entire culture of the hospital changed. Each obstacle could be identified at a glance and real-time adjustments in process were made.

It was the practice of this hospital to have pharmacy at the bedside to mix the tPA. With the added feature of viewing the display on multiple devices, a tracking display was installed in the pharmacy, so pharmacists were able to see in real time where the team was in the process, and prepare the medication to arrive exactly when it was needed.

Results

Using Trauma Timer™ the hospital achieved a best DTN time of 16.3 minutes and an average DTN time of 38.2 minutes, an improvement of 43.3 minutes.

During the beginning stages of implementation, features were added to the program, including the ability to see the display on more than one workstation, and the ability to start the clock in the patient's room and push the display to the larger main screen in the department. The program also tracked elapsed time since the patient was last known well, supporting the evidence-based practice of administering within 4.5 hours (Schwamm, L. et al., 2009), and supported more than one session running at a time.

During the later sessions the program was altered to accommodate the newer recommendation of DTN within 45 minutes, and the hospital changed its protocols accordingly. The hospital's tPA administration rate increased from 15% to 21% with an average DTN time of 38 minutes. The hospital was able to maintain DTN times under 45 minutes 75% of the time, and under 60 minutes 90% of the time.

Conclusions

Improvement in DTN times and efficiency in the care of stroke patients is possible with the use of Trauma Timer™, which serves as a visual tool to keep the entire team focused on the task at hand, a means to change the culture of the department, and a way to measure results and improve performance. This hospital was able to out-perform other Primary Stroke Centers in the surrounding area as well as many Comprehensive Stroke Centers. The program allows for customization according to hospital-specific protocols.

References

1. American Heart Association / American Stroke Association. Heart Disease and Stroke Statistics — 2019 At a Glance. Retrieved May 17, 2019.
2. Heidenreich, P., Zhao, X., Hernandez, A., Schwamm, L., & Smith, E. (2017). Impact of an Expanded Hospital Recognition Program for Stroke Quality of Care. JAHA, 1–19. doi:10.1161/JAHA.116.004278
3. Schwamm, L., Fonarow, G., Reeves, M., Pan, W., Frankel, M., Smith, E., … LaBresh, K. (2009). Get With The Guidelines–Stroke Is Associated With Sustained Improvement in Care for Patients Hospitalized With Acute Stroke or Transient Ischemic Attack. Circulation, 119, 107–115. doi:10.1161/CIRCULATIONAHA.108.783688
4. Smith, E. (2015). Door-to-Needle Times: Let's Not Leave Smaller Hospitals Behind. Stroke, 46, 1158–1159. doi:10.1161/STROKEAHA.115.008974