Jessica Sumner, MSN, RN, ACNS-BC, CEN; Danny Murray, BSN, RN
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Session E presented Friday, September 15, 2017
Purpose: The objective was to decrease ED door to CT and lab turnaround time to results to less than or equal to 45 minutes, improve the percentage of tests resulted in under 45 minutes to 85% or greater and decrease variation in the Code Stroke process.
Design: The design is a quality improvement project using Lean Six Sigma methodology.
Setting: The project setting is a suburban community hospital emergency department.
Participants/Subjects: The participants were a multidisciplinary team involving all ED staff, physicians, radiology technicians, laboratory technicians, stroke coordinator, stroke neurologist and Lean Six Sigma Black Belt participated in this project.
Methods: The project utilized lean six sigma methodologies which included a Murphy's analysis and process mapping to determine current state. Data analysis reviewed the demographics of patients, broke down the length of time for each step of the hyperacute stroke process, and analyzed current variation in practice. A swimlane was developed to detail future state which included direct to CT for EMS along with detailed standard work instructions for each person involved in the new process. The new process was implemented with improvements in scores but not to the level established in the control plan. A review of the process was completed and found that door to orders averaged about 20 minutes and 60% of the patients presented via the triage entrance of the department. The swimlanes and standard work instructions were updated to incorporate new work flows from triage. Criteria was set to give the triage nurse guidance and permission to activate the Team B process. The patient is brought immediately to the physician and then direct to CT. A new order entry process was also initiated along with overhead page activation of the Code Stroke team. A debriefing process was initiated to assist with identifying further quality improvement opportunities.
Results/Outcomes: Since implementation of the revised work flow, average CT turnaround compliance has gone from 64% in 45 minutes prior to implementation to 92% in 45 minutes post implementation, lab turnaround compliance has gone from 40% to 75%. The average lab turnaround time went from 56.46 minutes to 38.63 minutes. The average CT turnaround time went from 44.98 minutes to 27.93 minutes. A benefit from the new process is an increase in the number of patients recognized and an increase in the number of Alteplase (tPA) administrations.
Implications: The Lean Six Sigma methodology helped identify barriers and non-value added steps in the process. This enabled us to streamline and standardize our process. Role mapping has provided everybody with clear steps of what they are to do next. Clear criteria was given to the triage nurse of when to activate Team B/Code Stroke which reduced the subjectivity of the individual triage nurse and empowered the nurses to activate the process. Communication to the entire team including CT, lab and radiologist was enhanced by utilizing overhead paging. Identification of an ED physician champion and the end results have assisted with obtaining ED physician buy-in.
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