The same techniques that streamlined assembly lines in the auto industry can expedite receipt of tissue plasminogen activator (tPA) for patients with an acute ischemic stroke, a single-center study showed.

After processes that were wasting time were identified and addressed, the median door-to-needle time fell from 60 to 39 minutes (P<0.0001), according to Jin-Moo Lee, MD, PhD, of Washington University School of Medicine in St. Louis, and colleagues.

In addition, the percentage of patients treated within the American Heart Association’s Get With The Guidelines-Stroke goal of 60 minutes or less increased from 52% to 78% (P<0.0001), the researchers reported online in Stroke: Journal of the American Heart Association.

Earlier treatment with tPA has been associated with better outcomes following an acute ischemic stroke, and efforts have been made at centers around the country to reduce door-to-needle times. Most patients, however, do not receive tPA within an hour of arriving at the hospital. Lee and colleagues used a process modeled after Toyota’s automobile production lean manufacturing principles to identify ways to save time in getting patients with acute ischemic stroke from the door of the hospital to treatment with IV tPA. A multidisciplinary team that included a lean engineer, neurologists, patient care and radiology technicians, and physicians, nurses, and a pharmacist from the emergency department evaluated existing protocols using a tool called value stream analysis to uncover time-wasting and time-saving steps. They identified three areas that to be addressed:   Patients were being brought by emergency medical services (EMS) personnel first to the trauma bay, then to the CT scanner, and then back to the room.   Some tasks were being performed serially, rather than at the same time. Staff members were not being efficiently used.   There were delays in waiting for laboratory results in patients suspected of or known to be taking anticoagulation. The team changed the protocol to have EMS personnel bring the patient directly to the CT scanner and then to the patient room in the trauma bay. Also, various staff members were assigned different tasks that could be completed at the same time. Emergency department and neurology residents were tasked with obtaining the brief history and assessing stroke severity using the NIH Stroke Scale. A pharmacist was brought in to calculate and prepare the tPA dose, and a social worker gathered witnesses in person or over the phone to allow physicians to determine the time of stroke onset. And finally, the team implemented point-of-care testing of international normalized ratio. To evaluate the impact of these changes, the researchers looked at data from 132 patients treated with IV tPA over a 26-month period before implementation and 87 treated over a 12-month period after implementation. Onset-to-arrival time and the percentage of patients arriving off-hours did not differ between the two time periods. The shorter door-to-needle times seen after the protocol was streamlined were sustained throughout the year-long study period, even as the volume of patients treated with tPA increased. Placing the head CT scan at the beginning of the protocol was identified as a significant predictor of shorter door-to-needle times (P<0.0001). Longer onset-to-arrival times also were associated with a shorter time to treatment (P=0.035). That "has been found in several large intravenous tPA data sets and indicates an additional education opportunity to avoid 'exhausting' the tPA window when a patient arrives early," Lee and colleagues wrote. Patient safety was not affected by the protocol changes, as there were no changes in symptomatic intracerebral hemorrhage rate, discharge location, 90-day functional outcomes, length of hospital stay, or stroke mimic rate between the two time periods. The authors acknowledged that the study was limited in that it was conducted at a single center with small patient numbers. It is also possible that time-dependent factors unrelated to the implemented changes could have influenced the results.