title: Reducing door-to-needle times using Toyota's lean manufacturing principles and value stream analysis.
abstract: OBJECTIVE
  Earlier tissue-type plasminogen activator (tPA) treatment for acute ischemic stroke increases efficacy, prompting national efforts to reduce door-to-needle times. We used lean process improvement methodology to develop a streamlined intravenous tPA protocol.
  
  
  METHODS
  In early 2011, a multidisciplinary team analyzed the steps required to treat patients with acute ischemic stroke with intravenous tPA using value stream analysis (VSA). We directly compared the tPA-treated patients in the "pre-VSA" epoch with the "post-VSA" epoch with regard to baseline characteristics, protocol metrics, and clinical outcomes.
  
  
  RESULTS
  The VSA revealed several tPA protocol inefficiencies: routing of patients to room, then to CT, then back to the room; serial processing of workflow; and delays in waiting for laboratory results. On March 1, 2011, a new protocol incorporated changes to minimize delays: routing patients directly to head CT before the patient room, using parallel process workflow, and implementing point-of-care laboratories. In the pre and post-VSA epochs, 132 and 87 patients were treated with intravenous tPA, respectively. Compared with pre-VSA, door-to-needle times and percent of patients treated ≤60 minutes from hospital arrival were improved in the post-VSA epoch: 60 minutes versus 39 minutes (P<0.0001) and 52% versus 78% (P<0.0001), respectively, with no change in symptomatic hemorrhage rate.
  
  
  CONCLUSIONS
  Lean process improvement methodology can expedite time-dependent stroke care without compromising safety.
authors.affiliation: Washington University School of Medicine, Department of Neurology, and Emergency Department, Neurology and Neursurgery Center, Barnes-Jewish Hospital, 600 South Euclid Avenue, Box 8111, St Louis, MO 63110, USA.
authors.forename: Andria L
authors.initials: AL
authors.lastname: Ford
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Williams
authors.forename: Mary
authors.initials: M
authors.lastname: Spencer
authors.forename: Craig
authors.initials: C
authors.lastname: McCammon
authors.forename: Naim
authors.initials: N
authors.lastname: Khoury
authors.forename: Tomoko R
authors.initials: TR
authors.lastname: Sampson
authors.forename: Peter
authors.initials: P
authors.lastname: Panagos
authors.forename: Jin-Moo
authors.initials: JM
authors.lastname: Lee
mesh_terms: D000208:Acute Disease; D061605:Administration, Intravenous; D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000188:drug therapy*; D017598:Efficiency, Organizational; D004632:Emergency Medical Services / Q000458:organization & administration*; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006801:Humans; D007221:Industry / Q000458:organization & administration; D008297:Male; D008875:Middle Aged; D017146:Models, Organizational; D010348:Patient Care Team / Q000458:organization & administration; D015397:Program Evaluation; D012042:Registries / Q000706:statistics & numerical data; D020521:Stroke / Q000188:drug therapy*; D061665:Time-to-Treatment / Q000458:organization & administration*; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents