Improving Systems-Based Practice to Enhance Delivery of Acute Stroke Care. Door-to-Needle Times: You Can Do It Faster!

Transcription

1 Improving Systems-Based Practice to Enhance Delivery of Acute Stroke Care Door-to-Needle Times: You Can Do It Faster! Allyson Zazulia, MD Washington University School of Medicine St. Louis, MO Stroke & Cerebrovascular ARSaves 2012

2 Financial Disclosures Salary and Research Support National Institutes of Health Washington University School of Medicine No financial relationships with industry

3 Objectives: To recognize the importance of reducing door to needle time for IV tpa use in acute ischemic stroke To learn how to identify goals, barriers, and solutions to reducing door to needle time for IV tpa use in acute ischemic stroke To understand the process of Value Stream Mapping in improving delivery of acute stroke care.

4 Improving Systems-Based Practice to Enhance Delivery of Acute Stroke Care: Topics Reducing door to needle time Why How: value stream map Goals Barriers Solutions Telestroke: Reducing delays in patient acceptance/transfer

5 Meta-analysis of IV tpa: 0-3 hour window Level 1a evidence that 0.9 mg/kg IV tpa administered within 3 hours of stroke onset increases the likelihood of recovery/reduces likelihood of death/dependency at 90 days mrs 2 Absolute benefit 11-13% Wardlaw et al. Cochrane Database Syst Rev, 2009

6 Meta-analysis of IV tpa: hour window Level 1a evidence that 0.9 mg/kg IV tpa administered at 3 to 4.5 hours after stroke onset increases the likelihood of recovery/reduces likelihood of death/dependency at 90 days Absolute benefit 7% Lansberg et al. Stroke 2009;40:

7 Time is Brain Odds of favorable 3-mo outcome as onset-to-treatment time (p < ) 0-90 min OR 2.6 ( ) min OR 1.6 ( ) min OR 1.3 ( ) min OR 1.2 ( ) Pooled analysis of 3670 pts (from NINDS tpa, ATLANTIS, ECASS I, II, & III, EPITHET) Stroke & Cerebrovascular Lees et al. Lancet 2010;375:

8 Time is Brain Risk of death as onset-to-treatment time 0-90 min OR 0.8 ( ) min OR 1.1 ( ) min OR 1.2 ( ) min OR 1.5 ( ) Pooled analysis of 3670 pts (from NINDS tpa, ATLANTIS, ECASS I, II, & III, EPITHET) Stroke & Cerebrovascular Lees et al. Lancet 2010;375:

9 Goal: reduce door-to-needle (DTN) time AHA/ASA Target Stroke campaign: DTN time 60 min in 50% of acute ischemic stroke pts treated with IV tpa Brain Attack Coalition target for primary stroke centers1: DTN 60 min in 80% of AIS patients (DTN=door to needle time) 1Alberts et al. JAMA. 2000;283:3102 9

10 Reaching the goal Value Stream Mapping/Lean Processing Group process to create a map depicting everything that needs to happen in the production and delivery of a product Process of mapping serves as communication tool to Identify goals Expose inefficiencies and barriers Create solutions

11 Value Stream Mapping Step 1 Preparatory meeting to plan project Step 2 Communicate plans to affected parties Step 3 Focused Rapid Improvement Event to develop new process Requires participation from key process stakeholders

12 Rapid Improvement Event Evaluate current state Develop ideal state Identify inefficiencies/barriers in processes Initiate strategies to eliminate inefficiencies Develop metrics to track improvement

13 VSM continued Step 4 Refine flow map and disseminate to affected parties Step 5 Set start date and implement Step 6 Collect data and evaluate metrics of success Step 7 Implement continuous QA/QI activities

14 Current state STARS registry1 (~400 pts) Median DTN time: 96 min GWTG registry2 (> 25,000 pts) Median DTN time: 78 min DTN time 60 min in 26.6% Goal: DTN time 60 min in 50% of pts (80% for primary stroke centers) 1Albers et al. JAMA 2000;283: Fonarow et al. Circ 2011;123:750-8

15 Ideal state DTN time 60 min in 80% Average DTN time 30 min

16 Identify potential barriers to treatment Pre-hospital Lack of knowledge of stroke signs Lack of swift reaction in the real situation of stroke/recognition of acuity* Non-emergency mode of arrival to ED Transport to low stroke volume hospitals or those lacking treatment capabilities Relevant to DTN time *Teuschl & Brainin Int J Stroke 2010;5:

17 Barrier: non-emergency mode of transport No change in proportion of patients with stroke who present to ED via ambulance over past decade Kamel et al JAMA 2012;307:1026-8

18 Identify potential barriers to treatment In-hospital Education/awareness factors Lack of knowledge of stroke signs Lack of appreciation of acuity Biases against certain patient groups Ambivalence among some ED physicians Fear of rapid treatment compromising safety Natural proclivity to delay treatment System-based factors Lack of neurologist availability 24/7 Triage/ED flow issues

19 Barriers to rapid treatment: ED processes Systematic review of 54 studies (39,030 patients) assessing nature of barriers to rapid tpa treatment Failure to triage stroke as emergency Delay in neuroimaging Delay in medical assessment Difficulty obtaining informed consent Physician uncertainty in administering tpa Kwan et al Age Ageing 2004;33:116-21

20 Factors associated with increased DTN Patient factors Hospital factors Older age Fewer stroke admissions Female gender Fewer pts treated with tpa Black race Prior stroke/tia Atrial fibrillation Diabetes Arrival by private transport Arrival off hours Fonarow et al. Circ 2011;123:750-8

21 Barrier: Ambivalence among ED physicians Annals Emerg Med 2009;54:339-40

22 Barrier: Fear of compromised safety with lower DTN time Lower DTN time does not compromise safety in GWTG-stroke hospitals Fonarow et al. Circ 2011;123:750-8

23 Barrier: Natural tendency to delay treatment Clustering of treatment at end of time window Longer delay to treatment after 90minute mark 0-90 min stratum (n=302) min stratum (n=320) Median OTT 89 min 154 min DTN time 54 min 82 min Marler et al. Neurology 2000;55:1649-5

24 Barrier: In-house neurologist availability at academic centers ED triage RN activates acute stroke pager Potential delays Neurology resident performs rapid assessment Stroke attending or fellow comes in from clinic/office/home tpa decision

25 Solution: resident driven tpa protocol ED triage RN activates acute stroke pager In-house junior neurology resident, ED resident, ED staff respond Can call stroke attending as needed Junior neurology resident discusses case with senior neurology resident, reviews labs and CT results tpa decision Supported by Annual training NIHSS Thrombolysis protocol Thrombolysis literature Monthly interdepartmental quality control review Feedback to residents 1Ford et al. Stroke2009;40:1512-4

26 Resident-driven tpa protocol: efficacy 1Ford et al. Stroke2009;40:1512-4

27 Resident-driven tpa protocol: safety

28 Barrier: physician accessibility at nonacademic centers A majority of acute stroke patients present to hospitals lacking 24/7 availability of stroke specialists These patients are less likely to receive tpa Transfer to regional stroke center for tpa is possible, but means treatment delays 1Morgenstern LB et al Neurology 2004;62:

29 Solution: telestroke ( drip and ship ) Class I recommendations supporting telestroke in the acute stroke setting The NIHSS-telestroke examination is recommended when an NIHSSbedside assessment by a stroke specialist is not immediately available and this assessment is comparable to an NIHSS-bedside assessment (Class I, Level of Evidence A). Review of brain CT scans by stroke specialists or radiologists using teleradiology systems is useful for identifying exclusions for thrombolytic therapy in acute stroke patients (Class I, Level of Evidence A). Teleradiology systems are useful in supporting rapid imaging interpretation in time for thrombolysis decision making (Class I, Level of Evidence B). It is recommended that a stroke specialist using high-quality videoconferencing provide a medical opinion in favor of or against the use of intravenous tpa in patients with suspected acute ischemic stroke when on-site stroke expertise is not immediately available (Class I, Level of Evidence B). Schwamm et al Stroke 2009;40:

30 Telestroke-guided tpa leads to similar outcomes as treatment at stroke center Zaidi et al. Stroke 2011;42:3291-3

31 Improving telestroke at Wash U: support of spoke hospitals Parkland Health Center 130 bed community hospital No Neurologists Rare stroke patient admits pts treated with tpa EMS bypasses PHC Telemedicine robot deployed 2011 >60 patients evaluated in ED with stroke diagnosis 14 patients treated with tpa >113 pts transferred to BJH EMS no longer bypasses PHC

32 Improving telestroke at Wash U: reducing delays in patient acceptance/transfer Barriers: Inefficient routing of calls to services Frequent transfers of calls to find appropriate service Lack of ED bed availability

33 Improving telestroke at Wash U: reducing delays in patient acceptance/transfer Solution: Protocol developed to route calls to appropriate service Immediate acceptance of patient with behind the scenes allocation to appropriate service (no transfer of calls) Encourage direct admission to Neuro ICU, avoiding ED to ED transfer Communication between neurology resident, ICU fellow, and ICU charge nurse prior to bed placement Attending on line for all calls

34 Jul-Oct 2010 vs. Mar-Jun 2011 Prior to VSM After VSM p 14 (3.3) 9 (1.5) % 92% ICU direct admits Rate of patient calls (per month) Mean time to acceptance in minutes (SD) Patients accepted within 15 minutes Intervention Spencer et al ISC 2012

35 Barrier: ED processes Problems identified at BJH Overwhelming # of tasks to complete in short time Inefficient choreography Labs take too long

36 Problem 1: overwhelming # of tasks Admitting Patient identification Registration Room assignment EMS Deliver patient to room Report to nursing Nursing IV placement Monitor hook-up Vital sign monitoring Blood glucose Lab draw Weight estimate of patient Clinical Assessment History Medications/allergies Identification of witness Time of onset/last normal NIHSS Neuro exam Labs PT/PTT, CBC Emergent transport of bloods to lab Imaging Disconnect from monitor Transport to CT CT scan Transport from CT to room Reconnect to monitor Drug Preparation Order tpa Calculate tpa dose Prepare tpa Bolus and infuse tpa

37 Problem #2: Inefficient choreography CT Emergent Unit 1 CT 6 Nursing Station 1 Trauma Critical Care Ambulance Bay Slide courtesy of JM Lee

38 Problem 3: labs take too long Labs needed prior to giving tpa Platelets INR/PTT Blood glucose In 2010, it took on average 33 min to get results after ordering labs

39 Solution #1: Parallel processing

40 Solution #2: Streamlined choreography CT EmergentCT Unit 1 CT CT 6 Nursing Station 6 Nursing Station 1 Trauma Critical Care Trauma Critical Care Ambulance Bay Slide courtesy of JM Lee

41 Solution #3: Point of care labs POC labs for INR and glucose Platelets obtained as hemogram rather than CBC Don t wait for plt, PTT unless concern for coagulopathy/ac use

42 Metrics of success DTN time Number treated Safety Symptomatic ICH Other hemorrhage Stroke mimics

43 Protocol metrics

44 tpa metrics Intervention Time Interval (min) Door-to-Needle 40 Door-to-CT Number of Patients 0 Q1 Q2 Q3 Q4 Q5 Q6 Q1 Q2 Q3 Q4 Q5 Q Quarter

45 Discharge outcomes

46 Collateral benefits Greater treatment rates More patients for research studies Opportunities for interdepartmental collaboration Better education Better resource utilization

47 Decreasing DTN at your institution Determine rate limiting step(s) Stroke recognition? Locating witness? CT? Labs? Neurologist availability? Radiologist availability?

48 Decreasing DTN: Hospital and Pre-hospital Efforts Community Education: stroke recognition/mode of transport Hospital Education patient volume and tpa use EMS Pre-notification IV placement Bring witness to ED

49 Decreasing DTN: ED efforts Education: stroke recognition/counteract biases Creation of a protocol Parallel efforts (hx, time of onset, exam, blood, CT) Point-of-care labs/ Code Stroke designation Don t wait for plt, PT/INR, PTT (in most cases) Ensure highest acuity status for access to CT scanner Mix tpa early Periodic reminders of time Empower residents for decision-making Telemedicine if no neurologist availability Regular interdisciplinary review of cases/feedback

50 Stroke Neurology David Carpenter Andria Ford Jin-Moo Lee Renee Van Stavern Allyson Zazulia NNICU Michael Diringer Michael Rubin Neurology Residents Tomoko Sampson Robert Bucelli Mwiza Ushe Scott Norris Pablo Bravo Neuroradiology Colin Derdeyn Neurosurgery Greg Zipfel Emergency Medicine Brian Froekle Laura Heitsch Peter Panagos David Tan Neurology Fellows Naim Khoury Gyan Kumar Neuroscience Center Mary Spencer Adrienne Ford Neuroscience Nursing Jo-Ann Burns Tim Tranor Jennifer Wedner Emergency Nursing Jennifer Williams Lean Engineer Vikas Ghayal Brian Hoff