Abstract TP405: Raising the Bar, Lowering the Target

Background: In 2013 our growing regional stroke referral center was not meeting Target Stroke® best practice recommendations for door to needle times within 60 minutes. A Rapid Improvement Event (RIE) was held to decrease process waste and therefore improve treatment times. Process changes were implemented in January 2014. Twelve months of monitoring identified sustained improvement and evidence that the process could continue to improve therefore a second rapid improvement event was held in January 2015 targeting door to needle times within 45 minutes. Purpose: The purpose of the process improvement event was to decrease treatment times below 60 minutes targeting 45 minutes. Methods: The RIE was utilized as the platform to incorporate process improvement principles and evidence based practice in order to elevate the standard of care for patients experiencing ischemic stroke. A multidisciplinary team including pre-hospital and hospital staff met to develop a care model that would impact patients presenting with stroke like symptoms. Lean tools were used to capture waste and bring transparency to the process. A standardized pathway and standard work for each role were developed. Huddles to debrief on successes and barriers from each case were implemented as a way to increase staff engagement and familiarize them with the new process. Results: Significant improvement was achieved. Median door to needle treatment times decrease from 86 minutes to 49 minutes, a 43% improvement. Treatment within 60 minutes improved from 23% of eligible patient to 67% of eligible patients, this was an improvement of 66%. Treatment within 45 minutes improved from 6% of eligible patients to 45% of eligible patients, this was an improvement of 87%. Conclusion: Lean principles proved to be an effective tool for improving the thrombolytic delivery process for acute ischemic stroke patients.

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Application of Lean principles to improve early cardiac care in the emergency department

CJEM ◽

10.2310/8000.2011.110284 ◽

2011 ◽

Vol 13 (05) ◽

pp. 325-332 ◽

Cited By ~ 9

Author(s):

Zoë Piggott ◽

Erin Weldon ◽

Trevor Strome ◽

Alecs Chochinov

Keyword(s):

Emergency Department ◽

Cardiac Care ◽

Early Care ◽

Rapid Improvement ◽

Lean Principles ◽

Standard Work ◽

Coronary Syndrome ◽

Physician Assessment ◽

Before And After ◽

Electrocardiogram Ecg

ABSTRACTObjective:To achieve our goal of excellent emergency cardiac care, our institution embarked on a Lean process improvement initiative. We sought to examine and quantify the outcome of this project on the care of suspected acute coronary syndrome (ACS) patients in our emergency department (ED).Methods:Front-line ED staff participated in several rapid improvement events, using Lean principles and techniques such as waste elimination, supply chain streamlining, and standard work to increase the value of the early care provided to patients with suspected ACS. A chart review was also conducted. To evaluate our success, proportions of care milestones (first electrocardiogram [ECG], ECG interpretation, physician assessment, and acetylsalicylic acid [ASA] administration) meeting target times were chosen as outcome metrics in this before-and-after study.Results:The proportion of cases with 12-lead ECGs completed within 10 minutes of patient triage increased by 37.4% (p< 0.0001). The proportion of cases with physician assessment initiated within 60 minutes increased by 12.1% (p= 0.0251). Times to ECG, physician assessment, and ASA administration also continued to improve significantly over time (pvalues < 0.0001). Post-Lean, the median time from ECG performance to physician interpretation was 3 minutes. All of these improvements were achieved using existing staff and resources.Conclusions:The application of Lean principles can significantly improve attainment of early diagnostic and therapeutic milestones of emergency cardiac care in the ED.

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Abstract T P260: Confirmation: The Target Stroke Best Practice Strategies Work

Stroke ◽

10.1161/str.46.suppl_1.tp260 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Nojan Valadi ◽

Alexis Thomas

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Process Improvement ◽

Best Practice ◽

Stroke Patients ◽

High Performers ◽

Process Implementation ◽

Honor Roll ◽

Stroke Team ◽

Stroke Center

Background: A recent national push for optimizing stroke center performance led by the efforts of AHA/ASA to recognize high performers with the Target Stroke Honor Roll recognition have focused on achieving expedited treatment for stroke with door-to-needle (DTN) time of ≤60 minutes.Our organization recognized the need to optimize our performance and set an initial goal of achieving DTN time of ≤60 minutes in greater than 50% of our patients. The Target Stroke Initiative by the AHA/ASA identified 10 key strategies for best practice associated with reducing DTN times. Our organization adopted and implemented all of these strategies over a 30-day period. Methods: The Target Stroke best practice strategies were implemented over a 30-day period, and the Stroke Team worked collaboratively to identify other weaknesses needing to be addressed. DTN times ≤60 minutes from the 12 months prior to process improvement implementation were compared with the first 2 months post implementation. Results: There were 345 ischemic stroke patients treated at our facility during the 12 month period prior to the process implementation, with a total of 14 patients (1.12 per month) treated with tPA. The percentage of patients treated with tPA was 4%, and the percentage of patients treated with DTN ≤60 minutes was 0%. Over the two months following process implementation, 68 ischemic stroke patients were treated at our facility, with 11 patients treated with tPA (5.5 per month). The percentage of stroke patients treated with tPA was 16%, with 70% of patients treated with DTN ≤60 minutes. Conclusion: This study serves as confirmation that collaboration and implementation of the 10 key strategies for best practice as outlined by the Target Stroke Initiative, coupled with changes to identified areas of weakness, can improve and expedite the care of patients with acute ischemic stroke. This can substantially improve DTN times, as well as the overall number and percentage of patients that receive thrombolysis with a hopeful impact on their outcome as well as Target Stroke Honor Roll recognition for the facility. In conclusion, we recommend implementation of these best practice strategies to other facilities.

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Abstract TP255: Tackling Door in-Door Out Through a Statewide Initiative

Stroke ◽

10.1161/str.51.suppl_1.tp255 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Sheryl B Martin-Schild ◽

Deborah Spann ◽

Yvette Legendre ◽

Ted Colligan ◽

Paige Hargrove

Keyword(s):

Ischemic Stroke ◽

Process Improvement ◽

Emergency Response ◽

Standard Of Care ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Response Network ◽

Secondary Transfer ◽

Screening Study ◽

Median Interval

Background: The AHA/ASA has determined thrombectomy is standard-of-care up to 24 hours after last seen normal (LSN) for ischemic stroke patients with anterior circulation large vessel occlusion (LVO), provided the perfusion imaging profile meets criteria. Many patients require secondary transfer to access thrombectomy centers. The door in-door out (DIDO) is a target for process improvement. Methods: The Louisiana Emergency Response Network (LERN)’s stroke system of care was initiated in 2010. Submission of quarterly emergency department stroke data to LERN was voluntary as of Q1 2014 and was mandated as of Q1 2018 for hospitals attesting to Acute Stroke Ready Hospital (ASRH) capability. Sites across the state were invited to pilot expanded variable in order to assess LVO screening and baseline DIDO for patients with LVO. Results: Of 56 ASRHs, 34 sites submitted one or more quarters of data during the pilot phase contributing a total of 1808 cases. LVO screening was performed in 992 (54.9%) cases; 172 (17.3%) were LVO screened positive. VAN was used in 75.6% of LVO positive patients and CTA was used in 20.3%. Most patients (71.3%) arrived via ambulance. The median NIHSS in LVO positive patients was 12 (IQR 5-20). Transfer time was available in 114 (66%) LVO positive patients; median DIDO was 146 minutes (IQR 89-243 minutes). Transfer request time was available in 30 (17.4%) of LVO positive patients; median interval from transfer request to departure was 47 minutes (IQR 31-65 minutes). Discussion: Given that most patients with ischemic stroke caused by LVO will not present initially to a thrombectomy center, DIDO must be minimized to preserve penumbra and maximize likelihood of eligibility for thrombectomy when the thrombectomy center is accessed. LERN’s pilot LVO screening study established a baseline from which DIDO is a necessary target for intervention. Only 25% of LVO positive patients were transferred with DIDO less than 90 minutes. LERN’s initial goal is to shift the median DIDO to 90 minutes. Participation in the expanded variables targeting LVO screening and DIDO was mandated by LERN effective Q3 2018.

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Care of the Patient With Acute Ischemic Stroke (Posthyperacute and Prehospital Discharge): Update to 2009 Comprehensive Nursing Care Scientific Statement: A Scientific Statement From the American Heart Association

Stroke ◽

10.1161/str.0000000000000357 ◽

2021 ◽

Author(s):

Theresa L. Green ◽

Norma D. McNair ◽

Janice L. Hinkle ◽

Sandy Middleton ◽

Elaine T. Miller ◽

...

Keyword(s):

Ischemic Stroke ◽

Best Practices ◽

Acute Ischemic Stroke ◽

Nursing Care ◽

American Heart Association ◽

Best Practice ◽

American Heart ◽

Heart Association ◽

Standard Of Care ◽

Scientific Statement

In 2009, the American Heart Association/American Stroke Association published a comprehensive scientific statement detailing the nursing care of the patient with an acute ischemic stroke through all phases of hospitalization. The purpose of this statement is to provide an update to the 2009 document by summarizing and incorporating current best practice evidence relevant to the provision of nursing and interprofessional care to patients with ischemic stroke and their families during the acute (posthyperacute phase) inpatient admission phase of recovery. Many of the nursing care elements are informed by nurse-led research to embed best practices in the provision and standard of care for patients with stroke. The writing group comprised members of the Stroke Nursing Committee of the Council on Cardiovascular and Stroke Nursing and the Stroke Council. A literature review was undertaken to examine the best practices in the care of the patient with acute ischemic stroke. The drafts were circulated and reviewed by all committee members. This statement provides a summary of best practices based on available evidence to guide nurses caring for adult patients with acute ischemic stroke in the hospital posthyperacute/intensive care unit. In many instances, however, knowledge gaps exist, demonstrating the need for continued nurse-led research on care of the patient with acute ischemic stroke.

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Revascularization and functional outcomes after mechanical thrombectomy for acute ischemic stroke in elderly patients

Journal of Neurosurgery ◽

10.3171/2018.12.jns182399 ◽

2020 ◽

Vol 132 (4) ◽

pp. 1182-1187 ◽

Cited By ~ 1

Author(s):

Carrie E. Andrews ◽

Nikolaos Mouchtouris ◽

Evan M. Fitchett ◽

Fadi Al Saiegh ◽

Michael J. Lang ◽

...

Keyword(s):

Ischemic Stroke ◽

Elderly Patients ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Multivariate Logistic Regression Analysis ◽

Standard Of Care ◽

Stroke Severity ◽

Vessel Occlusion ◽

Younger Patients ◽

Success Of Treatment

OBJECTIVEMechanical thrombectomy (MT) is now the standard of care for acute ischemic stroke (AIS) secondary to large-vessel occlusion, but there remains a question of whether elderly patients benefit from this procedure to the same degree as the younger populations enrolled in the seminal trials on MT. The authors compared outcomes after MT of patients 80–89 and ≥ 90 years old with AIS to those of younger patients.METHODSThe authors retrospectively analyzed records of patients undergoing MT at their institution to examine stroke severity, comorbid conditions, medical management, recanalization results, and clinical outcomes. Univariate and multivariate logistic regression analysis were used to compare patients < 80 years, 80–89 years, and ≥ 90 years old.RESULTSAll groups had similar rates of comorbid disease and tissue plasminogen activator (tPA) administration, and stroke severity did not differ significantly between groups. Elderly patients had equivalent recanalization outcomes, with similar rates of readmission, 30-day mortality, and hospital-associated complications. These patients were more likely to have poor clinical outcome on discharge, as defined by a modified Rankin Scale (mRS) score of 3–6, but this difference was not significant when controlled for stroke severity, tPA administration, and recanalization results.CONCLUSIONSOctogenarians, nonagenarians, and centenarians with AIS have similar rates of mortality, hospital readmission, and hospital-associated complications as younger patients after MT. Elderly patients also have the capacity to achieve good functional outcome after MT, but this potential is moderated by stroke severity and success of treatment.

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Technical accounting: sugar extraction and losses

Sugar Industry ◽

10.36961/si25654 ◽

2020 ◽

pp. 712-721

Author(s):

Jan Maarten de Bruijn de Bruijn

Keyword(s):

Process Improvement ◽

Best Practice ◽

Continuous Process ◽

Extraction Yield ◽

Production Costs ◽

Raw Material ◽

Sugar Production ◽

Cost Leadership ◽

Sugar Extraction ◽

White Sugar

The bought sugar in the processed raw material (either beet or cane) comprises a high financial value and may contribute to somewhere around 50% of the white sugar production costs. It is therefore of the utmost importance to minimize sugar losses along the process and produce as much white sugar as possible from the raw material. This paper explains the principle of technical accounting as tool to control sugar extraction and losses in beet sugar manufacture. The sugar mass balance used to calculate the overall sugar extraction yield, as well as several simple calculations proposed for estimating the different sugar losses (like e.g. extraction (diffusion) losses, infection losses, sugar losses in molasses, etc.) in the subsequent process steps will be explained in detail. Proper technical accounting is considered indispensable for continuous process control and process improvement in pursuit of best-practice operation and cost-leadership.

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Ergonomic Process Improvement for Mapping Risk and Identifying Key Interventions for Eliminating Injuries from Needles and Sharps in the OR

Proceedings of the Human Factors and Ergonomics Society Annual Meeting ◽

10.1177/1071181320641166 ◽

2020 ◽

Vol 64 (1) ◽

pp. 716-720

Author(s):

Pramila Kalaga ◽

Barbara Wolford ◽

Matthew Mormino ◽

Timothy Kingston ◽

Julie Fedderson ◽

...

Keyword(s):

Risk Factors ◽

Process Improvement ◽

Injury Risk ◽

Best Practice ◽

Physical Workload ◽

Physical Factors ◽

Improvement Project ◽

Targeted Interventions ◽

Effective Interventions ◽

Sharps Injury

The risk of a needle stick or sharps injury in the operating room (OR) is high due to conditions such as minimal physical protective measures, frequent transfer of sharps, and reliance on human attention and skill for injury avoidance. An ergonomic process improvement project was initiated at a large metro teaching hospital to identify ergonomic risk factors for these OR injuries. To maximize the engagement of the front- end users, an ergonomic process improvement (EPI) team was developed, consisting of representatives from participating OR teams, an employee health nurse and two ergonomists. Surveys, observations, and interviews were conducted to quantify injury risk for the OR teams, evaluate barriers to best practice adherence, and identify opportunities for targeted interventions. Risk mapping was completed for the surgeons, surgical techs and OR nurses identifying double gloving and safe passing zone as areas in need of improvement. Through observation and interviews, researchers identified physical factors relating to musculoskeletal pain and cognitive factors leading to distractions as safety risk concerns. The overall success of the EPI was the engagement of the OR teams and surgeons in the process of identifying risk factors and potential opportunities for ergonomic solutions related to cognitive workload, physical workload, teamwork, and work design for injury prevention. The risk factors identified will provide the basis for developing targeted, effective interventions for eliminating injuries from needles and sharps within the OR.

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Abstract 115: Improving Door-to-Needle Times in Acute Ischemic Stroke: Interim Findings From Target: Stroke Phase II

Stroke ◽

10.1161/str.47.suppl_1.115 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Gregg C Fonarow ◽

Margueritte Cox ◽

Eric E Smith ◽

Jeffrey L Saver ◽

Mathew J Reeves ◽

...

Keyword(s):

Ischemic Stroke ◽

Phase I ◽

Acute Ischemic Stroke ◽

Phase Ii ◽

Best Practice ◽

Patient Characteristics ◽

Clinical Decision ◽

Absolute Difference ◽

First Year ◽

Rate Of Increase

Background: The benefits of intravenous tPA in acute ischemic stroke are time-dependent with guidelines recommending a door-to-needle (DTN) time of ≤60 minutes. The implementation of Target: Stroke Phase I in 2010 was associated with an increase in the proportion of patients with DTN times ≤60 minutes in the US from 28.9% in 2009 to 51.0% in 2013. This study aims to assess whether these improvements in DTN times could be maintained or further improved since the launch of Target: Stroke Phase II in Q2 2014. Methods: Target: Stroke Phase II identified and disseminated additional best practice strategies, provided updated clinical decision support tools, and set new hospital recognition goals. Rates of DTN times ≤60 minutes were compared during final 4 quarters of Phase I (Q4 2012-Q3 2013) vs. Phase II (Q2 2014-Q1 2015) and overall by linear weighted regression. Results: There were 99,176 intravenous tPA treated patients from 1228 GWTG-Stroke hospitals. Patient characteristics were similar during Phase I and II. Median DTN time significantly declined from the last 4 quarters of Phase I to the first 4 quarters of Phase II: 61 minutes (IQR 47-81) to 57 minutes (IQR 43-74) (P<0.0001). The % of patients with DTN times ≤60 minutes increased from last 4 quarters of Phase I to Phase II: 49.7% to 58.5%, absolute difference +8.8%, (P<0.0001). The % of patients with DTN times ≤45 minutes also increased from Phase I to Phase II: 22.0% to 29.2%, absolute difference +7.2%, (P<0.0001). The estimated annual rate of increase in patients with DTN times ≤60 minutes was 0.6% per year pre-Target Stroke, 5.6% per year during Phase I, and 8.6% in the first year of Phase II (P<0.0001) (Figure). Conclusions: The timeliness of tPA administration is continuing to improve in GWTG-Stroke hospitals participating in Target: Stroke Phase II. Nevertheless, ongoing quality improvement efforts will be required to meet the goals of ≥75% of patients with DTN times ≤60 minutes and ≥50% of patients with DTN times ≤ 45 minutes.

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Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018

International Journal of Stroke ◽

10.1177/1747493018786616 ◽

2018 ◽

Vol 13 (9) ◽

pp. 949-984 ◽

Cited By ~ 73

Author(s):

JM Boulanger ◽

MP Lindsay ◽

G Gubitz ◽

EE Smith ◽

G Stotts ◽

...

Keyword(s):

Emergency Department ◽

Ischemic Stroke ◽

Acute Stroke ◽

Transient Ischemic Attack ◽

Best Practice ◽

Stroke Care ◽

Stroke Management ◽

Practice Recommendations ◽

Prehospital Emergency ◽

Ischemic Attack

The 2018 update of the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners caring for persons with very recent symptoms of acute stroke or transient ischemic attack. The recommendations are intended for use by a interdisciplinary team of clinicians across a wide range of settings and highlight key elements involved in prehospital and Emergency Department care, acute treatments for ischemic stroke, and acute inpatient care. The most notable changes included in this 6th edition are the renaming of the module and its integration of the formerly separate modules on prehospital and emergency care and acute inpatient stroke care. The new module, Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care is now a single, comprehensive module addressing the most important aspects of acute stroke care delivery. Other notable changes include the removal of two sections related to the emergency management of intracerebral hemorrhage and subarachnoid hemorrhage. These topics are covered in a new, dedicated module, to be released later this year. The most significant recommendation updates are for neuroimaging; the extension of the time window for endovascular thrombectomy treatment out to 24 h; considerations for treating a highly selected group of people with stroke of unknown time of onset; and recommendations for dual antiplatelet therapy for a limited duration after acute minor ischemic stroke and transient ischemic attack. This module also emphasizes the need for increased public and healthcare provider’s recognition of the signs of stroke and immediate actions to take; the important expanding role of paramedics and all emergency medical services personnel; arriving at a stroke-enabled Emergency Department without delay; and launching local healthcare institution code stroke protocols. Revisions have also been made to the recommendations for the triage and assessment of risk of recurrent stroke after transient ischemic attack/minor stroke and suggested urgency levels for investigations and initiation of management strategies. The goal of this updated guideline is to optimize stroke care across Canada, by reducing practice variations and reducing the gap between current knowledge and clinical practice.

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The integration of lean, green and best practice business principles

Journal of Transport and Supply Chain Management ◽

10.4102/jtscm.v9i1.192 ◽

2015 ◽

Vol 9 (1) ◽

Cited By ~ 8

Author(s):

Annelize Wiese ◽

Rose Luke ◽

Gert J. Heyns ◽

Noleen M. Pisa

Keyword(s):

South Africa ◽

Business Model ◽

Best Practice ◽

Business Success ◽

Descriptive Case Study ◽

Lean Principles ◽

Clear Link ◽

Business Principles ◽

Practice Culture

Background: Whilst there are separate streams of established research on lean, green and best practice initiatives, the intersection of these three strategic principles has not been addressed extensively in the past.Objectives: In this study a framework to integrate lean, green and best practice principles into an integrated business model was developed as a strategy for businesses to develop sustainable competitive advantages.Method: A descriptive case study was conducted on Toyota South Africa Motors (TSAM) to understand whether a clear link between the company’s environmental approach, lean principles and established best practice culture could be determined. In addition, the case study tested the view that the implementation of these three principles concurrently resulted in improved business results.Results: The main findings of the study revealed that TSAM’s commitment to lean, green and best practice business principles contributed and was directly linked to its business success in terms of sales and market position.Conclusion: It is recommended that businesses implement an integrated lean, green and best practice business model as a strategy to reduce costs and sustainably enhance profitably and competitiveness.

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