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

CJEM ◽  
2011 ◽  
Vol 13 (05) ◽  
pp. 325-332 ◽  
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.

Abstract 17595: The Value of Continuous ST-Segment Monitoring in the Emergency Department: a Quasi-Experimental Pre-Post Study

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Leonie L Rose Bovino ◽  
Michele M Pelter ◽  
Mayur M Desai ◽  
Vanessa Jefferson ◽  
Laura K Andrews ◽  
...  
Keyword(s):  
Emergency Department ◽  
Diagnostic Accuracy ◽  
Intermediate Risk ◽  
Intervention Phase ◽  
Coronary Syndrome ◽  
St Segment ◽  
Significant Difference ◽  
Time To Diagnosis ◽  
Before And After ◽  
Risk Patients

Purpose: The AHA Practice Standards for ECG Monitoring recommend continuous ST-segment monitoring (C-STM) in patients presenting to the emergency department (ED) with signs and/or symptoms suggestive of acute coronary syndrome (ACS), but few studies have evaluated its use in the ED. Our aims were to compare the time to diagnosis and 30-day adverse events (return to the ED with signs and/or symptoms of ACS, hospital admission, acute myocardial infarction, use of reperfusion therapy, or mortality) before and after implementation of C-STM. We also evaluated the diagnostic accuracy of C-STM in detecting ischemia or infarction, using stress test and troponin I results as reference standards. Methods: We prospectively studied 163 adults (pre-intervention phase: n=78; intervention phase: n=85) in the ED at a single hospital. We stratified patients into low (n=51), intermediate (n=100), or high (n=12) risk using HEART scores. The principal investigator monitored participants, activating C-STM on bedside monitors in the intervention phase. We used likelihood ratios (LRs) as the measure of diagnostic accuracy. By convention, a positive (+) LR is diagnostic at >10 and a negative (-) LR at <0.1. Results: Overall, 9% of patients were diagnosed with ACS. There was no significant difference in median time to ACS diagnosis before and after implementation of C-STM (5.55 vs. 5.98 hours; p=0.43 for Mann-Whitney U test). In risk-stratified analyses, no significant pre-post difference in time to ACS diagnosis was found in low-, intermediate-, or high-risk patients. There was no difference in the rate of any 30-day adverse event before vs. after C-STM implementation (11.5% vs. 10.6%; p=0.85 Chi-squared test). None of 3 episodes of ST-segment changes on C-STM represented ACS. The +LR and -LR of C-STM for ischemia were 24.0 (95% CI 1.4 - 412.0) and 0.3 (95% CI 0.02 - 2.9), respectively; and for infarction were 13.7 (95% CI 1.7 - 112.3) and 0.7 (95% CI 0.3 - 1.5), respectively. Conclusion: In this sample of mainly low- to intermediate-risk patients, use of C-STM did not improve time to diagnosis or 30-day adverse outcomes, nor provide much benefit in detecting myocardial ischemia or infarction. Use of C-STM may need to be re-evaluated for patients with low to intermediate risk for ACS in the ED.

scholarly journals Decline of emergency admissions for cardiovascular and cerebrovascular events after the outbreak of COVID-19

2020 ◽  
Author(s):  
Viktoria Schwarz ◽  
Felix Mahfoud ◽  
Lucas Lauder ◽  
Wolfgang Reith ◽  
Stefanie Behnke ◽  
...  
Keyword(s):  
Emergency Department ◽  
The Novel ◽  
Emergency Admissions ◽  
Coronary Syndrome ◽  
Cerebrovascular Events ◽  
Significant Difference ◽  
Before And After ◽  
St Elevation ◽  
Ischemic Attack ◽  
Novel Coronavirus

Abstract Background The spread of the novel coronavirus SARS-CoV-2 and the guidance from authorities for social distancing and media reporting lead to significant uncertainty in Germany. As concerns have been expressed regarding the underdiagnosing of harmful diseases. We explored the rates of emergency presentations for acute coronary syndrome (ACS) and acute cerebrovascular events (ACVE) before and after spread of SARS-CoV-2. Methods We analyzed all-cause visits at a tertiary university emergency department and admissions for ACS and ACVE before (calendar weeks 1 to 9, 2020) and after (calendar weeks 10 to 16, 2020) the first coronavirus disease (COVID-19) case in the region of the Saarland, Germany. The data were compared with the same period of the previous year. Results In 2020 an average of 346 patients per week presented at the emergency department whereas in 2019 an average of 400 patients presented up to calendar week 16 (p=0.018; whole year 2019 = 395 patients per week). After the first COVID-19 diagnosis in the region, emergency department visit volume decreased by 30% compared with the same period in 2019 (p=0.0012). Admissions due to ACS decreased by 41% (p=0.0023 for all; Δ -71% (p=0.007) for unstable angina, Δ -25% (p=0.42) for myocardial infarction with ST-elevation and Δ -17% (p=0.28) without ST-elevation) compared with the same period in 2019 and decreased from 142 patients in calendar weeks 1 to 9 to 62 patients in calendar weeks 10 to 16. ACVE decreased numerically by 20% (p=0.25 for all; transient ischemic attack: Δ -32% (p=0.18), ischemic stroke: Δ -23% (p=0.48), intracerebral haemorrhage: Δ +57% (p=0.4)). There was no significant change in ACVE per week (p=0.7) comparing calendar weeks 1 to 9 (213 patients) and weeks 10 to 16 (147 patients). Testing of 3756 samples was performed to detect 58 SARS-CoV-2 positive patients (prevalence 1,54%, thereof one patient with myocardial and two with cerebral ischemia) up to calendar week 16 in 2020. Conclusions The COVID-19 pandemic was associated with a significant decrease in all-cause admission and admissions due to cardiovascular events in the emergency department. Regarding acute cerebrovascular events there was a numerical decrease but no significant difference.

scholarly journals Decline of emergency admissions for cardiovascular and cerebrovascular events after the outbreak of COVID-19

2020 ◽  
Vol 109 (12) ◽  
pp. 1500-1506 ◽  
Author(s):  
Viktoria Schwarz ◽  
Felix Mahfoud ◽  
Lucas Lauder ◽  
Wolfgang Reith ◽  
Stefanie Behnke ◽  
...  
Keyword(s):  
Emergency Department ◽  
The Novel ◽  
Emergency Admissions ◽  
Coronary Syndrome ◽  
Cerebrovascular Events ◽  
Significant Difference ◽  
Before And After ◽  
St Elevation ◽  
Ischemic Attack ◽  
Novel Coronavirus

Abstract Background The spread of the novel coronavirus SARS-CoV-2 and the guidance from authorities for social distancing and media reporting lead to significant uncertainty in Germany. Concerns have been expressed regarding the underdiagnosing of harmful diseases. We explored the rates of emergency presentations for acute coronary syndrome (ACS) and acute cerebrovascular events (ACVE) before and after spread of SARS-CoV-2. Methods We analyzed all-cause visits at a tertiary university emergency department and admissions for ACS and ACVE before (calendar weeks 1–9, 2020) and after (calendar weeks 10–16, 2020) the first coronavirus disease (COVID-19) case in the region of the Saarland, Germany. The data were compared with the same period of the previous year. Results In 2020 an average of 346 patients per week presented at the emergency department whereas in 2019 an average of 400 patients presented up to calendar week 16 (p = 0.018; whole year 2019 = 395 patients per week). After the first COVID-19 diagnosis in the region, emergency department visit volume decreased by 30% compared with the same period in 2019 (p = 0.0012). Admissions due to ACS decreased by 41% (p = 0.0023 for all; Δ − 71% (p = 0.007) for unstable angina, Δ − 25% (p = 0.42) for myocardial infarction with ST-elevation and Δ − 17% (p = 0.28) without ST-elevation) compared with the same period in 2019 and decreased from 142 patients in calendar weeks 1–9 to 62 patients in calendar weeks 10–16. ACVE decreased numerically by 20% [p = 0.25 for all; transient ischemic attack: Δ − 32% (p = 0.18), ischemic stroke: Δ − 23% (p = 0.48), intracerebral haemorrhage: Δ + 57% (p = 0.4)]. There was no significant change in ACVE per week (p = 0.7) comparing calendar weeks 1–9 (213 patients) and weeks 10–16 (147 patients). Testing of 3756 samples was performed to detect 58 SARS-CoV-2 positive patients (prevalence 1,54%, thereof one patient with myocardial and two with cerebral ischemia) up to calendar week 16 in 2020. Conclusions The COVID-19 pandemic was associated with a significant decrease in all-cause admission and admissions due to cardiovascular events in the emergency department. Regarding acute cerebrovascular events there was a numerical decrease but no significant difference.

Abstract TP405: Raising the Bar, Lowering the Target

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Theresa M Price
Keyword(s):  
Ischemic Stroke ◽  
Process Improvement ◽  
Best Practice ◽  
Eligible Patient ◽  
Standard Of Care ◽  
Hospital Staff ◽  
Rapid Improvement ◽  
Lean Principles ◽  
Standard Work ◽  
Process Waste

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.

Use of Ophthalmic Sonography to Evaluate for Intraocular Foreign Body in Both Outpatient and Emergency Department/Urgent Care Patients

2021 ◽  
pp. 875647932110332
Author(s):  
Patrick J. Fish
Keyword(s):  
Emergency Department ◽  
Foreign Body ◽  
Foreign Bodies ◽  
Outpatient Setting ◽  
Intraocular Foreign Body ◽  
Urgent Care ◽  
Posterior Chamber ◽  
Emergency Department Setting ◽  
Before And After ◽  
Glass Metal

Intraocular foreign bodies (IOFB) present differently depending on the type of material (wood, glass, metal) for the IOFB, extent of the injury, and location of the injury. IOFB and the injury can cause a perforation or penetration of the globe which can require more extensive treatment including surgery. Proper evaluation of the IOFB and injury can help to determine extent of the injury, the prognosis of the vision, and health of the eye before and after treatment but may be difficult for the physician depending on the view of the posterior chamber being compromised by media or simply by patient sensitivity. The extent of the injury may also prevent proper evaluation due to swelling, lacerations on the lids, or pain. Proper ophthalmic sonography can provide a quick evaluation of the globe for any IOFB in both the outpatient setting as well as emergency department setting. Evaluation via sonography may allow the physician to accurately diagnose and properly treat the patient to help restore and prevent further loss of vision.

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