LAUSR

Background: Lean thinking aims to streamline organisational processes to improve quality and patient safety through waste reduction and increased efficiency. Shortening the door to needle time is an indicator of quality improvement in acute stroke. Methods: Key areas for process improvement and streamlining were identified in the thrombolysis pathway. These included the pre-alert hospital system, the pre-alert for emergency CT and the acute stroke management proforma. A review of the existing process was conducted and compared with outcomes after implementation of the changes. Outcomes in a standard 9 to 5 working day were also compared with ‘on-call’ hours. Results: A total number of 9 patients received thrombolysis in the six months prior to implementation of the lean project. The absolute numbers of patients receiving thrombolysis improved by 60% in the six months after implementation, to 15 patients. A total number of 27 post implementation thrombolysis cases were reviewed. The door to imaging time improved from an average of 38 minutes, to 23 minutes. In hours this improved from 28 minutes to 13 minutes. Out of hours this improved from 44 minutes to 30 minutes. The average door to needle time was 73 minutes beforehand with an improvement to 49 minutes after 9 to 5 pm door to needle time improved from an average of 56 minutes to 34 minutes. Out of hours average door to needle time improved from 99 minutes to 63 minutes. The redesigned stroke proforma enabled swifter communication and clerking which was proven upon re audit. Conclusion: Lean process implementation streamlined the steps in the thrombolysis pathway. The door to needle time improved to under one hour, which is an international benchmark target. The success of this new strategy needs to embed the culture of the hyperacute management of stroke, and to strive for continual improvement.