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Effective management of patients with acute ischemic stroke based on lean production on thrombolytic flow optimization

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Abstract

The efficacy of thrombolytic therapy for acute ischemic stroke (AIS) decreases when the administration of tissue plasminogen activator (tPA) is delayed. Derived from Toyota Production System, lean production aims to create top-quality products with high-efficiency procedures, a concept that easily applies to emergency medicine. In this study, we aimed to determine whether applying lean principles to flow optimization could hasten the initiation of thrombolysis. A multidisciplinary team (Stroke Team) was organized to implement an ongoing, continuous loop of lean production that contained the following steps: decomposition, recognition, intervention, reengineering and assessment. The door-to-needle time (DNT) and the percentage of patients with DNT ≤ 60 min before and after the adoption of lean principles were used to evaluate the efficiency of our flow optimization. Thirteen patients with AIS in the pre-lean period and 43 patients with AIS in the lean period (23 in lean period I and 20 patients in lean period II) were consecutively enrolled in our study. After flow optimization, we reduced DNT from 90 to 47 min (p < 0.001¤). In addition, the percentage of patients treated ≤60 min after hospital arrival increased from 38.46 to 75.0 % (p = 0.015¤). Adjusted analysis of covariance confirmed a significant influence of optimization on delay of tPA administration (p < 0.001). The patients were more likely to have a good prognosis (mRS ≤ 2 at 90 days) after the flow optimization (30.77–75.00 %, p = 0.012¤). Our study may offer an effective approach for optimizing the thrombolytic flow in the management of AIS.

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References

  1. Studnek JR, Bentley M, Crawford JM, Fernandez AR (2010) An assessment of key health indicators among emergency medical services professionals. Prehosp Emerg Care 14(1):14–20

    Article  PubMed  Google Scholar 

  2. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group (1995) Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 333(24):1581–1587

    Article  Google Scholar 

  3. Hacke W, Kaste M, Bluhmki E, Brozman M, Davalos A, Guidetti D et al (2008) Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 359(13):1317–1329

    Article  CAS  PubMed  Google Scholar 

  4. Jl S (2006) Time is brain—quantified. Stroke 37(1):263–266

    Article  Google Scholar 

  5. Meretoja A, Keshtkaran M, Saver JL, Tatlisumak T, Parsons MW, Kaste M et al (2014) Stroke thrombolysis: save a minute, save a day. Stroke 45(4):1053–1058

    Article  PubMed  Google Scholar 

  6. Xu AD, Ding Y, Li M (2014) The current state, barriers and improving strategies of intravenous thrombolysisfor acute ischemic stroke in China. China J Stroke 9(6):522–528

    Google Scholar 

  7. Wang YL, Liao XL, Zhao XQ, Wang DZ, Wang C, Nguyen-Huynh MN et al (2011) Using recombinant tissue plasminogen activator to treat acute ischemic stroke in China: analysis of the results from the Chinese National Stroke Registry (CNSR). Stroke 42(6):1658–1664

    Article  CAS  PubMed  Google Scholar 

  8. Kwan J, Hand P, Sandercock P (2004) A systematic review of barriers to delivery of thrombolysis for acute stroke. Age Ageing 33(2):116–121

    Article  PubMed  Google Scholar 

  9. Garcia-Monco JC, Pinedo A, Escalza I, Ferreira E, Foncea N, Gomez-Beldarrain M (2007) Analysis of the reasons for exclusion from tPA therapy after early arrival in acute stroke patients. Clin Neurol Neurosurg 109(1):50–53

    Article  PubMed  Google Scholar 

  10. Chinese Society of Neurology (2015) Guidelines for Chinese diagnosis and treatment of acute ischemic stroke 2014. Chin J Neurol 48(4):246–257

    Google Scholar 

  11. Li W, Wang H, Wang YJ, Wu Y, Liu CC, Zhang ZH (2014) Effect of perfecting stroke green channel on improving intravenous thrombolysis rate of AIS. Chongqing Med 43(16):1979–1982

    Google Scholar 

  12. Qin JC, Zhou LS, Liu ML, Kong DL (2011) Value of emergency green track in rescuing patient s with acute ischemic stroke. Clin Focus 26(4):310–314

    Google Scholar 

  13. Lei L, Zhou HB, Peng K, Peng J, Yang YZ (2014) Analysis on epidemiological characteristics of cerebral stroke in residents of Shenzhen city from 2008 to 2013. Chin J Prev Control Dis 22(5):564–566

    Google Scholar 

  14. Zhou H, Chi H, Xiong J (2008) Analysis on the incidence and mortality of stroke in Urban residents of Shenzhen. Chin J Prev Control Chron Non-commun Dis 16(3):236–238

    Google Scholar 

  15. Becker RM (2001) Lean manufacturing and the Toyota production system. Automot Manuf Prod 113(6):64

    Google Scholar 

  16. Womack JP, Jones DT, Daniel R (1992) The machine that changed the world. Bus Horiz 35(3):81–82

    Article  Google Scholar 

  17. Holweg M (2007) The genealogy of lean production. J Oper Manag 25(2):420–437

    Article  Google Scholar 

  18. Joosten T, Bongers I, Janssen R (2009) Application of lean thinking to health care: issues and observations. Int J Qual Health Care 21(5):341–347

    Article  PubMed  PubMed Central  Google Scholar 

  19. Kim CS, Spahlinger DA, Kin JM, Billi JE (2006) Lean health care: what can hospitals learn from a world-class automaker? J Hosp Med 1(3):191–199

    Article  PubMed  Google Scholar 

  20. Ng D, Vail G, Thomas S, Schmidt N (2010) Applying the Lean principles of the Toyota production system to reduce wait times in the emergency department. CJEM 12(1):50–57

    Article  PubMed  Google Scholar 

  21. Bush RW (2007) Reducing waste in US health care systems. JAMA 297(8):871–874

    Article  CAS  PubMed  Google Scholar 

  22. Teich ST, Faddoul FF (2013) Lean management—the journey from Toyota to healthcare. Rambam Maimonides Med J 4(2):e0007

    Article  PubMed  PubMed Central  Google Scholar 

  23. Dorothy B, Leslie H, Shelly MM, Diana S, Contino JJ et al (2013) Barnes-Jewish Hospital applies lean methodology to acute stroke care, maximizing resources and slashing door-to-needle times. ED Manag 25(2):13–17

    Google Scholar 

  24. Ford AL, Williams JA, Spencer M, McCammon C, Khoury N, Sampson TR et al (2012) Reducing door-to-needle times using Toyota’s lean manufacturing principles and value stream analysis. Stroke 43(12):3395–3398

    Article  PubMed  PubMed Central  Google Scholar 

  25. Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM et al (2013) Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 44(3):870–947

    Article  PubMed  Google Scholar 

  26. Rizos T, Herweh C, Jenetzky E, Lichy C, Ringleb PR, Hacke W, Veltkamp R (2009) Point-of-care international normalized ratio testing accelerates thrombolysis in patients with acute ischemic stroke using oral antico-agulants. Stroke J Cereb Circ 40(11):3547–3551. doi:10.1161/STROKEAHA.109.562769

    Article  CAS  Google Scholar 

  27. Walter S, Kostopoulos P, Haass A, Lesmeister M, Grasu M, Grunwald I et al (2011) Point-of-care laboratory halves door-to-therapy-decision time in acute stroke. Ann Neurol 69(3):581–586

    Article  PubMed  Google Scholar 

  28. Wang Z (2009) Chinese stroke epidemiology and community groups to intervene. Chin J Front Med Sci (Electronic Version) 1(2):49–53

    Google Scholar 

  29. Cho HJ, Lee KY, Nam HS, Kim YD, Song TJ, Jung YH et al (2014) Process improvement to enhance existing stroke team activity toward more timely thrombolytic treatment. J Clin Neurol 10(4):328–333

    Article  PubMed  PubMed Central  Google Scholar 

  30. Kohrmann M, Schellinger PD, Breuer L, Dohrn M, Kuramatsu JB, Blinzler C et al (2011) Avoiding in hospital delays and eliminating the three-hour effect in thrombolysis for stroke. Int J Stroke 6(6):493–497

    Article  PubMed  Google Scholar 

  31. Erridge P (2016) The Pareto principle. Br Dent J 201(7):419

    Article  Google Scholar 

  32. Ralph CC, Charles L (2002) The Pareto principle in organizational decision making. Manag Decis 40(8):729–733

    Article  Google Scholar 

  33. Huang Q, Ma QF, Feng J, Cheng WY, Jia JP, Song HQ et al (2015) Factors associated with in-hospital delay in intravenous thrombolysis for acute ischemic stroke: lessons from China. PLoS One 10(11):e0143145. doi:10.1371/journal.pone.0143145

    Article  PubMed  PubMed Central  Google Scholar 

  34. Marler JR, Jones PW, Emr M (1996) Proceedings of a national symposium on rapid identification and treatment of acute stroke. NINDS, Washington, DC

  35. Dangayach NS, Panchabhai TS (2010) Point-of-care international normalized ratio measurements to assess eligibility for thrombolysis in acute ischemic stroke: some thoughts. Stroke J Cereb Circ 41(5):e431. doi:10.1161/STROKEAHA.109.574848

    Article  Google Scholar 

  36. Kollberg B, Dahlgaard JJ, Brehmer P-O (2007) Measuring lean initiatives in health care services: issues and findings. Int J Product Perform Manag 56(1):7–24

    Article  Google Scholar 

  37. Womack JP, Jones DT (1997) Lean thinking-banish waste and create wealth in your corporation. J Oper Res Soc 48(11):1148

    Article  Google Scholar 

  38. Brown DL, Johnston KC, Wagner DP et al (2004) Predicting major neurological improvement with intravenous recombinant tissue plasminogen activator treatment of stroke. Stroke 35(1):147–150

    Article  CAS  PubMed  Google Scholar 

  39. Zhang XQ, Li Q, He ZY (2015) Study on the correlation factors for short-term efficacy after intravenous thrombolytic therapy. Pract Pharm Clin Rem 18(11):1335–1338

    Google Scholar 

  40. Kimura K, Iguchi Y, Shibazaki K et al (2009) IV t-PA therapy in acute stroke patients with atrial fibrillation. J Neurol Sci 276(1–2):6–8

    Article  CAS  PubMed  Google Scholar 

  41. Meretoja A, Strbian D, Mustanoja S, Tatlisumak T, Lindsberg PJ, Kaste M (2012) Reducing in-hospital delay to 20 minutes in stroke thrombolysis. Neurology 79(4):306–313

    Article  PubMed  Google Scholar 

  42. Lindsberg PJ, Soinne L, Roine RO, Salonen O, Tatlisumak T, Kallela M et al (2003) Community-based thrombolytic therapy of acute ischemic stroke in Helsinki. Stroke 34(6):1443–1449

    Article  CAS  PubMed  Google Scholar 

  43. Tai YJ, Weir L, Hand P, Davis S, Yan B (2012) Does a ‘code stroke’ rapid access protocol decrease door-to-needle time for thrombolysis? Intern Med J 42(12):1316–1324

    Article  CAS  PubMed  Google Scholar 

  44. Meretoja A, Weir L, Ugalde M, Yassi N, Yan B, Hand P (2013) Helsinki model cut stroke thrombolysis delays to 25 minutes in Melbourne in only 4 months. Neurology 81(12):1071–1076

    Article  CAS  PubMed  Google Scholar 

  45. Hsieh CY, Chen WF, Chen CH et al (2014) Efforts to reduce the door-to-needle time of thrombolysis in acute ischemic stroke: video-assisted therapeutic risk communication. J Formos Med Assoc 113(12):929–933

    Article  PubMed  Google Scholar 

  46. Joosten T, Bongers I, Janssen R (2009) Application of lean thinking to health care: issues and observations. Int J Qual Health Care 21(5):341–347. doi:10.1093/intqhc/mzp036

    Article  PubMed  PubMed Central  Google Scholar 

  47. Libman RB, Wirkowski E, Alvir J, Rao TH (1995) Conditions that mimic stroke in the emergency department. Implications for acute stroke trials. Arch Neurol 52(11):1119–1122

    Article  CAS  PubMed  Google Scholar 

  48. Scott PA, Silbergleit R (2003) Misdiagnosis of stroke in tissue plasminogen activator-treated patients: characteristics and outcomes. Ann Emerg Med 42(5):611–618

    Article  PubMed  Google Scholar 

  49. Tsivgoulis G, Zand R, Katsanos AH, Goyal N, Uchino K, Chang J et al (2015) Safety of intravenous thrombolysis in stroke mimics: prospective 5-year study and comprehensive meta-analysis. Stroke 46(5):1281–1287

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgments

This work was supported in part by Guangdong Province Science and Technology Project (2013B021800102), Shenzhen Knowledge Innovation Program (20130322131035) and Shenzhen-based research project (JCYJ20140414170821262), Technology development item of Shenzhen science and technology innovation committee (CXZZ20140610151856719, JCYJ20151030151431727) and Clinical Doctor-Basic Scientist Combination Foundation of Shenzhen Second People’s Hospital.

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Authors and Affiliations

  1. Departments of Shenzhen Second People’s Hospital, Graduate School of Guangzhou Medical University, Shenzhen, Guangdong Province, China

    Zhuoyuan Liang, Lijie Ren & Ting Wang

  2. Department of Neurology, Shenzhen Second People’s Hospital, Sungang West Road, Shenzhen, 518000, Guangdong Province, China

    Zhuoyuan Liang, Lijie Ren, Ting Wang, Huoyou Hu & Yaping Wang

  3. Department of Neurosurgery, Shenzhen Key Laboratory of Neurosurgery, Shenzhen Second People’s Hospital, Shenzhen, Guangdong Province, China

    Weiping Li

  4. Department of Emergency, Shenzhen Second People’s Hospital, Shenzhen, Guangdong Province, China

    Dehong Liu

  5. Department of Radiology, Shenzhen Second People’s Hospital, Shenzhen, Guangdong Province, China

    Yi Lie

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  1. Zhuoyuan Liang
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Correspondence to Lijie Ren.

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Liang, Z., Ren, L., Wang, T. et al. Effective management of patients with acute ischemic stroke based on lean production on thrombolytic flow optimization. Australas Phys Eng Sci Med 39, 987–996 (2016). https://doi.org/10.1007/s13246-016-0442-1

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