NURS 6025 Transforming Nursing and Healthcare
Optimizing the Workflow in Stroke Care
A stroke is a medical emergency when the blood flow to the brain stops, which could lead to brain damage, disability, and death (American Stroke Association [ASA], 2013). It is one of the major cause of serious disability for adults and is the fifth leading cause of death in the United States (Centers for Disease Control and Prevention, 2018). For every minute passed during an ischemic stroke, there are 1.9 million neurons, 14 billion synapses, and 12 km (7.5 miles) of myelinated fibers are being destroyed (Saver, 2006). According to Saver (2006), “each hour in which treatment fails to occur, the brain loses as many neurons as it does in almost 3.6 years of normal aging” (p. 265). Hence, there is a real urgency to treat a patient with stroke once he or she arrives in an emergency room. The purpose of this study is to determine ways to analyze the current workflow in the emergency room (ER) of Adventist Health Hospital in Bakersfield and propose ways to improve the workflow as supported by evidenced-based practice research.NURS 6025 Transforming Nursing and Healthcare
Traditional Stroke Care
The goal of stroke care in the emergency department is to administer a thrombolytic (i.e. tPA) within 4.5 hours from the time of initial presentation of stroke symptoms. The current guideline for treatment (door-to-needle time [DTN]) is to administer a tPA within 60 minutes of patient arrival in the hospital (ASA/American Heart Association, 2013). The current workflow of the ER at Adventist Health Hospital in stroke care involves many steps. First, the emergency medical services (EMS) gives a report to a radio communication to the charge nurse. Upon arrival, the patient is brought in to the ambulance bay, where a registrar, ER doctor (ER MD) and triage nurse can talk to the patient. The ER MD then makes the decision if the patient meets a stroke alert. The secretary makes an overhead page saying “stroke alert in ambulance gurney” to alert laboratory, radiology, ER technician (ER-T) for time-sensitive interventions for this patient. The ER-T performs EKG and phlebotomist will perform lab draw while waiting for a call from CT scan if they are ready for the patient to be transported. NURS 6025 Transforming Nursing and Healthcare
Once the CT is ready, the secretary will alert the ER nurse to transfer the patient to CT room. From here, the patient will be evaluated if he or she has a brain bleed. If there is a brain bleed, the patient will be directed back immediately to the assigned bed in the ER and wait for further orders. If there is no brain bleed, the patient will have another exam in CT room called CT angiography to better locate the presence of the blood clot. Once, this is done, the patient is then transported to a weighing scale pad since the treatment is weight-based and the ER gurney does not have a built-in weighing scale. After this, the patient is transported back to an ER bed to be evaluated by teleneurologist if the patient is tPA candidate. The nurse will administer tPA if a patient is eligible for tPA. Refer to Appendix A for the flowchart.
Studies Involving Improved Workflow
Zinkstok, et al. (2016) implemented the Acute Brain Care (ABC) intervention study to optimize in-hospital stroke treatment and reduce DTN time in a single-center hospital. The first step in this project includes transferring the patient directly into the CT scanner upon arrival. Vital signs checks, brief neurological examination, and blood drawing are all performed simultaneously by the stroke team on the CT-table. After this, the patient is transferred to a dedicated ABC-room adjacent to the CT-room. The patients are weighed using a bed with built-in scales. The researchers found out that the traditional way of weighing a patient using a weight scale mat took more than 5 minutes (Zinkstok, et al., 2016). The results of the study showed that before the ABC intervention, there were no patients (0.0%) out of the 100 patients that were treated for stroke < = 30 minutes. After the introduction of the intervention, 234 (62.7%) of the 373 patients were treated <= 30 minutes. Moreover, the median DTN time decreased from 75 minutes to 28 minutes.NURS 6025 Transforming Nursing and Healthcare
Speirs and Mitchell (2015) studied the effect of a direct to CT approach to reducing the door-to-needle time. The interventions involve directing the EMS to CT upon patient’s hospital arrival and delaying other tasks until CT examination was adopted. The researchers compared data 1 year after the implementation of the new process. The results were significant. The door-to-CT time was decreased by 9.71 minutes, the door-to-CT result time was decreased by 11.68 minutes, and the door-to-needle time was decreased by 7.63 minutes. The researchers also found that 57.9% of patients received tPA within 60 minutes compared to 29.4% prior to the intervention.
Proposed Workflow and Technology
The proposed change is inspired by the evidence-based research. Upon receiving the EMS report, the charge nurse should call overhead page of a stroke alert and estimated time of arrival (ETA). For example, one should say “stroke alert to CT room, 5 minutes ETA”. Upon arrival, the patient should be transported directly to CT room where the stroke team can perform procedures for the patient. After the CT is done, the team can continue with their respective assignment while waiting if the patient needs CT angiogram done. Once the CT angiogram is done, the patient will be transported to a dedicated stroke room to evaluate if tPA is appropriate for the patient. A bed with built-in weighing scale should be present in this room. The nurse can also prepare and administer the tPA on this room. The patient will receive the tPA if he or she is deemed eligible. If it is not, he or she will receive the standard of care for stroke patients. Refer to Appendix B for the flowchart.
Importance of the Awareness of a Workflow
According to McGonigle and Mastrian (2018), “current-state mapping provides the opportunity for the process redesign team to distinguish between value-added and non-value-added activities” (p. 253). It is important to be aware of a workflow to know which areas of the process need improvement and which elements are irrelevant. This can be seen in the proposed workflow change when I eliminated the travel time of weighing a patient by using a bed with built-in weighing scale. I also made use of time when I proposed to incorporate continuing interventions in CT while waiting for the results of the CT scan to come back. Transport and waiting are two of the seven categories of waste listed by McGonigle and Mastrian (2018, p. 255). One can optimize a workflow process by being aware of its current state. NURS 6025 Transforming Nursing and Healthcare
Conclusion
Stroke care involves time-pressured interventions. The outcomes may greatly impact a patient’s quality of life. Properly implemented workflow redesign can result in achieving intended patient outcomes and safety benefits (McGonigle & Mastrian, 2018). Redesigning a workflow may mean eliminating unnecessary elements and activities by using a technology or an equipment. Every minute counts in stroke care and an elimination of a step will save time to implement the treatment. One can optimize a current workflow through workflow analysis, workflow redesign and adopting evidence-based research and practices.NURS 6025 Transforming Nursing and Healthcare