Saving critical time diagnosing stroke patients with MRI by borrowing 'lean' principles

National benchmarks call for getting stroke patients from the door of the emergency room to injection with the clot-busting drug known as intravenous tissue plasminogen activator, or IV tPA in 60 minutes or less because the sooner tPA is administered, the better the outcome. But before the drug can be administered, patients must receive either a CT or MRI scan, to determine whether they are suitable candidates for the drug treatment. While an MRI can provide more valuable diagnostic information, it takes longer than a CT scan. So, few hospitals in the country routinely use an MRI as first-line brain imaging for acute stroke patients.

However, teams at MedStar Washington Hospital Center and Suburban Hospital in Bethesda, Md., found that by analyzing and changing their work processes, they could reduce "door-to-needle" times from 93 to 55 minutes, a 40 percent difference and meet the benchmark of 60 minutes or less while using MRI for first-line brain imaging, according to the study's physicians. This research was supported by the NIH's National Institute of Neurological Disorders and Stroke.

"Using MRI scans gives doctors valuable information to help make treatment decisions, including the location and size of the stroke if present, when it occurred, the extent of blood vessel blockage and amount of brain tissue at risk, new or old bleeding, and potentially the cause of the stroke," said Amie Hsia, MD, medical director of the Comprehensive Stroke Center at MedStar Washington Hospital Center, and the study's senior author. "We borrowed ideas from manufacturers who use 'lean' production processes to make their plants more efficient, and applied them to healthcare. Our colleagues at Washington University in St. Louis had previously applied these principles to the evaluation of stroke with CT, which inspired us to take a similar approach with MRI." A critical factor in improving efficiency is teamwork among all the different areas involved in evaluating stroke patients, including emergency room physicians, nurses and technicians; radiology and laboratory staff; and acute stroke team physicians and nurses.

"We wanted to share with other hospitals exactly how we streamlined our processes so they could see what's possible, and consider applying similar interventions within their own institutions, to be able to use MRI scans when needed to quickly guide treatment decisions for patients with suspected stroke," added Dr. Hsia.

Among the efficiency-improving steps taken by the hospitals were creating process maps to identify roadblocks causing delays, reorganizing the work flow to reduce handoffs, and assigning specific roles to each member of the stroke team. The study's authors concluded that by using these approaches, other hospitals could reduce their door-to-needle times as well, and begin using MRI scans. The time-saving techniques are known as SMART, or Screening with MRI for Accurate and Rapid stroke Treatment.

In addition, according to Dr. Hsia, many of these interventions can also be applied to hospitals that primarily use screening CT scans, because they affect the processes before and after the brain scan rather than the imaging itself.