Barnes-Jewish Hospital applies lean methodology to acute stroke care, maximizing resources and slashing door-to-needle times

Parallel processing, point-of-care tests produce a “mountain of change”

Providers of emergency medicine fully understand the importance of time when caring for potential stroke patients. In appropriate patients, early treatment with thrombolytic drugs can prevent the kind of brain damage that causes paralysis and loss of speech, but if this treatment does not commence within 60 minutes of the start of the stroke, the risks associated with administration of these drugs begin to outweigh the potential benefits.

Recognizing the critical importance of the time between presentation and treatment or door-to-needle time, members of the dedicated clinical stroke team at Barnes-Jewish Hospital (BJH) in St. Louis, MO, became concerned when they started to see their times increase just a bit, explains Peter Panagos, MD, FACEP, FAHA, director of Neurovascular Emergencies at BJH and associate professor of Emergency Medicine and Neurology at Washington University School of Medicine.

“We have been tracking our progress since 2004, and every month we would meet as a multispecialty team of emergency physicians, neurologists, nursing, inpatient and ED pharmacy, and ancillary services to look at our previous month’s response to patients who present to the ED with stroke,” explains Panagos. “We noticed that we were having some creep up to and slightly over our internal threshold, which was one hour.”

In an effort to reverse this trend, the hospital made a conscious effort to put the entire stroke care process under a microscope, using lean-style methods to map out the flow of potential stroke victims, from the time they are picked up by an ambulance to when they receive treatment. It is an approach that lean methodology refers to as value-stream analysis. “We looked at every step along the process and determined where we were losing time and where we could make up time,” says Panagos.

Some of the hold-ups identified were easier to address than others, but the results of the effort have dramatically accelerated care. Since the new treatment procedures were implemented in February 2011, average door-to-needle times have improved by nearly 40%, and the number of patients treated within 60 minutes has increased from 52% to 78%.1

While the solutions devised at BJH are uniquely designed to fit the culture of the practice there, Panagos observes that some of the stroke-care efficiencies achieved by the institution’s stroke care improvement team have already been adopted with success at other centers. (Also, see Management Tip: Try small tests of change, below.)

Engage with pre-hospital providers

To make improvements in any stroke system, you have to consider the pre-hospital component, stresses Panagos. “If you don’t engage with your pre-hospital providers, you are losing an opportunity,” he says. For example, one of the changes that BJH made as result of its improvement effort was to empower pre-hospital providers to call ahead and activate the stroke team when they think they had convincing evidence that a patient was suffering a stroke. There are no repercussions if they get it wrong, says Panagos.

“To be perfect 100% of the time, you are going to miss a lot of patients, so we have empowered them to say that they think they have a stroke patient and to activate the team,” he says. “They are really the first responders for the stroke team at our center.”

Panagos acknowledges that to successfully make this type of change, there has to be a trusting relationship between the pre-hospital providers and the ED staff, but he notes that many EDs have nurtured this type of relationship. “A lot of emergency medicine physicians are medical directors for many EMS systems, so having that interaction, not only regarding stroke, but also many other disease processes, and being involved with education for EMTs and paramedics on a continual basis, facilitates that open dialogue,” he says.

Given that the ED at BJH has long encouraged pre-hospital providers to call ahead when they have a critically ill patient, empowering them to activate the stroke team was not a difficult change, says Panagos. However, a second improvement — a directive for pre-hospital providers to take potential stroke patients directly to the CT scanner rather than the usual entry point in the ED — required some education, he says.

“We had to really explain to them why we thought this was important and, fortunately, we have our CT scanners directly within the ED. If they were located remotely from the ED, that would have been a bigger issue,” says Panagos. “They bought into the fact that time is brain and earlier is better, and they wanted to be taken seriously in the process, which they should be.”

A bigger paradigm shift was getting the staff internally to adjust to this change because many other tasks had to be adjusted to accommodate the move. For example, now tasks like patient registration or obtaining an EKG need to be done on the fly with these patients because the traditional step of sending them to a bed has been eliminated. “That was a really big shift from our standpoint, and really a cultural shift in how we do business,” says Panagos.

Clearly define roles, responsibilities

The move also triggered a change in approach from serial processing to parallel processing, observes Jennifer Williams, PhDc, RN, ACNS-BC, the clinical nurse specialist in Emergency Services at BJH who oversaw implementation of the stroke care changes in the ED. “In moving patients straight to the CT scanner instead of going to a room, we allowed all the clinicians to gather in the same space at the same time so that people were hearing the same information,” she explains. “That was a complete behavior change because it used to be that a patient would go into a room, and then we would walk him back and forth, and so the team became separated as members went in different directions.”

Now, all the members of the stroke team are hearing the same information up front, says Williams. But this also means that the team members have to share the time that is spent asking the patient questions. “Everyone is taking turns talking. You have to share, and sometimes for health care providers, that is a challenge,” she explains.

The changes did not require the addition of any new personnel, says Panagos. To the contrary, the focus was on eliminating unnecessary steps in the process. “Like most areas of medicine, it is very difficult to get additional personnel or additional resources, so what we had to do was be more efficient with our existing people,” he says. “We assigned tasks so that one person was doing one job rather than two people doing the same job and stepping on each other’s toes.”

For example, the team engaged the social worker in the ED to be the person to go out in the waiting room and try to identify family members or witnesses whenever a potential stroke victim is brought to the ED. The social worker then brings these individuals to the bedside, where clinicians can obtain added information. In addition to saving time, the approach frees up clinicians to focus their time and energy on direct patient care. “We tried to streamline our existing resources so that everyone’s role was more clearly defined and, as a result, had a little bit more time to do what they should be doing,” adds Panagos.

It took time to finesse the approach so that it worked smoothly for the patient and all the team members, notes Williams. “For the first several weeks, when we were into the process change, all the members of the leadership team, as well as the team members that helped redesign the changes, made themselves available to hear all the feedback,” she explains. “We were present as many times as we possibly could be when the stroke alerts occurred. We wrote down notes, and we tried to rapidly fix things in the moment.”

Within two weeks of going live with the new approach, the team managing the stroke care changes held a meeting to fix processes that proved problematic, and then took charge of making sure that the tweaks were communicated to everyone involved. “We used a single source of communication between all of the team members,” explains Williams. This included representatives from nursing, neurology, emergency physicians, radiology, and the pre-hospital community, she says. “We just sent out the same message to everybody about what the changes were, how we wanted to support them, and what feedback we wanted.”

Consider point-of-care testing

Another change that proved particularly challenging to implement in the ED was the introduction of point-of-care testing for PT/INR (prothrombin time and international normalized ratio). The test is important with stroke patients because when the results produce a threshold of -1.7 or higher, the patients are not eligible to receive thrombolytic drugs. However, the stroke improvement team found that performing this test put a major drag on time-to-treatment.

“We were finding that the test, which traditionally would have to go to the lab, and would take anywhere from 20 to 25 minutes, was the root cause for most of our significant outliers when we went through our value stream analysis,” explains Panagos. “So we determined if we could identify those patients [who are ineligible to receive thrombolytic drugs] in the first few minutes, as opposed to 25 minutes later, that would shave off tremendous amounts of time.”

However, introducing the new point-of-care test proved to be a big organizational change, explains Williams. “We already had several point-of-care tests in the ED, but when we added the PT/INR, we had to add it into the design we had already created in the new process,” she says.

The lab had to train roughly 160 people, including all the nurses and the techs, how to perform the test, and conduct continued quality analysis to make sure the test is being performed accurately.

However, while this point-of-care component was particularly challenging, it produced “a mountain of change,” stresses Williams. “We went from knowing the PT/INR results at 40 minutes to knowing PT/INR at 10 minutes, so we really could say ‘yes’ or ‘no’ [to thrombolytic drug treatment] pending the CT scan, which neurology would be reading at that same moment, so it made everything accelerate,” she explains.

Identify strengths, weaknesses

One of the challenges of providing care at an academic medical center is that new personnel are constantly rotating through the ED, so getting clinicians and other personnel up-to-speed on the new stroke care procedures is an ongoing process, observes Panagos. “When our highly trained people are at the end of their month or two-month cycle in the ED, then all of a sudden we have a new team that comes on board, so our challenges might be different than someone else’s,” he says. (Also, see: Study: Strokes are becoming more common at a younger age, below.)

However, even with this obstacle, Panagos notes that the hospital has been able to maintain improvements in door-to-needle times. Further, while it probably wouldn’t make sense for another center to emulate precisely what BJH did to improve the efficiency of its stroke care process, Panagos suggests there are certainly bits and pieces that might work well elsewhere. In fact, he notes that several centers that have consulted with BJH are now directing their pre-hospital providers to bring potential stroke patients directly to their CT scanners as opposed to the traditional ED entry point. “That is a shift in how patients normally flow, and it typically meets with a lot of resistance from many aspects of the treatment team,” says Panagos. “But once it is accepted, it is something that makes a huge difference in care.”

However, Panagos adds that this type of large-scale change requires high-level support. “You really have to have a commitment from above to take care of stroke patients efficiently, safely, and quickly,” he says. And once that commitment is in place, every hospital or ED needs to identify what its strengths and weaknesses are, what resources it has, and how those resources can best be utilized, he says.

“On average, we are probably activating our stroke team seven or eight times for every patient we ultimately treat with thrombolytic drugs, so an observant person might say that is a lot of resources to be utilized for a very low treatment rate,” he says. “I would argue that it is an appropriate amount of resources because if we can identify the patients within the first two or three minutes, or maybe within five minutes, and establish whether they are a candidate or not a candidate for [clot-busting medicine], I think it frees up a lot of resources that may have historically been tied up while trying to figure out what is going on.”

The approach also fosters collaboration between neurology and emergency medicine, while exposing residents in each specialty to clinicians who approach stroke patients from a slightly different angle, adds Panagos. “We are training and sending 12 residents in emergency medicine out into the community each year. They are taking leadership roles in institutions all across the country, and the same thing with neurology,” he says. “So if we can do this at a training level, I think our ability to implement change on a wider theater or platform is crucial. It takes a broad view, but it is really what drives a lot of what we do here as part of our training mission.”


  1. Ford A, Williams J, Spencer M, et al. Reducing door-to-needle times using Toyota’s lean manufacturing principles and value stream analysis. Stroke 2012;43:A175.


  • Peter Panagos, MD, FACEP, FAHA, Director, Neurovascular Emergencies, Barnes-Jewish Hospital, and Associate Professor, Emergency Medicine and Neurology, Washington University School of Medicine in St. Louis, MO. E-mail:
  • Jennifer Williams, PhDc, RN, ACNS-BC, Clinical Nurse Specialist, Emergency Services, Barnes-Jewish Hospital, St. Louis, MO. E-mail:

Management Tip

Try small tests of change

If you want to improve your stroke care process, but your organization is not ready or prepared to make a big process leap, try a more focused, incremental approach, advises Jennifer Williams, PhDc, RN, ACNS-BC, a clinical nurse specialist in Emergency Services at Barnes-Jewish Hospital in St. Louis, MO.

“Take the thing that would be the most value-added for you, pilot it, track the data, get the feedback, and then figure out how to reinforce that process, and get front-line influence into how it fits into the workflow,” she says. “Then move on to your next thing and your next step because it takes a lot of resources to turn a great big ship in a new direction.”

These small, incremental tests of change can build a sense of success among the staff, and improve the chances for continued success going forward, adds Williams.