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Current Problems in Diagnostic Radiology 49 (2020) 333�336

Current Problems in Diagnostic Radiology

journal homepage: www.cpdrjournal.com

Decreasing Patient Dwell Times for Outpatient Cardiac Nuclear Medicine Studies: The Benefits of SMART Goals, Scope Limitations, and Society Guidelines in Quality Improvement

Carson Sibley, MDa,b,*, Camara Ayers, MHAa, Brent King, MDa,b, Travis Browning, MDa,b, Jeannie K. Kwon, MDa

a UT Southwestern Department of Radiology, Dallas, TX b Parkland Health and Hospital System, Dallas, TX

A B S T R A C T

Background: We describe a quality improvement project to improve patient dwell times for outpatient cardiac nuclear medicine exams. Preliminary data indi- cated that the mean patient dwell time was about 270 minutes. Our specific, measurable, achievable, relevant, and time-bound goal was to reduce patient dwell times for outpatient pharmacologically stressed cardiac nuclear medicine exams by 60 minutes over the course of 2 months. Methods: An interdisciplinary team was formed which used staff interviews and workflow observation to create a cause and effect diagram as well as a process map. Review of the national guidelines for cardiac nuclear medicine exams identified rest and stress intervals as intervention targets. A new protocol was designed and implemented. Results: The mean patient dwell time was improved from 270 to 184 minutes. Conclusions: Overall, we found that a clear specific, measurable, achievable, relevant, and time-bound goal, limited scope, and national guideline review allowed for a successful quality improvement project.

*Reprint requests: Carson Sibley MD, UT Southwestern Department of Radiology, 5323 Harry Hines Blvd Dallas TX, 75390.

E-mail addresses: [email protected], [email protected] (C. Sibley).

Problem

Introduction

The Health and Medicine Division of the National Academies of Science (previously named the Institute of Medicine) defines quality care as safe, timely, effective, efficient, equitable, and patient cen- tered.1 The American College of Radiology emphasizes that quality patient care can only be achieved when imaging is completed and reported in a timely manner. 2 Turn around times are a frequently used metric to assess quality in Radiology Departments.3 In an effort to improve quality of care, Radiology leaders have turned to industry and quality science.4-10

Background

The hospital administration identified a need to improve turn around times for our outpatient cardiac nuclear medicine exams. Preliminary data indicated that the mean patient dwell time (the time from patient sign-in to discharge) was about 270 minutes, with patients occasionally staying within the department for an excess of 360 minutes. Additionally, the nuclear medicine technol- ogists on the cardiac service reported missing lunch breaks and

experiencing a decreased capacity to assist with the general nuclear medicine studies.

Approach

SMART Goal and Scope

Specific, measurable, achievable, relevant, and time-bound (SMART) goals, originally described in business management, have been used in a variety of health care settings.11-14 Our SMART goal was to reduce the mean patient dwell time for outpatient pharmacologically stressed car- diac nuclear medicine exams by 60 minutes over the course of 2 months, from 270 minutes to less than 210 minutes. To define the scope of the project, outpatient exams were selected as the entirety of the patient dwell time occurred within the nuclear medicine department. This decreased variables external to the department such as patient transport. In our protocol for outpatient cardiac nuclear medicine exams, either treadmill exercise or pharmacologic agents are used to stress patients. If patients fail the treadmill test the exam is then con- verted to pharmacological stress. To simplify analysis, only patients who were initiated as pharmacological stress were included.

Methods: Cause and Effect Diagram, Process Map, and Society Guidelines

An interdisciplinary team was formed including radiologists, a quality assurance specialist, nuclear medicine technologists, and

CCauseandEffectDiagram

Increased Patient Dwell Times

Patient Factors • Mobility • Restroom • Gut Activity • Language Barrier • Health Literacy • Venous Anatomy

Reading Physician Factors • Threshold for accepting Gut activity • Threshold for Diagnostic quality

Technologist • Experience • IV Access • Spanish Speaking • Comfort Level with

Physician Threshold

Protocol • Stress and Rest Interval • Stress Type

• Pharmacologic • Treadmill

• Radiopharmaceutical • Sestamibi • Myoview

FIG 1. Cause and Effect Diagram to identify drivers and potential targets for intervention for increased patient dwell times.

PProcessMap Begin Exam

End Exam

Check with Provider

Intake Screen form clear and IV

access?

Rest Interval

Inject Tracer

Stress Scan

Stress Consent

EKG IV Drug

Inject Tracer

Stress Interval

Rest Scan

Images Diagnostic? Images Diagnostic?

Yes

No Yes

Patient Dwell Time

Rest Interval Stress Interval

FIG 2. Process Map for outpatient cardiac nuclear medicine exams. Diamonds indicate decision points. Stopwatches indicate recorded time points that can be measured for data analysis. The yellow highlight indicates target of intervention. The green arrow represents the total time the patient is within the department from the beginning to the end of the exam. (Color version of figure is available online.)

334 C. Sibley et al. / Current Problems in Diagnostic Radiology 49 (2020) 333�336

hospital administrators. Staff interviews were performed including hospital administration, nuclear medicine technologists, resident radiologists, and attending radiologists. After this was completed, a cause and effect diagram was created to categorize the nature of vari- ables that contributed to increased patient dwell times (Fig 1).

FIG 3. Intervention with an updated protocol. The initial protocol required the technologist The New Protocol changed the interval from 60 minutes to 30 minutes for scan time (ie, 8:30

Workflow observation was used to develop a process map to illus- trate the workflow from patient check-in to the end of the exam (Fig 2). The national guidelines for cardiac nuclear medicine exams cre- ated by the American Society of Nuclear Cardiology (ASNC) were reviewed as part of the analysis. Specifically for Tc-99m sestamibi,

to record the injection time (ie, 8:00) then add 60 minutes for the scan time (ie, 9:00). ).

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Intervention 12/20/2018

FIG 4. X-bar charts of rest and stress intervals over time demonstrate the mean rest interval for outpatient pharmacologically stressed cardiac nuclear medicine exams. The arrow indicates the formal protocol change. The dashed red line indicates the x-bar, and the solid red lines indicate the upper and lower control limits. (Color version of figure is available online.)

C. Sibley et al. / Current Problems in Diagnostic Radiology 49 (2020) 333�336 335

the radiopharmaceutical used at our institution, intervals of 45-60 minutes and 60 minutes are recommended by those guidelines for rest and pharmacologic stress respectively.15

Intervention

Preliminary data suggested that rest and stress intervals were averaging near 90 minutes, which is greater than recommended by the ASNC. As such, rest and stress intervals were identified as inter- vention targets. The initial workflow was analyzed. The technologist used a paper form to indicate when the patient needed to be scanned after radiopharmaceutical administration. The nuclear medicine technologist recorded the time of radiopharmaceutical injection and

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Patient Dwell Tim

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FIG 5. X-bar chart shows the mean patient dwell times for outpatient pharmacologically stre ation of our QI project in the form of staff interviews and workflow observation. The interven the x-bar, and the solid red lines indicate the upper and lower control limits. The dashed blue

then added 60 minutes to that injection time to generate a target stress time (Fig 3). This would cue the technologist to get the patient from the waiting room. Regularly, the technologist would ensure the patient consumed the water and snack provided to reduce gut activ- ity, assist with transferring the patient, and allow the patient to use the restroom, which resulted in the prolonged time.

After discussing with our team, the protocol was changed to add 30 minutes rather than 60 minutes to injection time. This would cue the technologist to get the patient sooner and allow time for the tech- nologist to address patient issues that arise prior to scanning. The workflow protocol was updated and presented to the staff during the monthly staff meeting. Questions were addressed and the new proto- col was implemented.

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ssed cardiac nuclear medicine exams. The observation arrow indicates the point of initi- tion arrow indicates the point of formal protocol change. The dashed red line indicates line indicates the dwell time goal. (Color version of figure is available online.)

336 C. Sibley et al. / Current Problems in Diagnostic Radiology 49 (2020) 333�336

Outcomes

The rest interval (the time between radiopharmaceutical injection and rest scan) and the stress interval (the time between radiophar- maceutical injection and stress scan) were measured before and after intervention. The rest interval improved from a mean of 66 minutes to a mean of 48 minutes after intervention. The stress interval improved from a mean of 78 minutes to 51 minutes (Fig 4). Prior to our project, the mean total patient dwell time from check-in to end exam was 273 minutes. After staff interviews and workflow observa- tions began, the mean patient dwell time decreased to a mean of 239 minutes. After formal intervention, the mean patient dwell time fur- ther improved to 184 minutes (Fig 5). The formal intervention occurred within 2 months of initiation of workflow observation, meeting our SMART goal. Patients stressed with the treadmill, both successful treadmill exercise stress exam and failed treadmill exam with conversion to pharmacologic stress, were not the focus of our project. However, mean dwell times decreased from 233 minutes to 185 minutes, a 48-minute improvement for this patient group.

Discussion

Patient dwell times were reduced by a mean of approximately 90 minutes exceeding our SMART goal of 60 minutes. We achieved nearly 30 minutes decreased mean patient dwell time after initiation of observation. This is likely secondary to many factors. One is the Hawthorne Effect, which describes change in behavior under obser- vation.16 Also, many of the technologists helped to devise the proto- col change and modified their workflow prior to formal intervention. Upon review of the ASNC guidelines, 1 additional potential target was identified. Tc-99m tetrofosmin requires only a 30-45 minutes delay compared to the 45-60 minutes delay for Tc-99m sestamibi.15

However, no intervention was planned secondary to interpreter pref- erence. Additional benefits included reports of smoother workflow and decreased missed lunch breaks. The reading physicians were sat- isfied with the earlier finish time for the cardiac exams and no increase in complaints with regards to image quality were reported. No negative effects of the intervention were identified.

Conclusion

We found that the Quality Improvement approach to decreasing patient dwell times was highly effective. Several factors were identified as keys to the success of the project. First, composing a SMART goal pro- vided a clear direction and timeframe vital to the completion of the project. Second, limiting the scope of the project to factors isolated to 1 department allowed for focused intervention and constructive data.

Thirdly, a thorough analysis of national guidelines provided a beneficial resource for analyzing complex workflow and ensuring optimal effi- ciency. Finally, utilizing an interdisciplinary team provided vital insight to the complexity of the process complemented by expertise in quality improvement. Hopefully, these keys to success will serve to encourage other quality improvement efforts in radiology and nuclear medicine.

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