Using body cameras to quantify the duration of a Code Stroke and identify workflow issues: a continuous observation workflow time study

Abstract

Objective: 'Code Stroke' (Code) is used in health services to streamline hyperacute assessment and treatment delivery for patients with ischaemic stroke. However, there are few studies that detail the time spent on individual components performed during a Code. We sought to quantify the time taken for each process during a Code and investigate associations with modifiable and non-modifiable factors.

Design: Continuous observation workflow time study.

Setting and participants: Recordings of 100 Codes were performed at a high-volume primary stroke centre in Melbourne, Australia, between January and June 2020 using a body camera worn by a member of the stroke team.

Main outcome measures: The main measures included the overall duration of Codes and the individual processes within the Code workflow. Associations between variables of interest and process times were explored using linear regression models.

Results: 100 Codes were captured, representing 19.2% of all Codes over the 6 months. The median duration of a complete Code was 54.2 min (IQR 39.1-74.7). Administrative work performed after treatment is completed (median 21.0 min (IQR 9.8-31.4)); multimodal CT imaging (median 13.0 min (IQR 11.5-15.7)), and time between decision and thrombolysis administration (median 8.1 min (IQR 6.1-10.8)) were the longest components of a Code. Tenecteplase was able to be prepared faster than alteplase (median 1.8 vs 4.9 min, p=0.02). The presence of a second junior doctor was associated with shorter administrative work time (median 10.3 vs 25.1 min, p<0.01). No specific modifiable factors were found to be associated with shorter overall Code duration.

Conclusions: Codes are time intensive. Time spent on decision-making was a relatively small component of the overall Code duration. Data from body cameras can provide granular data on all aspects of Code workflow to inform potential areas for improvement at individual centres.

Keywords: Clinical audit; STROKE MEDICINE; Stroke.

Figure 1

Sample representation of the patient journey during a Code Stroke with examples of component processes included during each time interval. The key processes in the top line are mutually exclusive, with its component processes able to occur in parallel and may overlap with other processes. ED, emergency department; EVT, endovascular thrombectomy.

Figure 2

Decision-making and team journey metrics stratified by imaging and treatment group. Team journey is defined as the total time spent by the stroke team on a Code. ^aDoor to CT (n=52). ^bCT completion time (n=50). ^cCT-to-decision time (n=59). Admin, administrative work (charting, notes, handover); DIDO, door-in-door-out time; EVT, endovascular thrombectomy.

Figure 3

Timeline demonstrating the median time of each key process during a Code Stroke. The percentage values reflect the task duration as a proportion of the sum of all median process times. Team journey is defined as the total time spent by the stroke team on a Code. DIDO, door-in-door-out time; DNT, door-to-needle time; ED, emergency department.

Figure 4

Timeline demonstrating the components of the ideal DNT at our centre of 21.4 min. The percentage values reflect the task duration as a proportion of the ideal DNT. DNT, door-to-needle time; ED, emergency department.