Background: Although the national quality improvement campaigns are implemented to reduce Door-to-Balloon (DTB) time in the U.S.A., the community hospitals in Japan lack human resources and appear to be particularly challenging to implement these strategies such as 24/7 in-house cardiologists. Hospitalist is well positioned to be leaders and perform work improvement. Recently, there is increasing recognition of the Hospitalist in Japan and we are engaged in work improvement. Here, we describe a new method named Training for Effective & efficient Action in Medical Service (TEAMS), and measure whether it reduces DTB time.
Methods: TEAMS is a practical method to help us provide high quality medical service efficiently by making the best use of the resources, technology, facilities and manpower at hand. We developed TEAMS by modifying Japanese Training Within Industry (TWI). TEAMS teaches us how to break down each task into its individual components, scrutinizing details and developing new methods by eliminating, combining, rearranging and simplifying these tasks. The new method developed with TEAMS is superior to stereotype strategies currently being implemented because it is conforming the actual conditions of the hospital when resource issues arise. We conducted a before and after study in a community hospital situated in a rural community. We enrolled consecutive patients with ST- elevation myocardial infarction who came to the emergency room and received primary percutaneous coronary intervention from April 1, 2013, to October 31, 2016. TEAMS was implemented in the cooperation with doctors, nurses, laboratory technicians and office workers from May 1, 2015. For example, the procedures before calling up a cardiologist were reviewed and standardized. The primary outcome was median DTB time. Secondary outcome included the individual components of DTB time and the proportion of patients treated < 90 and > 120min.
Results: There were 58 patients before the implementation of TEAMS and 44 patients after. Baseline clinical and demographic characteristics were similar between the two groups. The median ‘DTB,’ ‘Door to Electrocardiogram’ and ‘Door to Laboratory arrival’ times were significantly reduced after TEAMS implementation falling from 106 to 82min (p = 0.037), 14 to 6 min (p < 0.001), and 67 to 45 min (p = 0.003), respectively. There was no significant change in ‘Laboratory arrival to Balloon’ time, 32 to 33 min (p = 0.951). The proportion of patients treated < 90 min increased from 40% to 61% (p = 0.030) and > 120 min decreased from 35% to 11% (p = 0.007).
Conclusions: TEAMS decreases DTB time without additional resources or cost to the hospital. The Hospitalist also continues to contribute to the quality improvement with a multi-disciplinary team in Japan.
