A Network-Wide Stroke Team Program Reduces Time to Treatment for Endovascular Stroke Therapy in a Regional Stroke-Network

Abstract

Background and Purpose: Driven by the positive results of randomized, controlled trials of endovascular stroke therapies (EVT) in stroke patients with large vessel occlusion, different approaches to speed up the workflow for EVT candidates are currently being implemented worldwide. We aimed to assess the effect of a simple stroke network-wide workflow improvement project, primarily focusing on i.v. thrombolysis, on process times for patients undergoing EVT. Methods: In 2015, we conducted a network-wide, peer-to-peer acute stroke workflow improvement program for i.v. thrombolysis with the main components of implementing a binding team-based algorithm at every stroke unit of the regional network, educating all stroke teams about non-technical skills and providing a stroke-specific simulation training. Before and after the intervention we recorded periprocedural process times, including patients undergoing EVT at the 3 EVT-capable centers (January – June 2015, n = 80 vs. July 2015 – June 2016, n = 184). Results: In this multi-centric evaluation of 268 patients receiving EVT, we observed a relevant shortening of the median time from symptom onset to EVT specifically in patients requiring secondary transfer by almost an hour (300 min, 25–75% interquartile range [IQR] 231–381 min to 254 min, IQR 215.25–341 min; p = 0.117), including a reduction of the median door-to-groin time at the EVT-capable center in this patient group by 15.5 min (59 min, IQR 35–102 min to 43.5 min, IQR 27.75–81.25 min; p = 0.063). In patients directly admitted to an EVT-capable center, the median door-to-groin interval was reduced by 10.5 min (125 min, IQR 83.5–170.5 min to 114.5 min, IQR 66.5–151 min; p = 0.167), but a considerable heterogeneity between the centers was observed (p < 0.001). Conclusions: We show that a simple network-wide workflow improvement program primarily directed at fast i.v. thrombolysis also accelerates process times for EVT candidates and is a promising measure to improve the performance of an entire stroke network.

Simulation-Based Training of the Rapid Evaluation and Management of Acute Stroke (STREAM)—A Prospective Single-Arm Multicenter Trial

“…We have previously applied the stroke team approach to the sponsor's stroke admissions team (16) and consequently to our regional stroke network (17), which at the time consisted of seven stroke units. In that study, we found that the intervention (algorithm design, introducing CRM, and simulation training) was effective in reducing the network wide door-to-needle time from a median of 43 min (IQR 30–60 min) to 31 min (IQR 24–42 min) (16) and door-to-groin-time from 59 min (IQR 35–102 min) to 43 min (IQR 28–81 min) (25). However, these studies were limited to a regional network consisting of heterogeneous stroke units of different sizes with and without the capacity for EVT.…”

In‐hospital acute stroke workflow in acute stroke – Systems‐based approaches

“…Numerous studies have concluded the benefits of physician education and feedback on improving in‐hospital procedural metrics and streamlining reperfusion therapy delivery, with a 2019 meta‐analysis concluding that physician feedback results in the greatest median reduction in treatment time (64 minutes, P = .002). Components of physician education have been incorporated into multiple trials, all of which have improved in‐hospital workflows 40,78‐80 . A 2015 network‐wide stroke improvement programme found stroke education, and regular simulation training was critical to improving median DPT by 15.5 minutes; however, this did not reach statistical significance 78 .…”

“…Components of physician education have been incorporated into multiple trials, all of which have improved in‐hospital workflows 40,78‐80 . A 2015 network‐wide stroke improvement programme found stroke education, and regular simulation training was critical to improving median DPT by 15.5 minutes; however, this did not reach statistical significance 78 . A 5‐year prospective database registry concluded that the use of stroke triage education, procedural standardization and temporal feedback systems achieved significant reductions in angiography‐to‐recanalization times by 69 minutes, with significant improvements in all aspects of angiography workflow and associated clinical outcomes 80 .…”

Tools for your stroke team: adapting crew-resource management for acute stroke care

“…Our training sessions have significantly improved staff satisfaction, patient safety and stroke readiness 12. We applied this approach to our regional stroke network comprising seven stroke units, and found that the intervention (algorithm design, education about team communication and simulation training) as well as the implicit cultural changes reduced the network-wide door-to-needle11) time from a median of 43 min (IQR 30–60) to 31 min (IQR 24–42)12 and door-to-groin time by 16 min (from 59 min (IQR 35–102) to 43.3 min (IQR 28–81)) 11. We are currently conducting an interventional multicentre study in Germany to evaluate crew-resource management-based multipart intervention in acute stroke care (Simulation-based Training of Rapid Evaluation and Management for Acute Stroke trial, ClinicalTrials.gov Identifier: NCT03228251).…”