Reducing door-to-needle times in stroke thrombolysis to 13 min through protocol revision and simulation training: a quality improvement project in a Norwegian stroke centre

Abstract

BackgroundIn eligible patients with acute ischaemic stroke, rapid revascularisation is crucial for good outcome. At our treatment centre, we had achieved and sustained a median door-to-needle time of under 30 min. We hypothesised that further improvement could be achieved through implementing a revised treatment protocol and in situ simulation-based team training sessions. This report describes a quality improvement project aiming to reduce door-to-needle times in stroke thrombolysis.MethodsAll members of the acute stroke treatment team were surveyed to tailor the interventions to local conditions. Through a review of responses and available literature, the improvement team suggested changes to streamline the protocol and designed in situ simulation-based team training sessions. Implementation of interventions started in February 2017. We completed 14 simulation sessions from February to June 2017 and an additional 12 sessions from November 2017 to March 2018. Applying Kirkpatrick’s four-level training evaluation model, participant reactions, clinical behaviour and patient outcomes were measured. Statistical process control charts were used to demonstrate changes in treatment times and patient outcomes.ResultsA total of 650 consecutive patients, including a 3-year baseline, treated with intravenous thrombolysis were assessed. Median door to needle times were significantly reduced from 27 to 13 min and remained consistent after 13 months. Risk-adjusted cumulative sum charts indicate a reduced proportion of patients deceased or bedridden after 90 days. There was no significant change in balancing measures (stroke mimics, fatal intracranial haemorrhage and prehospital times).ConclusionsImplementing a revised treatment protocol in combination with in situ simulation-based team training sessions for stroke thrombolysis was followed by a considerable reduction in door-to-needle times and improved patient outcomes. Additional work is needed to assess sustainability and generalisability of the interventions.

Connecting simulation and quality improvement: how can healthcare simulation really improve patient care?

“…Team training using simulation can enable improvements in provider behaviours, 8 including those described by Ajmi et al, 1 where sequential tasks in time-critical patient journeys can be replaced by 'parallel processing'. Location is also relevant, as 'in situ simulation'-"taking place in the actual patient care setting/environment" 9 -affords a closer connexion to the physical environment for 'real', often ad hoc teams, to identify enablers or barriers for QI interventions.…”

“…In this edition of the journal, Ajmi and colleagues report on a simulation-based intervention that improved door-to-needle times and patient outcomes in acute ischaemic stroke. 1 This prompts reflection on the positioning of simulation-based methods within QI programmes, the role of trained simulation experts as part of QI-focused teams and the directions for future scholarly enquiry that supports integration of these fields.…”

The use of simulation to prepare and improve responses to infectious disease outbreaks like COVID-19: practical tips and resources from Norway, Denmark, and the UK

“…Simulation has a huge potential to help managing the global COVID-19 crisis in 2020 and in potentially similar future pandemics. Simulation can rapidly facilitate hospital preparation and education of large numbers of healthcare professionals and students of various backgrounds and has proven its value in many settings [1][2][3][4][5][6][7][8][9][10]. It can be utilised to scale-up workforce capacity through experiential learning.…”

Simuleringsbasert teamtrening virker

“…Nå foreligger det imidlertid resultater fra mange studier som dokumenterer at teamtrening fører til bedre resultat for pasientene. På generelt nivå er dette oppsummert i flere oversiktsartikler (7-9) og i flere studier som har vist en klar effekt på pasientoverlevelse (10)(11)(12)(13)(14)(15)(16)(17)(18).…”

“…Rask trombolytisk og/eller endovaskulaer behandling er avgjørende for best mulig pasientutfall. Ved Stavanger universitetssjukehus har man klart å redusere gjennomsnittlig dør-til-nål-tid fra 30 minutter til 13 minutter med en påfølgende reduksjon i 90-dagers sykelighet og dødelighet (15). Dette henger sannsynligvis sammen med et tverrfaglig kvalitetsforbedringsarbeid hvor regelmessige teamsimuleringer i akuttmottaket har vaert helt sentralt.…”