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      Implementation of stroke teams and simulation training shortened process times in a regional stroke network—A network-wide prospective trial

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          Abstract

          Background

          To meet the requirements imposed by the time-dependency of acute stroke therapies, it is necessary 1) to initiate structural and cultural changes in the breadth of stroke-ready hospitals and 2) to find new ways to train the personnel treating patients with acute stroke. We aimed to implement and validate a composite intervention of a stroke team algorithm and simulation-based stroke team training as an effective quality initiative in our regional interdisciplinary neurovascular network consisting of 7 stroke units.

          Methods

          We recorded door-to-needle times of all consecutive stroke patients receiving thrombolysis at seven stroke units for 3 months before and after a 2 month intervention which included setting up a team-based stroke workflow at each stroke unit, a train-the-trainer seminar for stroke team simulation training and a stroke team simulation training session at each hospital as well as a recommendation to take up regular stroke team trainings.

          Results

          The intervention reduced the network-wide median door-to-needle time by 12 minutes from 43,0 (IQR 29,8–60,0, n = 122) to 31,0 (IQR 24,0–42,0, n = 112) minutes (p < 0.001) and substantially increased the share of patients receiving thrombolysis within 30 minutes of hospital arrival from 41.5% to 59.6% (p < 0.001). Stroke team training participants stated a significant increase in knowledge on the topic of acute stroke care and in the perception of patient safety. The overall course concept was regarded as highly useful by most participants from different professional backgrounds.

          Conclusions

          The composite intervention of a binding team-based algorithm and stroke team simulation training showed to be well-transferable in our regional stroke network. We provide suggestions and materials for similar campaigns in other stroke networks.

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          Most cited references12

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          Reducing in-hospital delay to 20 minutes in stroke thrombolysis.

          Efficacy of thrombolytic therapy for ischemic stroke decreases with time elapsed from symptom onset. We analyzed the effect of interventions aimed to reduce treatment delays in our single-center observational series. All consecutive ischemic stroke patients treated with IV alteplase (tissue plasminogen activator [tPA]) were prospectively registered in the Helsinki Stroke Thrombolysis Registry. A series of interventions to reduce treatment delays were implemented over the years 1998 to 2011. In-hospital delays were analyzed as annual median door-to-needle time (DNT) in minutes, with interquartile range. A total of 1,860 patients were treated between June 1995 and June 2011, which included 174 patients with basilar artery occlusion (BAO) treated mostly beyond 4.5 hours from symptom onset. In the non-BAO patients, the DNT was reduced annually, from median 105 minutes (65-120) in 1998, to 60 minutes (48-80) in 2003, further on to 20 minutes (14-32) in 2011. In 2011, we treated with tPA 31% of ischemic stroke patients admitted to our hospital. Of these, 94% were treated within 60 minutes from arrival. Performing angiography or perfusion imaging doubled the in-hospital delays. Patients with in-hospital stroke or arriving very soon from symptom onset had longer delays because there was no time to prepare for their arrival. With multiple concurrent strategies it is possible to cut the median in-hospital delay to 20 minutes. The key is to do as little as possible after the patient has arrived at the emergency room and as much as possible before that, while the patient is being transported.
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            Analysis of Workflow and Time to Treatment and the Effects on Outcome in Endovascular Treatment of Acute Ischemic Stroke: Results from the SWIFT PRIME Randomized Controlled Trial.

            Purpose To study the relationship between functional independence and time to reperfusion in the Solitaire with the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME) trial in patients with disabling acute ischemic stroke who underwent endovascular therapy plus intravenous tissue plasminogen activator (tPA) administration versus tPA administration alone and to investigate variables that affect time spent during discrete steps. Materials and Methods Data were analyzed from the SWIFT PRIME trial, a global, multicenter, prospective study in which outcomes were compared in patients treated with intravenous tPA alone or in combination with the Solitaire device (Covidien, Irvine, Calif). Between December 2012 and November 2014, 196 patients were enrolled. The relation between time from (a) symptom onset to reperfusion and (b) imaging to reperfusion and clinical outcome was analyzed, along with patient and health system characteristics that affect discrete steps in patient workflow. Multivariable logistic regression was used to assess relationships between time and outcome; negative binomial regression was used to evaluate effects on workflow. The institutional review board at each site approved the trial. Patients provided written informed consent, or, at select sites, there was an exception from having to acquire explicit informed consent in emergency circumstances. Results In the stent retriever arm of the study, symptom onset to reperfusion time of 150 minutes led to 91% estimated probability of functional independence, which decreased by 10% over the next hour and by 20% with every subsequent hour of delay. Time from arrival at the emergency department to arterial access was 90 minutes (interquartile range, 69-120 minutes), and time to reperfusion was 129 minutes (interquartile range, 108-169 minutes). Patients who initially arrived at a referring facility had longer symptom onset to groin puncture times compared with patients who presented directly to the endovascular-capable center (275 vs 179.5 minutes, P < .001). Conclusion Fast reperfusion leads to improved functional outcome among patients with acute stroke treated with stent retrievers. Detailed attention to workflow with iterative feedback and aggressive time goals may have contributed to efficient workflow environments. (©) RSNA, 2016 Online supplemental material is available for this article.
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              Anaesthesiology as a model for patient safety in health care.

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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: VisualizationRole: Writing – original draft
                Role: ConceptualizationRole: InvestigationRole: Writing – original draft
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Writing – original draft
                Role: Investigation
                Role: Investigation
                Role: Investigation
                Role: Investigation
                Role: InvestigationRole: Writing – review & editing
                Role: InvestigationRole: Writing – review & editing
                Role: Investigation
                Role: Investigation
                Role: Investigation
                Role: InvestigationRole: Writing – review & editing
                Role: Investigation
                Role: Investigation
                Role: Investigation
                Role: Investigation
                Role: Investigation
                Role: InvestigationRole: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                5 December 2017
                2017
                : 12
                : 12
                : e0188231
                Affiliations
                [1 ] Department of Neurology, University Hospital Frankfurt, Frankfurt am Main, Germany
                [2 ] NICU Nursing Staff, University Hospital Frankfurt, Frankfurt am Main, Germany
                [3 ] Department of Neurology, Vitos Weil-Lahn, Weilmünster, Germany
                [4 ] Department of Neurology, Klinikum Hanau, Hanau, Germany
                [5 ] Department of Neurology, Krankenhaus Nordwest, Frankfurt am Main, Germany
                [6 ] Department of Neurology, Helios HSK Wiesbaden, Wiesbaden, Germany
                [7 ] Department of Neurology, Sankt Katharinen-Krankenhaus, Frankfurt am Main, Germany
                [8 ] Department of Neurology, Klinikum Aschaffenburg-Alzenau, Aschaffenburg, Germany
                [9 ] Geschäftsstelle Qualitätssicherung Hessen (GQH), Eschborn, Frankfurt, Germany
                University of Münster, GERMANY
                Author notes

                Competing Interests: FB received travel grants and speaker’s honoraria from Boehringer Ingelheim and Stryker Neurovascular; SW received speaker’s honoraria from Bayer Healthcare, Novartis, Bracco, b.e. Imaging GmbH, Merck Serono and consultant fees from Actelion; ST received speaker’s honoraria from UCB, Daiichi Sankyo and Bial and consultant fees from UCB and TEVA; UML received speaker’s honoraria from Bayer Health Care, Pfizer, Novartis, Genzyme, Roche, Merck Serono, Biogen Idec, Sanofi-Aventis, TEVA Pharma, Boehringer Ingelheim; HS received speaker’s honoraria from Bayer, Boehringer Ingelheim and Sanofi-Aventis; and WP received speaker’s honoraria from Boehringer Ingelheim, Stryker Neurovascular, research funding from Stryker Neurovascular, Novartis and consultant fees from Sanofi-Aventis. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

                Author information
                http://orcid.org/0000-0001-6935-8842
                Article
                PONE-D-17-32299
                10.1371/journal.pone.0188231
                5716597
                29206838
                f12cbe8a-92a8-4c60-8b40-12e96e0e36e6
                © 2017 Tahtali et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 3 September 2017
                : 2 November 2017
                Page count
                Figures: 5, Tables: 1, Pages: 13
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/100008349, Boehringer Ingelheim;
                Award Recipient :
                Boehringer Ingelheim supported this study with a research grant of 10.000,00 Euros to WP. The funder had not role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
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                Custom metadata
                IRB University Hospital Frankfurt has restricted access to the data underlying this study to protect patient confidentiality. Data are available from Waltraud Pfeilschifter ( waltraud.pfeilschifter@ 123456kgu.de , phone +49-69-6301-6395) for researchers who meet the criteria for access to confidential data upon individual decision of our IRB ( ethikkommission@ 123456kgu.de , phone +49-69-6301-3758).

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