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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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          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          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 references 12

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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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            Anaesthesiology as a model for patient safety in health care.

             Nancy D Gaba (2000)
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              Facilities available in European hospitals treating stroke patients.

              Stroke units decrease mortality and need for institutional care, but they are not widely available. The objective of the study was to determine, among European hospitals admitting acute stroke patients, how many are able to provide an appropriate level of care. Method- We randomly selected 886 hospitals in 25 countries. We used definitions derived from a European expert survey for comprehensive stroke centers (CSC), primary stroke centers (PSC), and minimum level required for any hospital ward (AHW) admitting stroke patients. We determined the proportion of hospitals meeting criteria for each category, and which facilities were not available. Participating hospitals treated approximately one-third of all strokes supposed to have occurred in these countries in 2005. Forty-three (4.9%) met criteria for CSC, 32 (3.6%) for PSC, 356 (40.2%) for AHW, and 455 (51.4%) provided a lower level of care. In 2005, hospitals meeting criteria for CSC, PSC, AHW, and none of them admitted 27 644 (8.3%), 17 365 (5.2%), 146 175 (44.1%), and 140 306 (42.3%) patients. There was no 24-hour availability for brain CT scan in 25% of hospitals not meeting criteria for AHW. Of 448 hospitals admitting at least 1 stroke per day, 51 (11.4%) met criteria for PSC or CSC, and 227 (50.7%) for AHW. Less than 10% of European hospitals admitting acute stroke patients have optimal facilities, and in 40% even the minimum level is not available. Because the availability of facilities does not grant their use, our study suggests that only few acute stroke patients are treated in appropriate centers in Europe.
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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
                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.

                Article
                PONE-D-17-32299
                10.1371/journal.pone.0188231
                5716597
                29206838
                © 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.

                Page count
                Figures: 5, Tables: 1, Pages: 13
                Product
                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
                Research Article
                Medicine and Health Sciences
                Neurology
                Cerebrovascular Diseases
                Stroke
                Medicine and Health Sciences
                Vascular Medicine
                Stroke
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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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