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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
  1. Soffien Chadli Ajmi1,2,
  2. Rajiv Advani3,
  3. Lars Fjetland4,
  4. Kathinka Dehli Kurz4,5,
  5. Thomas Lindner6,7,
  6. Sigrunn Anna Qvindesland8,
  7. Hege Ersdal2,6,
  8. Mayank Goyal9,
  9. Jan Terje Kvaløy5,10,
  10. Martin Kurz1,11
  1. 1 Department of Neurology, Stavanger University Hospital, Stavanger, Norway
  2. 2 Department of Quality and Health Technology, University of Stavanger, Stavanger, Norway
  3. 3 Department of Neurology, Stroke Unit, Oslo University Hospital, Oslo, Norway
  4. 4 Department of Radiology, Stavanger University Hospital, Stavanger, Norway
  5. 5 Department of Mathematics and Physics, University of Stavanger, Stavanger, Norway
  6. 6 Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
  7. 7 Research, The Regional Centre for Emergency Medical Research and Development, Stavanger, Norway
  8. 8 Research, Stavanger Acute Medicine Foundation for Education and Research, Stavanger, Norway
  9. 9 Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
  10. 10 Department of Research, University of Stavanger, Stavanger, Norway
  11. 11 Department of Clinical Medicine, University of Bergen, Bergen, Norway
  1. Correspondence to Dr Soffien Chadli Ajmi, Neurology, Stavanger University Hospital, Stavanger 4010, Norway; soffiena{at}


Background In 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.

Methods All 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.

Results A 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).

Conclusions Implementing 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.

  • simulation
  • quality improvement methodologies
  • medical emergency team
  • team training
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  • Contributors SCA is the corresponding author RA, TL, HE, MG and MK contributed to the drafting and revising the manuscript. LF, KDK and SAQ contributed to the design and conceptualisation of the study and revising the manuscript. TL, HE contributed to the design of the study. JTK contributed to the statistics, calculating, analysing and contributing to interpreting data and revising the manuscript. MK contributed to the design of the study and interpretation of the data including statistics.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests SCA is a research fellow funded by a Safer Healthcare Grant (University Research Fund). MG has a consulting agreement with Mentice, the remaining authors report no disclosures.

  • Patient consent for publication Not required.

  • Ethics approval This study was performed with the approval of the regional ethics committee (Regional Etisk Komite).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request.

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