Abstract
Background: Effective treatment with tissue plasminogen activator (tPA) critically relies on rapid treatment. Door-to-needle time (DNT) is a key measure of hospital efficiency linked to patient outcomes. Numerous changes can reduce DNT, but they are difficult to trial and implement. Discrete-event simulation (DES) provides a way to model and determine the impact of process improvements.Methods: A conceptual framework was developed to illustrate the thrombolysis process; allowing for treatment processes to be replicated using a DES model developed in ARENA. Activity time duration distributions from three sites (one urban and two rural) were used. Five scenarios, three process changes, and two reductions in activity durations, were simulated and tested. Scenarios were tested individually and in combinations. The primary outcome measure is median DNT. The study goal is to determine the largest improvement in DNT at each site.Results: Administration of tPA in the imaging area resulted in the largest median DNT reduction for Site 1 and Site 2 for individual test scenarios (12.6%, 95% CI 12.4–12.8%, and 8.2%, 95% CI 7.5–9.0%, respectively). Ensuring that patients arriving via emergency medical services (EMS) remain on the EMS stretcher to imaging resulted in the largest median DNT improvement for Site 3 (9.2%, 95% CI 7.9–10.5%). Reducing both the treatment decision time and tPA preparation time by 35% resulted in a 11.0% (95% CI 10.0–12.0%) maximum reduction in median DNT. The lowest median and 90th percentile DNTs were achieved by combining all test scenarios, with a maximum reduction of 26.7% (95% CI 24.5–28.9%) and 17.1% (95% CI 12.5–21.7%), respectively.Conclusions: The detailed conceptual framework clarifies the intra-hospital logistics of the thrombolysis process. The most significant median DNT improvement at rural hospitals resulted from ensuring patients arriving via EMS remain on the EMS stretcher to imaging, while urban sites benefit more from administering tPA in the imaging area. Reducing the durations of activities on the critical path will provide further DNT improvements. Significant DNT improvements are achievable in urban and rural settings by combining process changes with reducing activity durations.
Highlights
Stroke is a devastating disease, but is treatable with alteplase or tissue plasminogen activator [1] and endovascular thrombectomy (EVT) [2,3,4,5,6]
Process differences based on pathway type or out of hour resource differences are not well-defined in the literature. We address these gaps by developing a conceptual framework of the intra-hospital aspect of the thrombolysis treatment process by analyzing three urban and rural sites
The model was used to determine the impact of process changes and reduction in activity durations on Door-to-needle time (DNT) at each site in comparison to the site-specific baseline DNT
Summary
Stroke is a devastating disease, but is treatable with alteplase or tissue plasminogen activator (tPA) [1] and endovascular thrombectomy (EVT) [2,3,4,5,6]. Tissue plasminogen activator has been a proven treatment for acute ischemic stroke (AIS) since 1995 [1], and is widely available in urban and rural hospitals. Door-to-needle time (DNT) is a critical measure of hospital efficiency linked to patient outcomes and is defined as the time from a patient’s hospital arrival to the start of tPA treatment. Fast treatment with tPA has been reported in many urban hospitals, but rural hospitals struggle to reduce treatment times [11, 12]. A recent study analyzing the thrombolysis process for AIS in urban and rural hospitals highlighted that physician comfort, resource availability, and frequency of treating AIS patients were factors that lead to an inequality in treating patients quickly in rural settings [13]. Door-to-needle time (DNT) is a key measure of hospital efficiency linked to patient outcomes. Discrete-event simulation (DES) provides a way to model and determine the impact of process improvements
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