Optimising acute stroke care organisation: a simulation study to assess the potential to increase intravenous thrombolysis rates and patient gains.

Objectives: To assess potential increases in intravenous thrombolysis (IVT) rates given particular interventions in the stroke care pathway.

Design: Simulation modelling was used to compare the performance of the current pathway, best practices based on literature review and an optimised model.

Setting: Four hospitals located in the North of the Netherlands, as part of a centralised organisational model.

Participants: Ischaemic stroke patients prospectively ascertained from February to August 2010.

Intervention: The interventions investigated included efforts aimed at patient response and mode of referral, prehospital triage and intrahospital delays.

Primary And Secondary Outcome Measures: The primary outcome measure was thrombolysis utilisation. Secondary measures were onset-treatment time (OTT) and the proportion of patients with excellent functional outcome (modified Rankin scale (mRS) 0-1) at 90 days.

Results: Of 280 patients with ischaemic stroke, 125 (44.6%) arrived at the hospital within 4.5 hours, and 61 (21.8%) received IVT. The largest improvements in IVT treatment rates, OTT and the proportion of patients with mRS scores of 0-1 can be expected when patient response is limited to 15 min (IVT rate +5.8%; OTT -6 min; excellent mRS scores +0.2%), door-to-needle time to 20 min (IVT rate +4.8%; OTT -28 min; excellent mRS scores+3.2%) and 911 calls are increased to 60% (IVT rate +2.9%; OTT -2 min; excellent mRS scores+0.2%). The combined implementation of all potential best practices could increase IVT rates by 19.7% and reduce OTT by 56 min.

Conclusions: Improving IVT rates to well above 30% appears possible if all known best practices are implemented.