title: Thrombolysis in acute ischemic stroke: a simulation study to improve pre- and in-hospital delays in community hospitals.
abstract: BACKGROUND
  Various studies demonstrate better patient outcome and higher thrombolysis rates achieved by centralized stroke care compared to decentralized care, i.e. community hospitals. It remains largely unclear how to improve thrombolysis rate in decentralized care. The aim of this simulation study was to assess the impact of previously identified success factors in a central model on thrombolysis rates and patient outcome when implemented for a decentral model.
  
  
  METHODS
  Based on a prospectively collected dataset of 1084 ischemic stroke patients, simulation was used to replicate current practice and estimate the effect of re-organizing decentralized stroke care to resemble a centralized model. Factors simulated included symptom onset call to help, emergency medical services transportation, and in-hospital diagnostic workup delays. Primary outcome was proportion of patients treated with thrombolysis; secondary endpoints were good functional outcome at 90 days, Onset-Treatment-Time (OTT), and OTT intervals, respectively.
  
  
  RESULTS
  Combining all factors might increase thrombolysis rate by 7.9%, of which 6.6% ascribed to pre-hospital and 1.3% to in-hospital factors. Good functional outcome increased by 11.4%, 8.7% ascribed to pre-hospital and 2.7% to in-hospital factors. The OTT decreased 17 minutes, 7 minutes ascribed to pre-hospital and 10 minutes to in-hospital factors. An increase was observed in the proportion thrombolyzed within 1.5 hours; increasing by 14.1%, of which 5.6% ascribed to pre-hospital and 8.5% to in-hospital factors.
  
  
  CONCLUSIONS
  Simulation technique may target opportunities for improving thrombolysis rates in acute stroke. Pre-hospital factors proved to be the most promising for improving thrombolysis rates in an implementation study.
authors.affiliation: Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
authors.forename: Maarten M H
authors.initials: MM
authors.lastname: Lahr
authors.forename: Durk-Jouke
authors.initials: DJ
authors.lastname: van der Zee
authors.forename: Patrick C A J
authors.initials: PC
authors.lastname: Vroomen
authors.forename: Gert-Jan
authors.initials: GJ
authors.lastname: Luijckx
authors.forename: Erik
authors.initials: E
authors.lastname: Buskens
mesh_terms: D000208:Acute Disease; D002545:Brain Ischemia / Q000473:pathology / Q000503:physiopathology / Q000628:therapy*; D005260:Female; D006764:Hospitals, Community; D006801:Humans; D008297:Male; D008954:Models, Biological; D020521:Stroke / Q000473:pathology / Q000503:physiopathology / Q000628:therapy*; D015912:Thrombolytic Therapy; D013997:Time Factors