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A Simulation-based Approach for Improving Utilization of Thrombolysis in Acute Brain Infarction

Lahr, Maarten M.H. MSc (Res)*; van der Zee, Durk-Jouke PhD; Luijckx, Gert-Jan MD, PhD*; Vroomen, Patrick C.A.J. MD, PhD*; Buskens, Erik MD, PhD

doi: 10.1097/MLR.0b013e3182a3e505
Brief Report

Background: Treatment with tissue plasminogen activator (tPA) is the most effective treatment in acute brain infarction. However, estimated worldwide treatment rates are <10%, with many barriers hampering broad implementation. Organization and resource-intense randomized controlled trials cannot address all potential barriers simultaneously. Simulation, however, may provide an efficient research means for testing interventions aimed at resolving barriers along the care pathway.

Research design: A simulation-based approach reflecting the setup of a regional Dutch acute stroke pathway was used. First, barriers along the overall pathway were identified. Next, solutions to barriers were configured, and subsequently tested using simulation.

Results: Barriers along the stroke pathway and possible solutions were identified from the literature and expert consultation. The simulation model closely reproduced actually observed tPA treatment rate and overall process time (21.8% and 129 min for model outcomes vs. 22.1% and 127 min, P=0.89 and 0.64, respectively). Two barriers were overcome: (1) time spent by ambulance personnel on scene by a scoop-and-run protocol (1.4% increase in tPA rate, 7 min decrease in overall process time), and (2) time to laboratory results by introducing a point-of-care diagnostic device (3.2% increase in tPA rate, 20 min decrease in overall process time).

Conclusions: A simulation-based approach is well suited to efficiently assess solutions to barriers along the overall stroke pathway. Substantial improvements in treatment rates and efficacy of thrombolysis may be achieved by implementing a scoop-and-run protocol and point-of-care device.

Supplemental Digital Content is available in the text.

*Department of Neurology, University Medical Center Groningen

Department of Operations, Faculty of Economics & Business

Health Technology Assessment, Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands

Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website,

Supported by the Netherlands Organization for Health Research and Development (ZonMw); Ref.: 80-82800-98-104.

The authors declare no conflict of interest.

Reprints: Maarten M.H. Lahr, MSc (Res), Department of Neurology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, P.O. Box 30001, The Netherlands. E-mail:

© 2013 by Lippincott Williams & Wilkins.