Does clinical experience influence the effects of team simulation training in stroke thrombolysis? A prospective cohort study

Abstract

Objectives: After introducing a team simulation training programme at our hospital, we saw a reduction in door-to-needle times (DNT) for stroke thrombolysis but persisting variability prompting further investigation. Our objective is to examine this gap through assessing: (1) whether there is an association between DNT and the clinical experience of neurology registrars and (2) whether experience influences the benefits from attending simulation.

Design: Prospective cohort study.

Setting and participants: Patients treated with intravenous thrombolysis between January 2016 and 2020 at a Norwegian stroke centre.

Primary and secondary outcome measures: Using DNT and prior intravenous thrombolysis administrations (case-based definition of clinical experience) as continuous variables, a mixed effects linear regression model was performed to examine the association between clinical experience, DNT and simulation attendance. For dichotomised analyses, neurology registrars with 15 or more prior treatments were defined as experienced.

Results: A total of 532 patients treated by 36 neurology registrars from January 2016 to 2020 were included. There was a linear association between clinical experience and DNT (test for non-linearity p=0.479). Each prior intravenous thrombolysis administration was associated with a significant 1.1% decrease in DNT in the adjusted analysis (ΔDNT -1.1%; 95% CI, -2.2% to -0.0%; p=0.048). The interaction between effects of clinical experience and simulation on DNT was not statistically significant (p=0.150). In the dichotomised analysis, experienced registrars had similar gains from attending simulation sessions (mean DNT from 18.5 min to 13.5 min) compared with less experienced registrars (mean DNT from 22.4 min to 17.4 min).

Conclusions: Less experienced registrars had longer DNT in stroke thrombolysis. Attending team simulation training was associated with similar improvements for experienced and inexperienced neurology registrars. We suggest a focus on high-quality onboarding programmes to close the experience-related quality gap. Our findings suggest that both inexperienced and experienced neurology registrars might benefit from team simulation training for stroke thrombolysis.

Keywords: medical education & training; quality improvement; stroke; stroke medicine.

Figure 1. Patient selection^a. ^aDNT=door-to-needle time. Colours depicting planned analysis on different parts of the cohort. For dichotomised analyses, mean door-to-needle times were compared according to the clinical experience of neurology registrars and attendance at one or more simulation sessions. ‘Experienced’ neurology registrars are defined as having administered 15 or more prior intravenous thrombolysis treatments.

Figure 2. Scatterplot showing the association between patients’ door-to-needle time^a and the clinical experience of the neurology registrar (number of prior intravenous thrombolysis administrations) for patients treated before quality improvement. The line indicates the best non-linear fit based on splines (three knots) with 95% CIs for the mean. Test of non-linearity: p=0.479. ^aNatural logarithm transformed data shown on a logarithmic scale (y-axis) with labels showing values in minutes to depict the effect size.

Figure 3. Unadjusted mean door-to-needle time^a with 95% CIs according to the clinical experience of neurology registrars (dichotomised)^b and simulation attendance. ^aNatural logarithm transformed data shown on a logarithmic scale (y-axis) with labels showing values in minutes to depict the effect size. ^bExperienced registrars defined as having 15 or more prior intravenous thrombolysis treatments.