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Sequential Simulation (SqS): an empirical and theoretical model

Sequential Simulation (SqS): an empirical and theoretical model

Weldon, Sharon Marie ORCID: 0000-0001-5487-5265 (2018) Sequential Simulation (SqS): an empirical and theoretical model. In: Advances in Simulation. Meeting abstracts, 3 (66). BMC. ISSN 2059-0628 (Online) (doi:

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Ethics statement:
The authors declare that they have followed the guidelines for scientific integrity and professional ethics. The article does not contain any studies with human or animal subjects.

Introduction & Aim:
Stroke is one of the leading causes of morbidity and mortality worldwide. In eligible patients with acute ischemic stroke, early treatment with intravenous thrombolysis is crucial for a good patient outcome. We introduced simulation training sessions in conjunction with an improved treatment protocol as part of a quality improvement project to reduce door-to-needle times in stroke thrombolysis.

A questionnaire assessing our preexisting treatment protocol was sent to all members of the stroke team. A panel of experts reviewed the responses and suggested potential changes to streamline the treatment protocol. In February 2017, we introduced the new protocol along with weekly videotaped in-situ scenario based simulation sessions with all stroke team members as participants. Previous stroke patients acted as markers. Kirkpatrick’s four-level training evaluation model was used for assessment. Here we present 1) Participant reactions (level 1) on a Likert item from 0-10, and 2) Median door-to-needle times in stroke thrombolysis, a measure of clinical behavioral change (level 3), using a statistical process control method. Simulated performance and long term patient outcomes will be assessed in future analysis.

Results & Discussion:
Participant reactions were predominantly positive. Self-perceived learning scored a median of 8 (IQR 7-9). We compared door-to-needle times for 478 prospectively included patients with acute ischemic stroke treated with intravenous thrombolysis at our hospital from January 2014 – July 2017. There was a significant reduction in median door-to-needle time from 27 (IQR 19-41) to 13 minutes (IQR 9-21, p<0.001) for the 78 patients in the post-intervention group. The results remained significant regardless of time of admission. There were no significant changes in the rate of stroke mimics, prehospital time or fatal intracranial hemorrhage.

Simulation training in conjunction with protocol improvement led to an immediate and significant reduction of median door-to-needle time in stroke thrombolysis (Fig. 1). To our knowledge, no other published data have shown lower median treatment times. Combining simulation training with protocol change holds promise as a method both for effective implementation and significant results in attempts to reduce in-hospital delays in stroke thrombolysis. Effects on non-technical skills, provider variability and long term patient outcomes are yet to be evaluated.

Item Type: Conference Proceedings
Title of Proceedings: Advances in Simulation
Additional Information: Selected abstracts from the 24th Annual Meeting of the Society in Europe for the Simulation Applied to Medicine, held at Bilbao, Spain from 27-29 June 2018. *** © The Author(s) 2018. Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.
Uncontrolled Keywords: Simulation, SqS Simulation, Sequential Simulation, Model development
Subjects: R Medicine > RT Nursing
Faculty / School / Research Centre / Research Group: Faculty of Education, Health & Human Sciences
Faculty of Education, Health & Human Sciences > School of Health Sciences (HEA)
Last Modified: 28 Jul 2018 17:39

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