Development of Neurological Emergency Simulations for Assessment: Content Evidence and Response Process

BRAIN-SIM: Leveraging Simulation for Neurocritical Care Education with an Innovative Multidisciplinary Approach

Background and ObjectivesEarly recognition and response are paramount in the treatment of neurologic emergencies. Due to its complexity, neurocritical care continues to provoke unease for practitioners and trainees. Simulation provides a realistic opportunity for learners to detect an acutely deteriorating neurologic patient and make rapid-fire treatment decisions. A multidisciplinary simulation-based learning environment may improve trainee confidence when caring for the neurocritical care patient population.MethodsNine simulation lab sessions were performed with a multidisciplinary team including medical students, residents, critical care medicine fellows, advanced practice providers (APP), critical care pharmacy residents, and neuroscience unit nurses. High fidelity manikins capable of reproducing acute neurologic and physiologic emergencies were used. After the simulation, participants completed a survey utilizing Likert scale responses regarding simulation logistics, faculty competence, and pre- and post-simulation confidence levels managing specific acute neurologic emergencies and performing neurocritical care procedural skills.ResultsNine simulation lab sessions were conducted, and thirty-eight surveys were completed. Mean learner confidence levels in managing patients improved from pre- to post-simulation in patients with coma [3.18 ± 0.51 versus 4.32 ± 0.25 (P < .001)], status epilepticus [3.23 ± 0.55 versus 4.36 ± 0.29 (P < .001)], acute ischemic stroke [3.75 ± 0.59 versus 4.63 ± 0.43 (P < .001)], intracerebral hemorrhage [3.25 ± 0.74 versus 4.63 ± 0.43 (P < .001)], intracranial hypertension [3.25 ± 0.74 versus 4.63 ± 0.43 (P < .001)], respiratory failure [3.5 ± 0.77 versus 4.63 ± 0.43 (P = .0016)], and procedures such as central lines [2.2 ± 0.56 versus 3.8 ± 0.56 (P = .003)], intubations [2.25 ± 0.39 versus 3.63 ± 0.62 (P < .001)], and bronchoscopies [2 ± 0 versus 3.2 ± 0.56 (P = .004). Consistently, learners strongly agreed that faculty were knowledgeable, well-informed, and thorough. Learners commented that the simulation experiences were realistic and allowed them to identify areas for improvement.DiscussionSimulation training can be an effective method to improve neurocritical care education by increasing clinician confidence in managing neurologic emergencies and procedures while providing opportunities for multidisciplinary collaboration. Further evaluation of the effectiveness of simulation education in this patient care setting is warranted.

Education Research: Utilization of Simulation in Residency Programs: A Survey of Adult Neurology Residency Program Directors

Background and Objectives

Previous research has demonstrated that simulation-based medical education (SBME) can improve neurology trainees' confidence, knowledge, and competence. However, a general needs assessment and review of current SBME used within neurology are needed to guide SBME curriculum development. The objective of this study was to describe the current use of SBME in resident education and to assess perceived barriers to expanding SBME interventions.

Methods

We surveyed adult neurology residency program directors (PDs) listed in the Accreditation Council for Graduate Medical Education directory using a Qualtrics-based survey platform. Survey questions addressed current utilization of SBME and barriers to SBME growth.

Results

Seventy-five PDs of 171 contactable PDs responded to our survey (response rate 44%). Of the respondents, 84% (64/75) report using SBME in their adult neurology residencies. Of those using SBME, 87% (55/64) programs create their own cases. Most programs use simulation to teach neurocritical care topics (63%) and vascular neurology (78%); few use simulation to teach outpatient topics and teleneurology. Among programs that use SBME, there was variability in the frequency of the SBME interventions and in the target trainee cohort. Among responding programs, most expressed interest in expanding SBME in their curriculum (69%, 52/64), but frequently cited lack of faculty protected time (55%), funding (35%), and resident availability (32%) as barriers to doing so.

Discussion

Most responding programs use SBME. However, the frequency and target learner for SBME interventions varied between programs. Many programs wish to expand SBME at their institutions but are constrained by limited protected time and institutional financial support. We discuss potential solutions to the perceived barriers to SBME, including intra-institutional collaboration to advance SBME use and case diversity for learners and help innovate neurology medical education.

Improving Knowledge About Stroke Using Simulation Training

Background Stroke is a medical emergency that is risk-stratified using a national scoring system called the National Institute of Health Stroke Scale (NIHSS). The management of an acute stroke necessitates prompt management and swift decision-making. Human factors were identified in the literature as the main rate-limiting step to improving door-to-needle (DTN) time. We felt it would be prudent to design a local stroke course implemented at Great Western Hospital Swindon that incorporates both traditional and simulation-based elements to improve theoretical knowledge and emulate real-life scenarios. The objective of this course was to improve practical application in the efficient assessment and management of stroke patients, as this is critical to delivering timely treatment with thrombolysis or thrombectomy.  Methods Twenty-four medical professionals (medical students and resident doctors) participated in our course between November 2022 and July 2023. The domains assessed included understanding thrombolysis, understanding thrombectomy, confidence in performing NIHSS, and confidence in the assessment of stroke patients. The effectiveness of the stroke simulation course was assessed both quantitatively and qualitatively with pre- and post-course questionnaires. Results There was a significant improvement (p<0.05) in all four assessed domains. There was a significant increase (p=0.0003) in the mean difference of score 3.75 (95% CI: 2.43-5.07) in understanding thrombolysis. Similarly, understanding of thrombectomy was significantly improved (p=0.0002) with a mean difference in score of 3.4 (95% CI: 2.28-4.46). There was also a significant increase (p<0.0001) in confidence in completing NIHSS scoring by a mean of 4.33 (95% CI: 3.55-5.12). Lastly, there was a significant increase (p=0.0012) in the mean by 2.75 (95% CI: 1.51-3.99) in confidence in the assessment of stroke. Overall, 95.8% of the participants found the course at least good, if not very good or excellent, and 91.7% would recommend this course to others. Conclusion We found traditional and simulation-based training to be effective in improving understanding of thrombolysis, understanding of thrombectomy, confidence in NIHSS scoring, and confidence in the assessment of stroke patients. This study validates the effectiveness of our course in improving assessment and management in acute stroke patients. We infer that improvements in these domains coupled with simulation training focused on human factors (e.g., fatigue affecting decision-making or logistical issues such as delays in neuroimaging due to scanner availability) would achieve better DTN time in the participants of our course.

Smartphone Use in the Management of Neurological Emergencies: A Simulation-Based Study

BACKGROUND

Smartphone use in medicine is nearly universal despite a dearth of research assessing utility in clinical performance. We sought to identify and define smartphone use during simulated neuroemergencies.

METHODS

In this retrospective review of a prospective observational single-center simulation-based study, participants ranging from subinterns to attending physicians and stratified by training level (novice, intermediate, and advanced) managed a variety of neurological emergencies. The primary outcome was frequency and purpose of smartphone use. Secondary outcomes included success rate of smartphone use and performance (measured by completion of critical tasks) of participants who used smartphones versus those who did not. In subgroup analyses we compared outcomes across participants by level of training using t-tests and χ2 statistics.

RESULTS

One hundred and three participants completed 245 simulation scenarios. Smartphones were used in 109 (45%) simulations. Of participants using smartphones, 102 participants looked up medication doses, 52 participants looked up management guidelines, 11 participants looked up hospital protocols, and 13 participants used smartphones for assistance with an examination scale. Participants found the correct answer 73% of the time using smartphones. There was an association between participant level and smartphone use with intermediate participants being more likely to use their smartphones than novice or advanced participants, 53% versus 29% and 26%, respectively (p < 0.05). Of the intermediate participants, those who used smartphones did not perform better during the simulation scenario than participants who did not use smartphones (smartphone users' mean score [standard deviation] = 12.3 [2.9] vs. nonsmartphone users' mean score [standard deviation] = 12.9 (2.7), p = 0.85).

CONCLUSIONS

Participants commonly used smartphones in simulated neuroemergencies but use didn't confer improved clinical performance. Less experienced participants were the most likely to use smartphones and less likely to arrive at correct conclusions, and thus are the most likely to benefit from an evidence-based smartphone application for neuroemergencies.

Evaluating the effects of simulation training on stroke thrombolysis: a systematic review and meta-analysis

BACKGROUND

Ischaemic strokes are medical emergencies, and reperfusion treatment, most commonly intravenous thrombolysis, is time-critical. Thrombolysis administration relies on well-organised pathways of care with highly skilled and efficient clinicians. Simulation training is a widespread teaching modality, but results from studies on the impact of this intervention have yet to be synthesised. This systematic review and meta-analysis aimed to synthesise the evidence and provide a recommendation regarding the effects of simulation training for healthcare professionals on door-to-needle time in the emergency thrombolysis of patients with ischaemic stroke.

METHODS

Seven electronic databases were systematically searched (last updated 12th July 2023) for eligible full-text articles and conference abstracts. Results were screened for relevance by two independent reviewers. The primary outcome was door-to-needle time for recombinant tissue plasminogen activator administration in emergency patients with ischaemic stroke. The secondary outcomes were learner-centred, improvements in knowledge and communication, self-perceived usefulness of training, and feeling 'safe' in thrombolysis-related decision-making. Data were extracted, risk of study bias assessed, and analysis was performed using RevMan™ software (Web version 5.6.0, The Cochrane Collaboration). The quality of the evidence was assessed using the Medical Education Research Study Quality Instrument.

RESULTS

Eleven studies were included in the meta-analysis and nineteen in the qualitative synthesis (n = 20,189 total patients). There were statistically significant effects of simulation training in reducing door-to-needle time; mean difference of 15 min [95% confidence intervals (CI) 8 to 21 min]; in improving healthcare professionals' acute stroke care knowledge; risk ratio (RR) 0.42 (95% CI 0.30 to 0.60); and in feeling 'safe' in thrombolysis-related decision-making; RR 0.46 (95% CI 0.36 to 0.59). Furthermore, simulation training improved healthcare professionals' communication and was self-perceived as useful training.

CONCLUSION

This meta-analysis showed that simulation training improves door-to-needle times for the delivery of thrombolysis in ischaemic stroke. However, results should be interpreted with caution due to the heterogeneity of the included studies.

Reviews in Medical Education: Advances in Simulation to Address New Challenges in Neurology

Simulation is an engaging modality of medical education that leverages adult learning theory. Since its inception, educators have used simulation to train clinicians in bedside procedures and neurologic emergencies, as well as in communication, teamwork, and leadership skills. Many applications of simulation in neurology are yet to be fully adopted or explored. However, challenges to traditional educational paradigms, such as the shift to competency-based assessments and the need for remote or hybrid platforms, have created an impetus for neurologists to embrace simulation. In this article, we explore how simulation might be adapted to meet these current challenges in neurologic education by reviewing the existing literature in simulation from the field of neurology and beyond. We discuss how simulation can engage neurology trainees who seek interactive, contextualized, on-demand education. We consider how educators can incorporate simulation for competency-based evaluations and procedural training. We foresee a growing role of simulation initiatives that assess bias and promote equity. We also provide tangible solutions that make simulation an educational tool that is within reach for any educator in both high-resource and low-resource settings.

Simulation-based assessment of trainee's performance in post-cardiac arrest resuscitation

Objectives

To assess trainees’ performance in managing a patient with post-cardiac arrest complicated by status epilepticus.

Methods

In this prospective, observational, single-center simulation-based study, trainees ranging from sub interns to critical care fellows evaluated and managed a post cardiac arrest patient, complicated by status epilepticus. Critical action items were developed by a modified Delphi approach based on American Heart Association guidelines and the Neurocritical Care Society’s Emergency Neurological Life Support protocols. The primary outcome measure was the critical action item sum score. We sought validity evidence to support our findings by including attending neurocritical care physicians and comparing performance across four levels of training.

Results

Forty-nine participants completed the simulation. The mean sum of critical actions completed by trainees was 10/21 (49%). Eleven (22%) trainees verbalized a differential diagnosis for the arrest. Thirty-two (65%) reviewed the electrocardiogram, recognized it as abnormal, and consulted cardiology. Forty trainees (81%) independently decided to start temperature management, but only 20 (41%) insisted on it when asked to reconsider. There was an effect of level of training on critical action checklist sum scores (novice mean score [standard deviation (SD)] = 4.8(1.8) vs. intermediate mean score (SD) = 10.4(2.1) vs. advanced mean score (D) = 11.6(3.0) vs. expert mean score (SD) = 14.7(2.2))

Conclusions

High-fidelity manikin-based simulation holds promise as an assessment tool in the performance of post-cardiac arrest care.

Simulation-Based Assessment of Graduate Neurology Trainees' Performance Managing Acute Ischemic Stroke

BACKGROUND AND OBJECTIVES

Multidisciplinary acute stroke teams improve acute ischemic stroke management but may hinder trainees' education which in turn may contribute to poorer outcomes in community hospitals upon graduation. Our goal was to assess graduate neurology trainee performance independent of a multi-disciplinary stroke team in the management of acute ischemic stroke, tissue plasminogen activator (tPA)-related hemorrhage, and cerebral herniation syndrome.

METHODS

In this prospective, observational, single-center simulation-based study, participants (sub-interns to attending physicians) managed a patient with acute ischemic stroke followed by tPA-related hemorrhagic conversion leading to cerebral herniation. Critical actions were developed by a modified Delphi approach based on relevant American Heart Association guidelines and the Neurocritical Care Society's Emergency Neurological Life Support protocols. The primary outcome measure was graduate neurology trainees' critical action item sum score. We sought validity evidence to support our findings by comparing trainees' performance across four levels of training.

RESULTS

Fifty-three trainees (including 31 graduate neurology trainees) and five attending physicians completed the simulation. The mean sum of critical actions completed by graduate neurology trainees was 15/22 (68%). Ninety percent of graduate neurology trainees properly administered tPA, 84% immediately stopped tPA infusion following patient deterioration, but only 55% reversed tPA according to guidelines. There was a moderately strong effect of level of training on critical action sum score (level 1 mean score [standard deviation (SD)] = 7.2 (2.8) vs. level 2 mean score (SD) = 12.3 (2.6) vs. level 3 mean score (SD) = 13.3 (2.2) vs. level 4 mean score (SD) = 16.3 (2.4), p < .001, R² = 0.54).

DISCUSSION

Graduate neurology trainees reassuringly perform well in initial management of acute ischemic stroke, but frequently make errors in the treatment of hemorrhagic transformation after thrombolysis, suggesting the need for more education surrounding this low frequency, high-acuity event. High-fidelity simulation holds promise as an assessment tool for acute stroke management performance.