An Emergency Medicine Milestone-Based Simulation Curriculum: Acute Ischemic Stroke

Stroke Code From EMS to Thrombectomy: An Interdisciplinary In Situ Simulation for Prompt Management of Acute Ischemic Stroke

INTRODUCTION

Treatment of acute ischemic stroke is challenging because it requires prompt management, interdisciplinary collaboration, and adherence to specific guidelines. This resource addresses these challenges by providing in situ simulated practice with stroke codes by practicing clinicians at unannounced times.

METHODS

An emergency department team was presented with a 55-year-old simulated patient with speech difficulty and right-sided weakness. The team had to assess her efficiently and appropriately, including activating the stroke team via the hospital paging system. The stroke team responded to collaboratively coordinate evaluation, obtain appropriate imaging, administer thrombolytic therapy, and recognize the need for thrombectomy. Learners moved through the actual steps in the real clinical environment, using real hospital equipment. Upon simulation completion, debriefing was utilized to review the case and team performance. Latent safety threats were recorded, if present. Participants completed an evaluation to gauge the simulation's effectiveness.

RESULTS

Six simulations involving 40 total participants were conducted and debriefed across New York City Health + Hospitals. One hundred percent of teams correctly identified the presenting condition and assessed eligibility for thrombolytic and endovascular therapy. Evaluations indicated that 100% of learners found the simulation to be an effective clinical, teamwork, and communication teaching tool. Debriefing captured several latent safety threats, which were rectified by collaboration with hospital leadership.

DISCUSSION

Impromptu, in situ simulation helps develop interdisciplinary teamwork and clinical knowledge and is useful for reviewing crucial times and processes required for best-practice patient care. It is particularly useful when timely management is essential, as with acute ischemic stroke.

Simulation-Based Assessments and Graduating Neurology Residents' Milestones: Status Epilepticus Milestones

BACKGROUND

The American Board of Psychiatry and Neurology and the Accreditation Council for Graduate Medical Education (ACGME) developed Milestones that provide a framework for residents' assessment. However, Milestones do not provide a description for how programs should perform assessments.

OBJECTIVES

We evaluated graduating residents' status epilepticus (SE) identification and management skills and how they correlate with ACGME Milestones reported for epilepsy and management/treatment by their program's clinical competency committee (CCC).

METHODS

We performed a cohort study of graduating neurology residents from 3 academic medical centers in Chicago in 2018. We evaluated residents' skills identifying and managing SE using a simulation-based assessment (26-item checklist). Simulation-based assessment scores were compared to experience (number of SE cases each resident reported identifying and managing during residency), self-confidence in identifying and managing these cases, and their end of residency Milestones assigned by a CCC based on end-of-rotation evaluations.

RESULTS

Sixteen of 21 (76%) eligible residents participated in the study. Average SE checklist score was 15.6 of 26 checklist items correct (60%, SD 12.2%). There were no significant correlations between resident checklist performance and experience or self-confidence. The average participant's level of Milestone for epilepsy and management/treatment was high at 4.3 of 5 (SD 0.4) and 4.4 of 5 (SD 0.4), respectively. There were no significant associations between checklist skills performance and level of Milestone assigned.

CONCLUSIONS

Simulated SE skills performance of graduating neurology residents was poor. Our study suggests that end-of-rotation evaluations alone are inadequate for assigning Milestones for high-stakes clinical skills such as identification and management of SE.