Stroke Simulation Improves Acute Stroke Management: A Systems-Based Practice Experience

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.

Telestroke Training: Considerations for Expansion of Vascular Neurology Program Requirements

Telemedicine for stroke (Telestroke) has been a key component to efficient, widespread acute stroke care for many years. The expansion of reimbursement through the Furthering Access to Stroke Telemedicine Act and rapid deployment of telemedicine resources during the COVID-19 public health emergency have further expanded remote care, with practitioners of varying educational backgrounds, and experience providing acute stroke care via telemedicine (Telestroke). Some Telestroke practitioners have not had fellowship-level vascular neurology training and many are without training specific to virtual modalities. While many vascular neurology fellowship programs incorporate Telestroke training into the curriculum, components of this curriculum are not consistent, extent of involvement is variable, and not all fellows receive hands-on training in remote care. Furthermore, the extent of training and evaluation of Telestroke in American Board of Psychiatry and Neurology training requirements and Accreditation Council for Graduate Medical Education assessments for vascular neurology fellowship are not standardized. We suggest that Telestroke be formally incorporated into vascular neurology fellowship curricula and provide considerations for key components of this training and metrics for evaluation.

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.

Using Neurology Trainees as Standardized Patients in a Neurological Emergency Simulation Curriculum for Medical Students

Purpose

Simulation manikins have limited ability to mimic neurological exam findings, which has historically constrained their use in neurology education. We developed a cased-based simulation curriculum in which neurology trainees acted as standardized patients (SPs) and portrayed the neurologic exam for medical students.

Materials/Methods

We ran monthly simulations of two cases (acute stroke and seizure) with resident/fellow SPs. Pre-/post-session surveys assessed students' self-rated confidence in neurological clinical skills (gathering a history, performing an exam, presenting a case) and knowledge domains. Questions about students' attitudes about neurology were adapted from a validated assessment tool. Paired t-tests were performed for quantitative items. Qualitative thematic analysis identified key themes.

Results

Sixty-one students participated. Post-session, students reported significantly higher self-confidence in all neurological clinical skills and knowledge domains (p < 0.002). Greater than ninety-five percent agreed the session met the learning objectives; 95% recommended it to others. Resident/fellow SPs were cited as the most effective educational component. Students appreciated evaluating acute emergencies and reported an increased interest in neurology careers.

Conclusions

A case-based simulation curriculum with neurology trainees portraying the SP increased students' self-reported knowledge, skills, and confidence in managing neurological emergencies. Our intervention may improve medical student neurology education and increase interest in the field. Future research should evaluate clinical skills objectively.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-024-02016-w.

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.

Improvement of Confidence and Knowledge Retention for Stroke Management Among Internal Medicine Trainees During an Institution-Specific, Protocol-Oriented Lecture Based Intervention

Background

Acute stroke management is an essential component of neurology residency education. Internal medicine trainees are less likely to receive dedicated training in acute stroke care despite having to care for hospitalized patients with a stroke diagnosis.

Objective

The objectives of this survey-based quality improvement study were to: 1) assess pre-existing confidence and knowledge about acute stroke care among internal medicine trainees and 2) measure change after an institution-specific, protocol-oriented "value added lecture" (intervention).

Methods

Pre-intervention survey and knowledge assessment was given to internal medicine physicians, residents, and students, followed by the intervention on acute stroke management, during academic year 2019-2020. Post-intervention assessment was administered immediately post-intervention, and again at end of rotation. A 10-point Likert scale was used to indicate confidence. Statistics were performed using Student's T-Test.

Results

Fifty-one respondents participated, out of a possible 162 (31% participation rate); 13 (25%) of the 51 respondents completed the delayed post-intervention survey. Only twenty-six (51%) participants had previously received a lecture on acute stroke management. Respondents' knowledge and confidence on acute stroke management improved after intervention (p<0.0001), with no change in these scores by end of rotation (p=0.31). Forty-five (88%) respondents agreed or strongly agreed that a targeted stroke didactic was a useful part of internal medicine training.

Conclusions

An institution-specific, protocol-oriented lecture improved stroke management knowledge and confidence among internal medicine trainees, particularly among earlier trainees. A dedicated stroke management lecture should be considered as an addition to internal medicine training programs' curricula.

Curriculum Innovations: A Comprehensive Teleneurology Curriculum for Neurology Trainees

Introduction and Problem Statement

As the role of teleneurology expands, it is important to prepare trainees to perform virtual encounters proficiently.

Objectives

We created a comprehensive multimodality teleneurology curriculum for residents to teach key aspects of telehealth encounters including the virtual examination and skill development across several environments.

Methods and Curriculum Description

We developed and implemented a teleneurology curriculum focused on teaching the virtual neurologic examination, measuring teleneurology competency, and providing opportunities for trainees to perform telehealth encounters in multiple settings. Residents (N = 22) were first surveyed on what methods would be most helpful to learn teleneurology. Trainees observed a faculty member conducting a teleneurology visit with another faculty member playing a patient. Residents then practiced a teleneurology encounter during a 10-minute objective structured clinical examination (OSCE) at a simulation center. After positive feedback from the fall of 2020, we adapted the OSCE to be completely remote in the spring of 2021 for senior residents. Trainees then performed teleneurology visits during their continuity clinics and subspecialty clinic rotations.

Results and Assessment Data

All neurology residents from adult and child neurology and neuropsychiatry programs at New York University Grossman School of Medicine participated in the curriculum. Residents identified a variety of teaching modalities that would help them learn teleneurology: didactics with slides (25%), live demonstration (25%), simulated experience (23%), starting with live patients (23%), and articles/reading material (4%). To date, 68 trainees participated in the OSCE. Trainees who completed on-site and remote simulations reported increased comfort (p < 0.05) and interest in teleneurology (p < 0.05) and requested more access to simulations during training. Sensorimotor assessment and adequate visualization of the affected limb were identified as areas for improvement.

Discussion and Lessons Learned

Our multimodal 3-year teleneurology curriculum provides opportunities for residents to learn and apply teleneurology. Survey tools helped strengthen the curriculum to optimize educational potential. We implemented a teleneurology simulation with and without the use of a simulation center. We plan to expand our teleneurology clinical and simulation experiences to trainees based on our data and further developments in teleneurology and to track the progress of teleneurology skills as residents advance through training.

A Systematic Review on the Effectiveness of Systems-Based Practice Curricula in Health Professions Education

This systematic review aims to evaluate the effectiveness of systems-based practice (SBP) curricula from the perspective of health professions students and workers. A total of 8468 citations were sourced from six electronic databases and manual searches conducted independently by two researchers, of which 44 studies were eventually included. A meta-analysis using a random effects model and a meta-synthesis using the thematic synthesis approach were conducted. Most studies targeted medical students, residents, and resident physicians from various clinical specialties. Almost half of all studies focused on didactic or knowledge-based interventions to teach SBP. About a third of all studies measured non-self-evaluated knowledge change, clinical abilities, and clinical outcomes. Both meta-analysis and meta-synthesis results revealed positive outcomes of increased knowledge of SBP, increased recognition of SBP as a core competency in one's profession, and increased application of SBP knowledge in one's profession. Meta-synthesis results also revealed negative outcomes at the institutional and teacher/health professions level. This review highlights the importance of SBP education and supports the effectiveness of SBP curricula. There is a need to address the negative outcomes at the institutional and teacher/health professions level. Moreover, future studies could investigate the integration of self-assessment outcomes with comparison to some external standard.

Education Research: Junior Neurology Residents Achieve Competency but Not Mastery After a Brief Acute Ischemic Stroke Simulation Course

Background and Objectives

Simulation bootcamps are used to onboard neurology trainees. It is not known whether these bootcamps result in competency for acute ischemic stroke (AIS).

Methods

For this prospective, single-center pre-post educational intervention study, the Angoff standard setting method was used to determine a Minimum Passing Score (MPS) and Mastery Score for 2 AIS simulations. Junior neurology residents completed precourse knowledge and confidence assessments and had traditional didactic teaching. A week later, each resident completed the first scored AIS simulation. Each resident then practiced stroke care in an unscored simulation. Two to 8 weeks later, each resident was evaluated in an unannounced AIS simulation (the post-test). Postgraduate year (PGY)-3 adult neurology senior residents also completed a knowledge and confidence assessment and were scored on just the AIS post-test case. Using independent and paired t tests, respectively, we compared the junior residents' retention test performance to their baseline assessment and to senior residents' performance.

Results

Thirteen junior residents (9 PGY-2 adult neurology residents and 4 PGY-3 child neurology residents) participated in the course. Only 3 junior residents (23%) initially achieved the MPS in the first AIS simulation. After the simulation course, 9 junior residents (69%) achieved the MPS threshold. Although none achieved mastery, junior residents' mean performance score in the simulation improved (mean score preintervention [SD] = 10.3 [2.8] vs mean score postintervention [SD] = 15.7 [2.6], p < 0.001) and their confidence increased (mean score preintervention [SD] = 3.3 [1.9] vs mean score postintervention [SD] = 4.9 [1.2], p < 0.001, d = 1.7). Eight PGY-3 adult neurology residents were scored on the AIS post-test. Five reached MPS (63%), and 1 demonstrated mastery. The simulation scores of the postcourse juniors and seniors were similar (junior resident mean score [SD] = 15.7 [2.6] vs senior resident mean score [SD] = 16.0 [2.5], p = 0.793).

Discussion

A brief AIS simulation course may improve junior residents' performance and confidence to a level comparable with senior residents, although not to mastery.

Scoping Review: Innovations in Clinical Neurology Education

Advances in adult learning theory and instructional technologies provide opportunities to improve neurology knowledge acquisition. This scoping review aimed to survey the emerging landscape of educational innovation in clinical neurology. With the assistance of a research librarian, we conducted a literature search on November 4, 2021, using the following databases: PubMed, Embase, Scopus, Cochrane Library, Education Resources Information Center, and PsycINFO. We included studies of innovative teaching methods for medical students through attending physician-level learners and excluded interventions for undergraduate students and established methods of teaching, as well as those published before 2010. Two authors independently reviewed all abstracts and full-text articles to determine inclusion. In the case of disagreement, a third author acted as arbiter. Study evaluation consisted of grading level of outcomes using the Kirkpatrick model, assessing for the presence of key components of education innovation literature, and applying an author-driven global innovation rating. Among 3,830 identified publications, 350 (175 full texts and 175 abstracts) studies were selected for analysis. Only 13 studies were included from 2010 to 2011, with 98 from 2020 to 2021. The most common innovations were simulation (142), eLearning, including web-based software and video-based learning (78), 3-dimensional modeling/printing (34), virtual/augmented reality (26) podcasts/smartphone applications/social media (24), team-based learning (17), flipped classroom (17), problem-based learning (10), and gamification (9). Ninety-eight (28.0%) articles included a study design with a comparison group, but only 23 of those randomized learners to an intervention. Most studies relied on Kirkpatrick Level 1 and 2 outcomes-the perceptions of training by learners and acquisition of knowledge. The sustainability of the innovation, transferability of the innovation to a new context, and the explanation of the novel nature of the innovations were some of the least represented features. We rated most innovations as only slightly innovative. There has been an explosion of reports on educational methods in clinical neurology over the last decade, especially in simulation and eLearning. Unfortunately, most reports lack adequate assessment of the validity and effect of the respective innovation's merits, as well as details regarding sustainability and transferability to new contexts.

Simulation-based team training improves door-to-needle time for intravenous thrombolysis

PURPOSE

There is a clinical need for shortened door-to-needle time (DNT) for intravenous thrombolysis, but effective training methods are missing. Simulation training improves teamwork and logistics in numerous fields. Still, it is not clear if simulation improves logistics in stroke.

METHODS

To evaluate the efficiency of a simulation training programme, the DNT of participating centres was compared with the rest of stroke centres in the Czech Republic. Patients' data were prospectively collected from the nationally used Safe Implementation of Treatments in Stroke Registry. The outcome was an improvement in DNT in 2018 as compared with 2015 (after and before the simulation training). Scenarios were based on real clinical cases, and simulation courses were conducted in a standardly equipped simulation centre.

FINDINGS

Between 2016 and 2017, 10 courses were conducted for stroke teams from 9 of all 45 stroke centres. DNT data were available both in 2015 and 2018 from 41 (91%) stroke centres. The simulation training improved the DNT in 2018 as compared with 2015 by 30 min (95% CI 25.7 to 34.7) and as compared with 20 min (95% CI 15.8 to 24.3) in stroke centres without the simulation training (p=0.01). Any parenchymal haemorrhage occurred in 5.4% and 3.5% of patients treated in centres without and with simulation training (p=0.054), respectively.

CONCLUSIONS

DNT was considerably shortened nationally. It was feasible to implement simulation as a nationwide training programme. The simulation was associated with improved DNT; however, other studies should confirm that such an association is causal.

Nutritional Counseling of Stroke Patients by Neurology Residents, a Call to Action

Background

Poor diet quality has been found to be an independent risk factor for mortality in stroke. However, it is unknown to what extent Neurologists are trained and are comfortable enough to provide dietary counseling to stroke patients.

Objective

To assess the knowledge, attitudes, and practices of neurology residents relating to dietary counseling of stroke patients.

Methods

An online anonymous survey was administered to neurology residents throughout the country between August and November 2019 among a total of 109 (68%) US neurology programs. Self-reported practices and knowledge regarding stroke prevention through nutritional counseling were queried using validated questionnaires.

Results

453 responses out of a potential 672 were received. A minority of residents (12.3%) consistently offered nutritional counseling to stroke patients. 47.7% considered that it was not the neurologist's role to provide nutritional counseling to stroke patients. 83.4% of residents felt that it was the responsibility of the dietician to provide nutritional counseling, yet only 21.4% of residents consistently referred stroke patients to a dietician. 77.9% of respondents felt nutritional counseling is important for stroke patients, yet 65.6% felt they were not adequately trained to provide nutritional counseling.

Conclusion

Neurologists in training believe diet to be an important part of stroke prevention, but practical knowledge and training in nutrition are suboptimal. This study suggests the need to include nutrition as an integral part of neurology training, to ensure neurologists feel empowered to be an important part of the team providing nutritional counseling to stroke patients.

Simulation-based training improves process times in acute stroke care (STREAM)

BACKGROUND

The objective of the STREAM Trial was to evaluate the effect of simulation training on process times in acute stroke care.

METHODS

The multicenter prospective interventional STREAM Trial was conducted between 10/2017 and 04/2019 at seven tertiary care neurocenters in Germany with a pre- and post-interventional observation phase. We recorded patient characteristics, acute stroke care process times, stroke team composition and simulation experience for consecutive direct-to-center patients receiving intravenous thrombolysis (IVT) and/or endovascular therapy (EVT). The intervention consisted of a composite intervention centered around stroke-specific in situ simulation training. Primary outcome measure was the 'door-to-needle' time (DTN) for IVT. Secondary outcome measures included process times of EVT and measures taken to streamline the pre-existing treatment algorithm.

RESULTS

The effect of the STREAM intervention on the process times of all acute stroke operations was neutral. However, secondary analyses showed a DTN reduction of 5 min from 38 min pre-intervention (interquartile range [IQR] 25-43 min) to 33 min (IQR 23-39 min, p = 0.03) post-intervention achieved by simulation-experienced stroke teams. Concerning EVT, we found significantly shorter door-to-groin times in patients who were treated by teams with simulation experience as compared to simulation-naive teams in the post-interventional phase (-21 min, simulation-naive: 95 min, IQR 69-111 vs. simulation-experienced: 74 min, IQR 51-92, p = 0.04).

CONCLUSION

An intervention combining workflow refinement and simulation-based stroke team training has the potential to improve process times in acute stroke care.

Simulation for Neurology training: Acute setting and beyond

Simulation-based training is adapted for teaching neurology, and it can offer multiple programs for general and specialized neurologists. Indeed, simulation training is "learner-centered", assuring sessions tailored to each learner level, and provides a realistic, safe, controlled and reproducible environment to improve knowledge, technical and non-technical skills, including situational awareness, communication, teamwork and leadership. Indeed, simulation tools allow multidisciplinary sessions with different team members (nurses, physician associates, specialist trainees, technicians) participating with their experiences. Multidisciplinary scenarios maximize awareness on the "human factors" and contribute to the safety of future patients. Simulation sessions require clear learning objectives and debriefing points tailored to the learning groups, but instructors may vary the scenarios in real time according to learners' actions. Different simulation techniques are applied according to learning objectives. The simulation session always includes a briefing, a simulation scenario and a structured debriefing, driven by the instructor, which is crucial for learning consolidation. In neurology training, simulation methods are applicable for: i) training on emergency situations, where the neurologist team has to manage in frontline a specific medical emergency (stroke, status epilepticus, coma, neuromuscular respiratory failure); ii) improving technical skills (lumbar puncture, electroencephalography (EEG), cervical ultrasound and transcranial Doppler, endovascular thrombectomy procedures, neuroradiological investigations); iii) improving procedures and patient pathways (stroke pathway, telemedicine); and iv) training non-technical skills (communication, teamwork, leadership). This manuscript provides a brief overview on the general principles of simulation techniques and their potential application in neurology training, in the acute setting and beyond.

Effect of multi-level stroke education on treatment and prognosis of acute ischemic stroke

This observational study aimed at the significance of multi-level education in the treatment and prognosis of acute ischemic stroke. Multi-level stroke education was carried out among residents and medical staff for one year in Guancheng district. After 1 year, 519 patients with acute ischemic stroke admitted to The First People's Hospital of Zhengzhou were invited to the study, 272 patients from the Guancheng district were divided into the experimental group, and 247 patients who were not from the Guancheng district but in the neighborhood of The First People's Hospital of Zhengzhou were divided into the control group. Statistical methods were applied to analyze the degree of awareness of stroke, the time from onset to hospital, the route to hospital, the number of patients coming to the hospital within 4.5 h, the number of intravenous thrombolysis, door-to-needle time (DNT), modified Rankin scale (MRS) score, and the number of hemorrhagic transformation cases. After one year of multi-level systematic stroke education, there were significant differences in stroke awareness between the experimental group and the control group in terms of limb weakness (87.87 vs. 62.75%), speech inarticulation (78.3 vs. 55.06%), facial paralysis (69.12 vs. 38.06%), limb numbness (57.35 vs. 29.15%), consciousness disorder (62.50 vs. 42.11%), walking instability with severe dizziness (39.97 vs. 15.79%) (P<0.05). There was no statistical significant difference in unclear vision or blind eyes or severe headache (P>0.05). There were statistical differences between the two groups in the time from the onset to the hospital (14.82±17.67 vs. 25.92±25.23), emergency medical services (EMS) (36.02 vs. 16.19%), number of patients coming to the hospital within 4.5 h (67 vs. 32), venous thrombolysis cases (55 vs. 17), DNT time (42.43±17.30 vs. 63.35±26.53), hemorrhagic transformation cases (11 vs. 21), and MRS score grade ≥2 (230 vs. 169) (P<0.05). Multi-level education can effectively improve the patient's awareness of stroke, encourage more patients to use EMS system to the hospital. More patients were aware that they should reach the hospital within 4.5 h. It helps shorten DNT time and give more patients the opportunity to receive intravenous thrombolysis or intravascular thrombectomy, which may improve the prognosis and reduce hemorrhagic transformation without reducing mortality.

Contemporary Management of Acute Ischemic Stroke Across the Continuum: From TeleStroke to Intra-Arterial Management

In this comprehensive contemporary review of acute ischemic stroke management, what is new and different will be highlighted beginning with prehospital stroke systems of care, emergency medical systems, and mobile stroke units, followed by hospital stroke teams, emergency evaluation, telemedicine, and brain and vascular imaging, and finishing with emergency treatments including thrombolysis and mechanical thrombectomy.

Simulation: Is it the Future of Training in Critical Care Medicine?

How to cite this article: Kulkarni AP. Simulation: Is it the Future of Training in Critical Care Medicine? IJCCM 2019;23(11):495-496.

Simulation-Based Training of the Rapid Evaluation and Management of Acute Stroke (STREAM)-A Prospective Single-Arm Multicenter Trial

Introduction: Acute stroke care delivered by interdisciplinary teams is time-sensitive. Simulation-based team training is a promising tool to improve team performance in medical operations. It has the potential to improve process times, team communication, patient safety, and staff satisfaction. We aim to assess whether a multi-level approach consisting of a stringent workflow revision based on peer-to-peer review and 2–3 one-day in situ simulation trainings can improve acute stroke care processing times in high volume neurocenters within a 6 months period.

Methods and Analysis: The trial is being carried out in a pre-test-post-test design at 7 tertiary care university hospital neurocenters in Germany. The intervention is directed at the interdisciplinary multiprofessional stroke teams. Before and after the intervention, process times of all direct-to-center stroke patients receiving IV thrombolysis (IVT) and/or endovascular therapy (EVT) will be recorded. The primary outcome measure will be the “door-to-needle” time of all consecutive stroke patients directly admitted to the neurocenters who receive IVT. Secondary outcome measures will be intervention-related process times of the fraction of patients undergoing EVT and effects on team communication, perceived patient safety, and staff satisfaction via a staff questionnaire.

Interventions: We are applying a multi-level intervention in cooperation with three “STREAM multipliers” from each center. First step is a central meeting of the multipliers at the sponsor's institution with the purposes of algorithm review in a peer-to-peer process that is recorded in a protocol and an introduction to the principles of simulation training and debriefing as well as crew resource management and team communication. Thereafter, the multipliers cooperate with the stroke team trainers from the sponsor's institution to plan and execute 2–3 one-day simulation courses in situ in the emergency department and CT room of the trial centers whereupon they receive teaching materials to perpetuate the trainings.

Clinical Trial Registration: STREAM is a registered trial at https://clinicaltrials.gov/ct2/show/NCT03228251.