Testing Confounders in Brain Death Determination: A New Simulation Model

Assessing Outcome Measurements and Impact of Simulation in Neurocritical Care Training: A Systematic Review

ABSTRACT

AIM: The use of simulation training in neurocritical care is increasing. Yet, the pooled impact on patient and trainee outcomes remains unclear. This systematic review aims to determine the outcome measurements used after simulation training in neurocritical care and to synthesize the current evidence about the impact of simulation training on these outcomes. METHODS: A 3-step search was conducted in CINAHL, Cochrane, MEDLINE, PsychINFO, and Scopus. The inclusion criteria were composed of studies exploring simulation training in neurocritical care, published in English between 2000 and 2023. Two reviewers independently conducted screening, critical appraisal, and data extraction, using standardized Joanna Briggs Institute tools. Meta-analysis was precluded because of clinical, methodological, and statistical heterogeneity. RESULTS: Nine relevant studies were found: 1 quality improvement project and 8 quasi-experimental studies. The overall quality of the relevant studies was moderate to high (61.1%-77.8%). Three types of outcome measurements for simulation in neurocritical care were identified: knowledge and clinical performance; confidence and comfort; and teamwork, communication, and leadership skills. Simulation training was associated with a significant improvement in knowledge and clinical performance, and confidence and comfort, but not in communication and leadership skills. CONCLUSION: Significant improvement in trainees' outcomes was observed. The current literature includes significant heterogeneity in the methods of evaluating simulation outcomes, although no patient outcomes were observed. Investigating the effect of simulation in neurocritical care training on patient outcomes in future studies is warranted.

The 2023 American Academy of Neurology, American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care Medicine Pediatric and Adult Brain Death/Death by Neurologic Criteria Determination Consensus Guidelines: What the Critical Care Team Needs to Know

Guidelines for brain death/death by neurologic criteria (BD/DNC) determination were revised to provide a consistent and updated approach to BD/DNC evaluation across all ages by the American Academy of Neurology, American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care Medicine. This article is intended to complement the guidelines and highlight aspects relevant to the critical care community; the actual guidelines should be used to update hospital protocols and dictate clinical practice. Because BD/DNC evaluations are conducted in the ICU, it is essential for members of the critical care community to familiarize themselves with these guidelines. The fundamental concept of BD/DNC has not changed; BD/DNC is permanent loss of function of the brain as a whole, including the brain stem, resulting in coma, brainstem areflexia, and apnea in the setting of an adequate stimulus. The BD/DNC evaluation requires a sufficient observation period to ensure there is no chance of recovery, followed by exclusion of potentially confounding conditions like hypothermia, hypotension, severe metabolic disturbances, or medication effects. Specific guidance is provided for patients who were treated with therapeutic hypothermia or medical or surgical interventions to manage intracranial hypertension. The guidelines outline a structured and meticulous neurologic examination and detail the responses consistent with BD/DNC. A protocol is provided for how to safely perform apnea testing, including modifications needed for patients on extracorporeal membrane oxygenation. Controversial issues such as consent, BD/DNC evaluation in pregnancy, preservation of neuroendocrine function, and primary posterior fossa injuries are addressed. The ultimate goal is to ensure a consistent and accurate approach to BD/DNC evaluation in patients of all ages, fostering public trust in the medical community's ability to determine death. By adhering to these guidelines, critical care clinicians can confidently navigate the challenging aspects of BD/DNC determination.

The effectiveness of video training in improving intensive care nurses' knowledge about brain death identification

BACKGROUND

Because patients diagnosed with brain death in intensive care units constitute a potential cadaveric donor group for organ transplantation, intensive care units are potential donor sources. Nurses who closely monitor the patient collaborate with medical personnel in the recognition and early diagnosis of brain death. Nurses also have an important role in supporting the patient's family. Therefore, it is very important for nurses to know the diagnostic criteria for brain death.

AIM

The aim of this study was to compare the effectiveness of theoretical education and video-assisted education in equipping intensive care nurses to recognize brain death.

STUDY DESIGN

A randomized, experimental study was conducted between February and May 2020 with a total of 50 intensive care nurses, split into 25 in the video-assisted training group and 25 in the theoretical training group. In study, intensive care nurses were given a theoretical training and video-assisted training on brain death criteria. One group was trained theoretically and the other group used a video showing criteria for brainstem reflexes (pupil assessment, spontaneous breathing, corneal reflex, retching and coughing assessments) and deep tendon reflexes in a simulated patient, supported by animation. The data were collected before, immediately after and 3 months after the training using the Brain Death Criteria Knowledge Test, the Brain Death Case Test, and the Training Effectiveness Evaluation Form. The independent samples t-test, Mann-Whitney U test, Friedman test, Wilcoxon test, and Chi-square test were used for statistical analysis of data.

RESULTS

It was found that the knowledge scores of both groups immediately after training and 3 months after training were higher than before the training (p < .001). However, the post-training knowledge scores of the video-assisted training group were significantly higher than those of the theoretical training group (p = .011).

CONCLUSIONS

To enable intensive care nurses to identify brain death, video-assisted training with a simulated patient is recommended, as is repeating the training at regular intervals.

RELEVANCE TO CLINICAL PRACTICE

The simulated patient video-assisted training method can be used for in-service training to provide intensive care nurses with the ability to identify brain death. The training may be repeated at regular intervals (e.g., every 3 months) to increase nurse recall.

Simulation-Based Training Improves Fellows' Competence in Brain Death Discussion and Declaration

BACKGROUND

Despite well-defined American Academy of Neurology guidelines for death by whole brain criteria (brain death), there is marked variability in national practice, which some have attributed to lack of formal education. Further, communication with surrogates and families about brain death is integral to brain death declaration. As such, we developed a targeted brain death curriculum combining didactics and simulation-based education to improve examination and subsequent communication skills with families.

METHODS

Multidisciplinary critical care fellows participated in (1) didactic and case-based curriculum, (2) brain death simulated examination (SimMan3G mannequin), and (3) a standardized family scenario with delivery of a brain death diagnosis to a surrogate "family member". Fellows completed a precurriculum and postcurriculum multiple choice knowledge test and survey (Likert 1 to 10 scale) evaluating measures regarding diagnosis and communication of brain death. t Test and 2-tailed Wilcoxon signed rank test were used for statistical analysis (P<0.05).

RESULTS

Thirteen critical care fellows participated in the curriculum. Most fellows [80% (N=12)] had only participated in 0 to 5 brain death declarations before this intervention. There was significant improvement across all measures: self-rated knowledge (P=0.004), perceived knowledge relative to peers (P=0.002), confidence (P=0.001), and comfort (P=0.001) with performing a brain death exam, and comfort with family discussion (P=0.01). Objective test scores improved from 56 to 73% after simulation (P=0.004). All fellows found the curriculum beneficial.

CONCLUSION

Trainees may lack sufficient exposure to brain death education. Didactics with simulation-based education can improve objective knowledge and subjective measures of comfort with brain death declaration and surrogate communication.

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.

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.

Using Objective Structured Clinical Exams (OSCE) to Teach Neurology Residents to Disclose Prognosis after Hypoxic Ischemic Brain Injury

BACKGROUND

Neurologists need to be adept at disclosing prognosis and breaking bad news. Objective structured clinical examinations (OSCE) allow trainees to practice these skills.

METHODS

In 2017, in conjunction with the NYU School of Medicine Simulation Center, neurology faculty designed an OSCE case in which a resident had to inform a standardized patient (SP) her father had severe global hypoxic ischemic injury. The residents were surveyed on the experience using a Likert scale from 1 (worst) to 5 (best). The SP completed a behavioral anchored checklist and marked items as "not done," "partly done," or "well done".

RESULTS

57 third and fourth year neurology residents completed the case from 2018 to 2020, 54 (95%) of whom completed the post-OSCE survey. Residents reported feeling moderately prepared for the simulation (mean Likert score 3.7/5), and thought their performance was average (3.4/5). Overall, they found the case to be very helpful (4.6/5). The residents performed well in the realms of maintaining professionalism (64% rated "well done"), developing a relationship (62% rated "well done"), and information gathering (61% rated "well done"). There was room for improvement in the realms of providing education and presenting the bad news (39% and 37% rated "partly/not done," respectively).

CONCLUSIONS

OSCE cases can be used to teach neurology trainees how to discuss prognosis and break bad news. Feedback about this simulation was positive, though its efficacy has yet to be evaluated and could be a future direction of study.

Brain Death Determination: An Interprofessional Simulation to Determine Brain Death and Communicate with Families Focused on Neurology Residents

INTRODUCTION

Significant variation exists in determining brain death despite an expectation of competence for all neurology residents. In addition, family discussions regarding brain death are challenging and may influence organ donation.

METHODS

We developed two simulations of increasing complexity for PGY 2 and PGY 3 neurology residents. High-fidelity mannequins were used to simulate patients; standardized actors portrayed family members. In the first simulation, residents determined brain death and shared this information with a grieving family. In the second simulation, residents determined brain death in a more complicated scenario, requiring ancillary testing and accurate result interpretation. Following the determination, residents met with a challenging family. The residents worked with an interdisciplinary team and responded to the family's emotions, used active listening skills, and supported the family through next steps.

RESULTS

Twelve residents completed the simulations. Prior to the simulation, three (25%) residents felt comfortable discussing a brain death diagnosis; following the simulation, eight (67%) residents felt comfortable/very comfortable discussing brain death. Prior to the simulation, eight (67%) residents stated they knew prerequisites for performing a brain death examination and seven (58%) agreed they knew indications for ancillary testing; these numbers increased to 100% following the simulation. The number of residents who felt comfortable performing the brain death exam increased from five (42%) to 10 (83%).

DISCUSSION

This simulation of determining brain death and leading difficult family meetings was well-received by neurology residents. Further work should focus on the effects of simulation-based education on practice variation and organ donation consent rates.

Controversies in Brain Death Declaration: Legal and Ethical Implications in the ICU

Purpose of review

This article provides a brief overview of the history and complexities of brain death determination. We examine a few legal cases that highlight some of the controversies surrounding the validity of brain death tests in light of varying state laws and institutional policy, the appropriateness of making religious accommodations, the dilemma of continuing organ-sustaining support in a pregnant brain-dead patient, and the issue of whether to obtain informed consent from surrogate decision makers before proceeding to testing.

Recent findings

In response to physician concerns about navigating these complex cases, especially with laws that vary from state to state, the American Academy of Neurology has published a position statement in January of 2019 endorsing brain death as the irreversible loss of all functions of the entire brain. It provides positions on the determination of brain death as well as guidance surrounding requests for accommodation.

Summary

Although death by neurologic criteria has been accepted as death medically for over 40 years, legal variance exists throughout the states, especially regarding religious accommodations and in pregnancy. Questions of whether to obtain informed consent from surrogate decision makers prior to brain death testing remain, and there is no guideline regarding obtaining ancillary testing. We expect to see continued cases that cause medical, legal, and ethical controversies in our ICUs. As such, uniform training in proper methodology in performing the brain death examination and appropriate use of ancillary testing is crucial, and there is a need for legal consistency in the acceptance of the medical standard.

Simulation in Neurocritical Care: Past, Present, and Future

Simulation-based medical education is a technique that leverages adult learning theory to train healthcare professionals by recreating real-world scenarios in an interactive way. It allows learners to emotionally engage in the assessment and management of critically ill patients without putting patients at risk. Learners are encouraged to work at the edge of their expertise to promote growth and are provided with feedback to nurture development. Thus, the training is targeted to the learner, not the patient. Despite its origins as a teaching tool for neurological diseases, simulation-based medical education has been historically abandoned by neurocritical care educators. In contrast, other critical care educators have embraced the technique and built an impressive foundation of literature supporting its use. Slowly, neurocritical care educators have started experimenting with simulation-based medical education and sharing their results. In this review, we will investigate the historical origins of simulation in the neurosciences, the conceptual framework supporting the technique, current applications, and future directions.

Teleneurology Consultations for Prognostication and Brain Death Diagnosis

The diagnosis of brain death and the determination of neurologic prognosis following cardiac arrest are important reasons for neurology consultation in the intensive care unit. In hospitals without access to neurology consultation, it may be challenging to address these important questions with high reliability in a timely manner. The American Academy of Neurology has established consensus criteria for diagnosis of brain death, which include (i) comatose state; (ii) presence of apnea; and (iii) absence of brainstem reflexes in the setting of a diagnosis of underlying brain injury compatible with brain death. It has recently been shown that virtual assessment of coma using standardized scales is feasible with good inter-rater reliability. The supervision of apnea testing and the neurologic examination of the brainstem by a remote neurologist are possible if conducted in conjunction with a well-trained and experienced bedside team. In this communication, we explore the essential clinical and legal framework that can support using virtual teleconsultations to address this complex topic.

Variability in reported physician practices for brain death determination

OBJECTIVES

The degree of training and variability in the clinical brain death examination performed by physicians is not known.

METHODS

Surveys were distributed to physicians (including physicians-in-training) practicing at 3 separate academic medical centers. Data, including level of practice, training received in completion of a brain death examination, examination components performed, and use of confirmatory tests were collected. Data were evaluated for accuracy in the brain death examination, self-perceived competence in the examination, and indications for confirmatory tests.

RESULTS

Of 225 total respondents, 68 reported completing brain death examinations in practice. Most physicians who complete a brain death examination reported they had received training in how to complete the examination (76.1%). Seventeen respondents (25%) reported doing a brain death examination that is consistent with the current practice guideline. As a part of their brain death assessment, 10.3% of physicians did not report completing an apnea test. Of clinicians who obtain confirmatory tests on an as-needed basis, 28.3% do so if a patient breathes during an apnea test, a clinical finding that is not consistent with brain death.

CONCLUSIONS

There is substantial variability in how physicians approach the adult brain death examination, but our survey also identified lack of training in nearly 1 in 4 academic physicians. A formal training course in the principles and proper technique of the brain death examination by physicians with expert knowledge of this clinical assessment is recommended.

A Needs Assessment of Brain Death Education in Pediatric Critical Care Medicine Fellowships

OBJECTIVES

To assess the current training in brain death examination provided during pediatric critical care medicine fellowship.

DESIGN

Internet-based survey.

SETTING

United States pediatric critical care medicine fellowship programs.

SUBJECTS

Sixty-four pediatric critical care medicine fellowship program directors and 230 current pediatric critical care medicine fellows/recent graduates were invited to participate.

INTERVENTIONS

Participants were asked demographic questions related to their fellowship programs, training currently provided at their fellowship programs, previous experience with brain death examinations (fellows/graduates), and perceptions regarding the adequacy of current training.

MEASUREMENTS AND MAIN RESULTS

Twenty-nine program directors (45%) and 91 current fellows/graduates (40%) responded. Third-year fellows reported having performed a median of five examinations (interquartile range, 3-6). On a five-point Likert scale, 93% of program directors responded they "agree" or "strongly agree" that their fellows receive enough instruction on performing brain death examinations compared with 67% of fellows and graduates (p = 0.007). The responses were similar when asked about opportunity to practice brain death examinations (90% vs 54%; p < 0.001). In a regression tree analysis, number of brain death examinations performed was the strongest predictor of trainee satisfaction. Both fellows and program directors preferred bedside demonstration or simulation as educational modalities to add to the fellowship curriculum.

CONCLUSIONS

Pediatric critical care medicine fellows overall perform relatively few brain death examinations during their training. Pediatric critical care medicine fellows and program directors disagree in their perceptions of the current training in brain death examination, with fellows perceiving a need for increased training. Both program directors and fellows prefer additional training using bedside demonstration or simulation. Since clinical exposure to brain death examinations is variable, adding simulated brain death examinations to the pediatric critical care medicine fellowship curriculum could help standardize the experience.

Neurology Education for Critical Care Fellows Using High-Fidelity Simulation

BACKGROUND

Simulation is becoming a more common modality in medical education. The data regarding effectiveness of simulation in critical care neurology education are limited.

METHODS

We administered a three-scenario simulation course to critical care fellowship trainees at a large academic medical center as a part of their core curriculum requirement. Pre- and posttests assessing medical knowledge and trainee confidence in managing neurologic disease were completed by all trainees. Overall satisfaction and effectiveness were evaluated following the course. Change in trainee knowledge and confidence before and after the course was assessed for improvement.

RESULTS

Sixteen trainees completed the simulation course. Prior to completion, medical knowledge was 5.2 ± 0.9 (of 8 possible correct answers) and following the course was 6.4 ± 1.3 (p = 0.002). Overall confidence improved from 15.4 ± 4.9 (of 30 possible points) to 20.7 ± 3.3 (p = <0.0001). Confidence was significantly improved for neurologic diseases directly assessed during the course (p = <0.0001) as well as for those not directly assessed (p = 0.004).

CONCLUSIONS

Simulation is an effective means of neurologic education for critical care trainees, with improvement in both medical knowledge and trainee confidence after completion of a three-scenario simulation experience. This course ensures the exposure of critical care trainees to neurologic diseases that are required curricular milestones to successfully complete the fellowship training program.

A new strategy in neurocritical care nurse continuing stroke education: A hybrid simulation pilot study

Introduction

High-fidelity simulation is frequently utilized in medical education. Its use in the neurosciences is limited by the inherent limitations of the manikin to simulate neurological changes. We report here the use of a hybrid simulation – a combination of lecture and high-fidelity manikin – in the education of neurosciences nurses, involved in care of neurocritical care patients.

Methods

Neurosciences nurses from at the University of Missouri, Columbia, MO, USA, which is an academic, tertiary-care medical center participated in the simulation during Spring of 2016. The simulation involved a patient presenting with acute intracerebral hemorrhage (ICH) who neurologically deteriorated to brain death. Pre- and post-simulation questionnaires were administered using a questionnaire with five-point Liker scale.

Results

Seventy-two responses were returned. The majority had 0–5 years of nursing experience with 83.8% having prior critical care experience. Pre-simulation, the majority of nurses (85.7%) agreed or strongly agreed with managing patients with ICH. When the responses of “agree” were compared to “strongly agree”, a significant improvement (p<0.001) in all responses except confidence in speaking with other healthcare providers was found.

Conclusion

Nurses reported significant improvement in understanding and managing patients with acute ICH and neurological deterioration after participating in a neurocritical care hybrid simulation. This study shows the benefit of using hybrid simulation in the education of neurocritical care nurses.

Variability in Diagnosing Brain Death at an Academic Medical Center

Objective. Research continues to highlight variability in hospital policy and documentation of brain death. The aim of our study was to characterize how strictly new guidelines of American Academy of Neurology (AAN) for death by neurological criteria were practiced in our hospital prior to appointment of neurointensivists. Method. This is a retrospective study of adults diagnosed as brain dead from 2011 to 2015. Descriptive statistics compared five categories: preclinical testing, neurological examination, apnea tests, ancillary test, and documentation of time of death. Strict adherence to AAN guidelines for brain death determination was determined. Result. 76 patients were included in this study. Preclinical prerequisites were fulfilled in 53.9% and complete neurological examinations were documented in 76.3%. Apnea test was completed in 39.5%. Ancillary test was completed in 29.8%. Accurate documentation of time of death occurred in 59.2%. Overall, strict adherence to current AAN guidelines for death by neurological criteria was correctly documented in 38.2%. Conclusion. Our study shows wide variability in diagnosing brain death. These findings led us to update our death by neurological criteria policy and increase awareness of brain death determination with the goal of improving our documentation following current AAN guidelines.

Improving uniformity in brain death determination policies over time

Objective:

To demonstrate that progress has been made in unifying brain death determination guidelines in the last decade by directly comparing the policies of the US News and World Report's top 50 ranked neurologic institutions from 2006 and 2015.

Methods:

We solicited official hospital guidelines in 2015 from these top 50 institutions, generated summary statistics of their criteria as benchmarked against the American Academy of Neurology Practice Parameters (AANPP) and the comparison 2006 cohort in 5 key categories, and statistically compared the 2 cohorts' compliance with the AANPP.

Results:

From 2008 to 2015, hospital policies exhibited significant improvement (p = 0.005) in compliance with official guidelines, particularly with respect to criteria related to apnea testing (p = 0.009) and appropriate ancillary testing (p = 0.0006). However, variability remains in other portions of the policies, both those with specific recommendation from the AANPP (e.g., specifics for ancillary tests) and those without firm guidance (e.g., the level of involvement of neurologists, neurosurgeons, or physicians with education/training specific to brain death in the determination process).

Conclusions:

While the 2010 AANPP update seems to be concordant with progress in achieving greater uniformity in guidelines at the top 50 neurologic institutions, more needs to be done. Whether further interventions come as grassroots initiatives that leverage technological advances in promoting adoption of new guidelines or as top-down regulatory rulings to mandate speedier approval processes, this study shows that solely relying on voluntary updates to professional society guidelines is not enough.

Simulation training for emergency teams to manage acute ischemic stroke by telemedicine

Telemedicine contributes to initiating early intravenous recombinant tissue plasminogen activator (rt-PA) treatment for patients with acute cerebral infarction in areas without a stroke unit. However, the experience and skills of the emergency teams in the spokes to prepare patients and administer rt-PA treatment are ill-defined. Improving these skills could vastly improve management of acute stroke by telemedicine. We developed a medical simulation training model for emergency teams to perform intravenous rt-PA treatment in a telestroke system.From February 2013 to May 2015, 225 learners from 6 emergency teams included in the telestroke system "Virtuall"-in Lorrain (northeastern France)-received a standardized medical simulation training module to perform rt-PA treatment. All learners were assessed with the same pretraining and posttraining test consisting of 52 items. The percentage of right answers was determined for every learner before and after training.Median percentages of right answers were significantly higher in the posttraining test overall (82 ± 10 vs. 59 ± 13% pretraining; P < 0.001), but also in all professional subgroups: physicians (88 ± 8 vs. 67 ± 12%; P < 0.001), paramedical staff (80 ± 9 vs. 54 ± 12%; P < 0.001), nurses (80 ± 8 vs. 54 ± 12%; P < 0.001), and auxiliary nurses (76 ± 17 vs. 37 ± 15%; P = 0.002).We describe for the first time a training model for emergency teams in a telestroke system. We demonstrate significant gain in knowledge for all groups of healthcare professionals. This simulation model could be applied in any medical simulation center and form the basis of a standardized training program of spokes in a telestroke system.

Identifying Potential Ventilator Auto-Triggering Among Organ Procurement Organization Referrals

Context:

Ventilator auto-trigger is the delivery of an assisted mechanical ventilated breath over the set ventilator frequency in the absence of a spontaneous inspiratory effort and can be caused by inappropriate ventilator trigger sensitivity. Ventilator auto-trigger can be misinterpreted as a spontaneous breath and has the potential to delay or prevent brain death testing and confuse health-care professionals and/or patient families.

Objective:

To determine the frequency of organ donor referrals from 1 Organ Procurement Organization (OPO) that could benefit from an algorithm designed to assist organ recovery coordinators to identify and correct ventilator auto-triggering.

Design:

This retrospective analysis evaluated documentation of organ donor referrals from 1 OPO in central Texas during the 2013 calendar year that resulted in the withdrawal of care by the patient’s family and the recovery of organs.

Main Outcome Measures:

The frequency of referrals that presented with absent brain stem reflexes except for additional respirations over the set ventilator rate was determined to assess for the need of the proposed algorithm.

Results:

Documentation of 672 organ procurement organization referrals was evaluated. Documentation from 42 referrals that resulted in the withdrawal of care and 21 referrals that resulted in the recovery of organs were identified with absent brain stem reflexes except for spontaneous respirations on the mechanical ventilator. As a result, an algorithm designed to identify and correct ventilator auto-trigger could have been used 63 times during the 2013 calendar year.