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

Streamlining Acute Stroke Processes and Data Collection: A Narrative Review

(1) Background: Acute ischemic stroke treatment has been thoroughly studied to identify strategies to reduce treatment times. However, many centers still struggle to achieve fast treatment times. Additionally, studies primarily focus on larger, more advanced centers; yet, smaller centers often face longer treatment times. (2) Objectives: The aim of this study is to analyze the existing literature reviewing stroke treatment processes in primary and comprehensive stroke centers that investigated or reduced treatment times. The articles identified were categorized based on the focus areas and approaches used. (3) Results: Three main categories of improvements were identified in the literature: (1) standardization of processes, (2) resource management, and (3) data collection. Both primary and comprehensive stroke centers were able to reduce treatment times through standardization of the processes. However, challenges such as variations in hospital resources and difficulties incorporating data collection software into workflow were highlighted. Additionally, many strategies to optimize resources and data collection that can benefit primary stroke centers were only conducted in comprehensive stroke centers. (4) Conclusions: Many existing strategies to improve stroke treatment times, such as pre-notification and mass stroke team alerts, have been implemented in both primary and comprehensive stroke centers. However, tools such as simulation training are understudied in primary stroke centers and should be analyzed. Additionally, while data collection and feedback are recognized as crucial for process improvement, challenges persist in integrating consistent data collection methods into clinical workflow. Further development of easy-to-use software tailored to clinician needs can help improve stroke center capabilities to provide feedback and improve treatment processes.

Artificial intelligence in interventional radiology: Current concepts and future trends

While artificial intelligence (AI) is already well established in diagnostic radiology, it is beginning to make its mark in interventional radiology. AI has the potential to dramatically change the daily practice of interventional radiology at several levels. In the preoperative setting, recent advances in deep learning models, particularly foundation models, enable effective management of multimodality and increased autonomy through their ability to function minimally without supervision. Multimodality is at the heart of patient-tailored management and in interventional radiology, this translates into the development of innovative models for patient selection and outcome prediction. In the perioperative setting, AI is manifesting itself in applications that assist radiologists in image analysis and real-time decision making, thereby improving the efficiency, accuracy, and safety of interventions. In synergy with advances in robotic technologies, AI is laying the groundwork for an increased autonomy. From a research perspective, the development of artificial health data, such as AI-based data augmentation, offers an innovative solution to this central issue and promises to stimulate research in this area. This review aims to provide the medical community with the most important current and future applications of AI in interventional radiology.

Curriculum Innovation: Design, Implementation, and Evaluation of an Interdisciplinary Teamwork-Focused Neurocritical Care In Situ Simulation Training Program

Introduction and Problem Statement

Neurocritical care (NCC) is a niche clinical subspecialty dependent on interdisciplinary cohesion to operate in critical situations. Team cohesion in an intensive care unit (ICU) depends not only on technical skills or medical knowledge but also on nontechnical skills such as teamwork, communication, and leadership. Developing and practicing these skills as an interdisciplinary team is not standard in most professional training programs.

Objectives

This project aimed to (1) design and implement a NCC in situ simulation program aimed at practicing teamwork, (2) demonstrate feasibility and acceptability of recurring in situ simulations, and (3) assess baseline teamwork scores and clinician preparedness to respond to a clinical emergency.

Methods and Curriculum Description

The NLN Jeffries Simulation Theory was used to guide the simulation program design. A 1-year pilot project consisted of monthly NCC in situ simulations. Debriefing with Good Judgment was used to guide postsimulation reflection. Feasibility was evaluated by participation metrics and simulation schedule adherence. Acceptability was assessed through postsimulation evaluations. Teamwork and preparedness were measured using the Mayo High Performance Teamwork Scale (MHPTS) and 10-point Likert scale, respectively. Statistical comparison of MHPTS scores between disciplines and preparedness before vs after simulation was conducted.

Results and Assessment Data

In 1 year, we conducted 12 in situ simulations, with 167 simulation learner encounters, representing 95 unique learners and 72% of our core NCC team (i.e., nurses, advanced practice providers [APPs], fellows, faculty). Analysis of program evaluations (84% survey completion rate) showed that 91% of all learners strongly agreed that the simulation provided an experiential, collaborative, trusting, and learner-centered environment. Overall, MHPTS scores were similar between disciplines, although in pairwise comparison, pharmacists rated teamwork significantly lower than both nurses (p = 0.01) and APPs (p = 0.004). Learners rated their preparedness to respond to a clinical emergency significantly higher after the simulation (p < 0.001).

Discussion and Lessons Learned

In situ simulation training is a feasible and acceptable method to introduce teamwork training into ICU culture. Team-based simulation improves self-reported preparation to respond to clinical emergencies. Simulation training that takes place in the clinical setting provides a powerful tool for enhancing teaching and addressing patient care gaps.

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.

Stroke Admission Simulation: Engaging Novice and Expert Nurses

In today's changing health care climate, clinical nurse educators are being challenged to educate nurses with a wide range of experience. This article describes the development and facilitation of a low-fidelity simulation used to educate nurses about identified gaps in standardized care during stroke admissions on a medical-surgical stroke unit at Legacy Emanuel Medical Center. The simulation was developed for use by novice and expert medical-surgical stroke nurses simultaneously. With the use of Bloom's Revised Taxonomy (Anderson et al., 2001), roles within the simulation were tailored to encourage the learning of nurses with varying levels of expertise. Overall, learners appeared to benefit from the class, which included the stroke admission simulation. Mean test scores increased from 55% pretest to 80% posttest. Additionally, 98% of learners found the simulation and lecture moderately helpful or extremely helpful. [J Contin Educ Nurs. 2024;55(3):113-119.].

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.

Society for Simulation in Healthcare Guidelines for Simulation Training

BACKGROUND

Simulation has become a staple in the training of healthcare professionals with accumulating evidence on its effectiveness. However, guidelines for optimal methods of simulation training do not currently exist.

METHODS

Systematic reviews of the literature on 16 identified key questions were conducted and expert panel consensus recommendations determined using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology.

OBJECTIVE

These evidence-based guidelines from the Society for Simulation in Healthcare intend to support healthcare professionals in decisions on the most effective methods for simulation training in healthcare.

RESULTS

Twenty recommendations on 16 questions were determined using GRADE. Four expert recommendations were also provided.

CONCLUSIONS

The first evidence-based guidelines for simulation training are provided to guide instructors and learners on the most effective use of simulation in healthcare.

Educational and Patient Care Impacts of In Situ Simulation in Healthcare: A Systematic Review

ABSTRACT

This systematic review was performed to assess the effectiveness of in situ simulation education. We searched databases including MEDLINE and Embase for studies comparing in situ simulation with other educational approaches. Two reviewers screened articles and extracted information. Sixty-two articles met inclusion criteria, of which 24 were synthesized quantitatively using random effects meta-analysis. When compared with current educational practices alone, the addition of in situ simulation to these practices was associated with small improvements in clinical outcomes, including mortality [odds ratio, 0.66; 95% confidence interval (CI), 0.55 to 0.78], care metrics (standardized mean difference, -0.34; 95% CI, -0.45 to -0.21), and nontechnical skills (standardized mean difference, -0.52; 95% CI, -0.99 to -0.05). Comparisons between in situ and traditional simulation showed mixed learner preference and knowledge improvement between groups, while technical skills showed improvement attributable to in situ simulation. In summary, available evidence suggests that adding in situ simulation to current educational practices may improve patient mortality and morbidity.

[Intravenous thrombolysis of ischemic stroke-Current status]

Intravenous thrombolysis (IVT) treatment with alteplase (rtPA) is an essential part of the routine treatment of patients with ischemic stroke since its introduction in the late 1990s. Rapid treatment is of essential importance. For patients with an unclear time window, various mismatch concepts have been established to identify salvageable brain tissue prior to IVT. Numerous official contraindications for rtPA are not evidence-based; for example, current data from observational studies show that systemic thrombolytic treatment is possible even in patients receiving direct oral anticoagulant (DOAC) treatment. Tenecteplase (TNK) is an alternative thrombolytic agent with some pharmacologic advantages. The most recent guidelines indicate that TNK is particularly advantageous over rtPA in patients treated in combination with endovascular stroke therapy (EST). The combination of IVT and EST should primarily be performed in the 4.5‑h time window in patients without contraindications; in the later time window EST alone is conceivable if it can be performed without delay.

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.

Engaging teaching strategies in neurology: the flipped classroom and simulation training

Just as neurology continues to expand its diagnostic and therapeutic modalities, so too does neurology education continue to expand in its pedagogical modalities. In this article, we describe two educational techniques-the flipped classroom and simulation-that we have incorporated in our teaching of neurology to students and doctors in training, with some practical tips for their successful implementation.

Training with High Fidelity Simulation in the Care of Patients with Coronavirus-A Learning Experience in Native Health Care Multi-Professional Teams

The training of emergency and intensive care teams in technical and non-technical skills is fundamental. The general aim of this study was to evaluate the training of various professional teams with simulations based on the care of COVID-19 patients using Zone 3 simulations (native emergency medical services and intensive care units-ICU teams) in the Region of Murcia (Spain). A mixed pilot study was designed (qualitative/quantitative) comprised of three phases: Phase 1: detection of needs (focus groups), Phase 2: design of simulation scenarios, and Phase 3: training with high-fidelity simulation and evaluation of competences. The results were used to determine the real training needs of these health professionals, which were used to design four simulation scenarios in line with these needs. The team competences were evaluated before and after the training session, with increases observed after the training sessions, especially in non-technical skills such as communication. Training with zone 3 simulation, with multi-professional native emergency and intensive care teams who provided care to patients with coronavirus was shown to be an effective method, especially for training in non-technical skills. We should consider the training needs of the professionals before the start of any training program to stay one-step ahead of crisis situations.

Interdisciplinary management of acute ischaemic stroke - current evidence on training requirements for endovascular stroke treatment. Position Paper from the ESC Council on Stroke and the European Association for Percutaneous Cardiovascular Interventions with the support of the European Board of Neurointervention: A step forward

Stroke, a vascular disease of the brain, is the #1 cause of disability and a major cause of death worldwide. Stroke has a major negative impact on the life of stroke-affected individuals, their families and the society. A significant proportion of stroke victims indicate that would have preferred death over their after-stroke quality of life. Mechanical thrombectomy (MT), opening the occluded artery using mechanical aspiration or a thrombus-entrapment device, is a guideline-mandated (class I, level of evidence A) treatment modality in patients with large vessel occlusion stroke. MT clinical benefit magnitude indicates that a universal access to this treatment strategy should be the standard of care. Today there is a substantial geographic variation in MT deliverability, with large-scale disparities in MT implementation. In many countries effective access to MT remains severely limited. In addition, many of the MT-treated patients are treated too late for a good functional outcome because of logistic delays that include transportations to remotely located, scarce, comprehensive stroke centres. Position Paper from the European Society of Cardiology Council on Stroke and European Association for Percutaneous Cardiovascular Interventions on interdisciplinary management of acute ischaemic stroke, developed with the support of the European Board of Neurointervention fills an important gap in systematically enabling interventional cardiologists to support stroke intervention in the geographic areas of unmet needs in particular. We review strengths and weaknesses of the document, and suggest directions for the next steps that are swiftly needed to deliver MT to stroke patients more effectively.