Emergency management of status epilepticus in a high-fidelity simulation: A prospective study

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.

First-Response ABCDE Management of Status Epilepticus: A Prospective High-Fidelity Simulation Study

Respiratory infections following status epilepticus (SE) are frequent, and associated with higher mortality, prolonged ICU stay, and higher rates of refractory SE. Lack of airway protection may contribute to respiratory infectious complications. This study investigates the order and frequency of physicians treating a simulated SE following a systematic Airways-Breathing-Circulation-Disability-Exposure (ABCDE) approach, identifies risk factors for non-adherence, and analyzes the compliance of an ABCDE guided approach to SE with current guidelines. We conducted a prospective single-blinded high-fidelity trial at a Swiss academic simulator training center. Physicians of different affiliations were confronted with a simulated SE. Physicians (n = 74) recognized SE and performed a median of four of the five ABCDE checks (interquartile range 3–4). Thereof, 5% performed a complete assessment. Airways were checked within the recommended timeframe in 46%, breathing in 66%, circulation in 92%, and disability in 96%. Head-to-toe (exposure) examination was performed in 15%. Airways were protected in a timely manner in 14%, oxygen supplied in 69%, and antiseizure drugs (ASDs) administered in 99%. Participants’ neurologic affiliation was associated with performance of fewer checks (regression coefficient −0.49; p = 0.015). We conclude that adherence to the ABCDE approach in a simulated SE was infrequent, but, if followed, resulted in adherence to treatment steps and more frequent protection of airways.

The Efficacy and Use of a Pocket Card Algorithm in Status Epilepticus Treatment

Objective

To determine whether a pocket card treatment algorithm improves the early treatment of status epilepticus and to assess its utilization and retention in clinical practice.

Methods

Multidisciplinary care teams participated in video-recorded status epilepticus simulation sessions from 2015 to 2019. In this longitudinal cohort study, we examined the sessions recorded before and after introducing an internally developed, guideline-derived pocket card to determine differences in the adequacy or timeliness of rescue benzodiazepine. Simulation participants were queried 9 months later for submission of a differentiating identification number on each card to assess ongoing availability and utilization.

Results

Forty-four teams were included (22 before and 22 after the introduction of the pocket card). The time to rescue therapy was shorter for teams with the pocket card available (84 seconds [64-132]) compared with teams before introduction (144 seconds [100-162]) (U = 94; median difference = -46.9, 95% confidence interval [CI]: -75.9 to -21.9). The adequate dosing did not differ with card availability (odds ratio 1.48, 95% CI: 0.43-5.1). At the 9-month follow-up, 32 participants (65%) completed the survey, with 26 (81%) self-reporting having the pocket card available and 11 (34%) confirming ready access with the identification number. All identification numbers submitted corresponded to the hard copy laminated pocket card, and none to the electronic version.

Conclusions

A pocket card is a feasible, effective, and worthwhile educational tool to improve the implementation of updated guidelines for the treatment of status epilepticus.

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.

Prolonged mechanical ventilation in patients with terminated status epilepticus and outcome: An observational cohort study

OBJECTIVE

Classical clinical characteristics associated with successful or unsuccessful extubation are unreliable in neurocritically ill patients, and attempts to predict successful extubation in this context have failed. We aimed to investigate the frequency of mechanical ventilation (MV) in adult patients in status epilepticus (SE) and its clinical associations, to identify predictors at SE onset of prolonged postictal MV, and to determine the associated outcomes with prolonged MV.

METHODS

From 2012 to 2018, SE patients treated in intensive care units at a Swiss academic care center were included. Multivariable Poisson regression adjusting for potential confounders, such as continuously administered anesthetics, was performed to identify risks for postictal MV for >24 h after SE and its association with no return to neurologic function and death. Linear regression was performed to identify correlations between the durations of administered specific anesthetics and postictal MV.

RESULTS

Of 262 patients, 42% were ventilated, with 24% being on ventilators for >24 h after SE. Patients with prolonged postictal MV were extubated at a median of 7 days, with 56% not being extubated on the day of successful weaning from MV because of altered consciousness and/or lack of airway-protective reflexes. After extubation, noninvasive ventilation and reintubation were rarely needed. Prolonged postictal MV was associated with increased risk for death independent of potential confounders, including fatal etiology of SE, age, SE severity, and use of anesthetics (relative risk for every additional day = 2.7, p = .024). At SE onset, decreased consciousness and presumed fatal etiology predicted prolonged postictal MV. Anesthetics were associated with prolonged MV, but linear regression could not identify significant correlations.

SIGNIFICANCE

Our data reveal that prolonged postictal MV is frequent and an independent risk factor for death. Extubation is often delayed for days despite sufficient weaning from the ventilator and altered airway-protective reflexes in only few patients. Studies need to investigate whether more rigorous extubation strategies improve outcome.

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.

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.

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

OBJECTIVE

To document two sources of validity evidence for simulation-based assessment in neurological emergencies.

BACKGROUND

A critical aspect of education is development of evaluation techniques that assess learner's performance in settings that reflect actual clinical practice. Simulation-based evaluation affords the opportunity to standardize evaluations but requires validation.

METHODS

We identified topics from the Neurocritical Care Society's Emergency Neurological Life Support (ENLS) training, cross-referenced with the American Academy of Neurology's core clerkship curriculum. We used a modified Delphi method to develop simulations for assessment in neurocritical care. We constructed checklists of action items and communication skills, merging ENLS checklists with relevant clinical guidelines. We also utilized global rating scales, rated one (novice) through five (expert) for each case. Participants included neurology sub-interns, neurology residents, neurosurgery interns, non-neurology critical care fellows, neurocritical care fellows, and neurology attending physicians.

RESULTS

Ten evaluative simulation cases were developed. To date, 64 participants have taken part in 274 evaluative simulation scenarios. The participants were very satisfied with the cases (Likert scale 1-7, not at all satisfied-very satisfied, median 7, interquartile range (IQR) 7-7), found them to be very realistic (Likert scale 1-7, not at all realistic-very realistic, median 6, IQR 6-7), and appropriately difficult (Likert scale 1-7, much too easy-much too difficult, median 4, IQR 4-5). Interrater reliability was acceptable for both checklist action items (kappa = 0.64) and global rating scales (Pearson correlation r = .70).

CONCLUSIONS

We demonstrated two sources of validity in ten simulation cases for assessment in neurological emergencies.

Frequency and Implications of Complications in the ICU After Status Epilepticus: No Calm After the Storm

OBJECTIVES

To investigate the frequency, types, and implications of complications during intensive care in patients after status epilepticus has been successfully terminated.

DESIGN

Retrospective study.

SETTING

ICUs at a Swiss tertiary academic medical care center.

PATIENTS

Data were collected from the digital patient records of all adult patients with status epilepticus from 2012 to 2018.

INTERVENTIONS

None.

METHODS

Primary outcomes were defined as frequency of complications following status epilepticus termination and return to premorbid functional baseline. Univariable analyses regarding the relative risks of complications occurring after status epilepticus termination for no return to premorbid neurologic function were estimated by Poisson regression with robust error variance.

RESULTS

Of 311 patients with status epilepticus, 224 patients (72%) were treated on the ICU for more than 24 hours following status epilepticus termination. Ninety-six percent of patients remained in a prolonged state of altered consciousness for a median of 2 days (interquartile range, 1-3 d) and 80% had complications during their ICU treatment. Fifty-five percent had new-onset delirium with a median duration of 2 days (interquartile range, 1-3 d). Forty-two percent had mechanical ventilation for a median of 4 days (interquartile range, 2-11 d) and 21% had nosocomial infections diagnosed after status epilepticus. Multivariable analyses revealed that mechanical ventilation for more than 24 hours after status epilepticus, and arterial hypotension requiring vasopressors were independently associated with increased risk of no return to premorbid function (RRfor each additional day = 1.01; 95% CI, 1.02-1.03 and RRfor each additional day = 1.03; 95% CI, 1.01-1.05) and death (RRfor each additional day = 1.11; 95% CI, 1.04-1.19 and RRfor each additional day = 1.15; 95% CI, 1.03-1.28). Delirium was independently associated with a decreased relative risk of death (RRfor each additional day = 0.55; 95% CI, 0.37-0.80), but prolonged ICU- and hospital stays.

CONCLUSIONS

Complications after status epilepticus termination are frequent and associated with no return to premorbid function, death, and prolonged ICU- and hospital stays. These results call for heightened awareness and further studies mainly regarding prediction and preventive strategies in this context.