157 How to Effectively Integrate Telestroke by Utilizing Mock In Situ Telestroke Training in the Emergency Department

Abstract

Telestroke is a service that connects physicians with patients requiring emergent consultation at anytime from any location. Prior to implementing “live” telestroke, the neurology department collaborated with the SimLab and the ED and created mock in situ telestroke (MIST) scenarios. Our goal was to ensure that ED team was comfortable using the telestroke cart and implementing a telestroke code. Our ultimately goal was to avoid any delays by adding this technology. We created an interdepartmental, interdisciplinary team from the emergency department, neurology and the Patient Safety Institute (our simulation center). Our team is composed of physicians, physician assistants and nurses. Before going “live” with Telestroke, our team met to review our goals and objectives and to create a plan for education. We decided to focus our training on ED nurses. ED nurses were required to an online component. All other portions were taught live in the ED. Nursing education was done in 4 steps: 1) All nurses working in the ED were required to 4 and 8 continuing education units in Stroke and the National Institute of Health Stroke Scale (NIHSS) certification course. 2) Our ED nursing educator and our neurology team trained our ED nurses during different shifts for five days on how and when to operate the telestroke cart. 3) Live training during the MIST codes. a) Four content experts observed each case from patient presentation through disposition and debriefed his/her topic of expertise. 4) Following MIST codes, nurses were offered additional help in focused on performing the NIHSS exam and any questions they had After each MIST code with debriefing, the debriefers met to review areas for improvement and unanticipated issues. Our results are broken down into the following categories: When informally surveyed at the end of the first three MISTs, nurses indicated they were not comfortable with 1. the telecart and 2. How to perform a NIHSS assessment. Because of nursing feedback, we offered all nurses an opportunity to be trained again on how to utilize the telestroke cart and how to perform a NIHSS. Some of the variables captured included door-to-stroke Team, door-to-tPA decision, Door-to-tPA Actual. During the first 7 weeks of telestroke, there were a total of 119 stroke codes, 21 of which were telestroke cases. A total of 5 cases were offered tPA via telestroke and the decision to give tPA was documented (average 44 minutes). Door to tPA decision is the time that the neurologist gave approval to give tPA. In one case the family and patient refused and in another case there was a delay due to patient's hemodynamic stability. This metric is meant to show how long it takes from arrival to making the decision to treat.Table 1Telestroke vs. Stroke cases (2/1/17 - 3/27/17)VariableAverage Time (min) TelestrokeAverage Time (min; n=119) All Stroke CodesArrival to Stroke Team Assessment09:29 (n=21)09:20 (n=119)Door to TPA Decision44:00 (n=5)Door to TPA Actual01:05:45 (n=4)56:00 (n=13) Open table in a new tab Our goal was to optimize operational flow and patient assessment during our stroke codes when introducing telestroke by creating a curriculum for nursing staff with a built-in process for implementing improvement after each code. While our number of MIST codes is small, we were able to demonstrate that our average door to tPA was not overall different.