Abstract
Background: Acute stroke management in the ED is complex requiring a team-based approach, particularly as the therapeutic window for ischemic strokes has been extended to 24 hours from symptom onset. Objectives: To train and educate neurology, emergency medicine (EM) residents and nursing staff on acute stroke management in the ED using a case simulation based approach. Methodology: We designed five case studies (4 standardized patients and 1 high-fidelity mannequin) exhibiting signs and symptoms of acute stroke. Two anterior circulation large vessel occlusions (one eligible for IV thrombolytic and one eligible for mechanical thrombectomy in the extended time window), one basilar thrombosis requiring intervention, one hypertensive hemorrhage and one stroke mimic were included. A total of 17 PGY 1 EM, 7 PGY 2 neurology, 1 stroke fellow, 5 ED nurses, 3 ED and 2 Neurology faculty members divided into 5 teams rotating through all cases. All residents completed didactic education, a 7 item survey (rated 1-5) and a 10 item quiz on acute stroke management pre- and post-simulation. Each group was allotted 15 minutes to assess the patient, interpret results and advice management followed by a10 minute focused debriefing and feedback session. Objective improvements were assessed using paired T-test analysis of pre and post testing. Results: Pre vs. post simulation self-assessment survey of: I. Knowledge, understanding and management of acute stroke (2.83 +/- 0.82 vs. 3.63 +/- 0.6, p < 0.0001); II. Use of IV-tPA (3.13 +/- 0.85 vs. 4.17 +/- 0.70, p < 0.0001); III. Mechanical thrombectomy (3.00 +/- 0.83 vs. 4.13 +/- 0.74, p < 0.0001); IV. Blood pressure management (3.21 +/- 0.83 vs. 4.12 +/- 0.76, p < 0.0001); V. Team member responsibilities (2.73 +/- 0.98 vs. 4.08 +/- 0.83, p < 0.0001) and VI .Asking for help (3.71 +/- 1.04 vs. 4.58 +/- 0.58, p = 0.0003) improved. The role of neurology in stroke management from the ED perspective remained unchanged (3.75 +/- 0.99 vs. 4.13 +/- 0.74, p = 0.1191), however all quiz results improved (7.33 +/- 1.83 vs. 8.58 +/- 1.35, p = 0.0048). Conclusion: Case based simulation was successful in training and educating neurology and EM residents and ED nursing staff on acute stroke management, improving medical knowledge, communication and effective teamwork.
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