Development of a Statewide EMS Stroke Triage Protocol

Novel Simulation Lab Exercises
to Improve Acute Stroke Care
Timothy Lukovits, MD
and
Heather A. Martin, MSN, RN, CNRN-NSCU
Dartmouth-Hitchcock Medical Center
Disclosures and conflicts of interest
Outline
•
•
•
•
•
•
Review of literature
Process used to develop exercises
DHMC Simulation Lab
Physician exercise
Nurse exercise
Audience participation
How can we assess and train
residents better?
Advantages of simulation training
• Provides reaslistic but error-forgiving clinical
experience, including rare but critical situations
• Reproducible scenarios lead to standardized
training and emphasize important concepts/skills
• Scenarios can be tailored to each participant's
educational level
• Exercises can “isolate” a resident and “uncover”
their weaknesses
• Recordable for review later
Different components of a typical
medical simulation
• Scenarios
• Computerized patient simulators
(“dummies”)
• Facilitator in control room
• Videotaping for review
Development of Sim Lab Exercise
for Stroke Training
•
•
•
•
Literature review
Scenario development
Optimization of exercise (no mannequin)
Development of resident evaluation form and
debriefing process
• Additional scenarios
• Refinement
• Center for Medical Simulation
• Society for Simulation in Healthcare
• Society for Academic Emergency Medicine
(SAEM) Simulation Case Library
Skills evaluated in stroke exercise 1
•
•
•
•
•
•
•
•
Identification of stroke mimics
Management of hypoglycemia, elev BP
Efficient hx and exam
Interpreting data (CT)
Communicating risks/benefits of tpa
Triaging “distractor” calls
Working with ED staff
Managing acute complications
Grading the graders
DHMC Simulation Center
Sim Lab Exercise
• Basic “layout” of exercise
• Video (11, 17, 35, 19:30)
• Video 2 (6:10)
The future
• Development of other simulations
– ICH, status epilepticus, spinal cord compression
– Exercises for ER staff, other residency programs,
teams of physicians and nurses
• Refinement of the debriefing and measuring
effect of exercise
• Simulated telemedicine evaluations
• Mini simulations/role playing on phone calls
Challenge of Providing Education to
Nursing
• Nurses have complex schedules
– Shift work(nights/eves/days)
• Financial cost of providing education
• Large dependence on reading articles or self
learning computer based modules
• Typically driven by competency based (ie. What
the regulation agencies like JCAHO make us do)
• Need to provide education to a large number of
nurses at the same time
Identifying a Gap in Knowledge
• DHMC neuro nurses with a large influx of
“new” team members
• Evidence that many nurses were not
knowledgeable about hemorrhagic versus
ischemic stroke
• Multiple NSCU nurses indicated a fear of
administering TPA due to knowledge deficit
Neuro Symposium
• A yearly gathering of neuro science nurses at
DHMC
• Provided a great opportunity to present a
stroke patient scenario to a large number of
participants
• Strong encouragement and facilitation of the
the “new” nurses to attend the Neuro
Symposium
Large Group Simulation
• Basics
– Actors carry out the care of a simulated patient in
the front of the room.
– The patient scenario is a living case study
– Participants have the opportunity to join in and are
encouraged to do so.
– The experience is discussed during the debriefing
period
• What went well?
• What might we have done differently?
• What do you need more education on?
Large Group Simulation
Setting the Scene for the Simulation
• Small video of patient delivery
Meet Theresa Kennedy
• Small clip of patient care
The Advantages
• Participants are able to experience an actual
patient situation
• Participants use clinical reasoning as the
scenario unfolds
• Participants can think about how they would
care for the patient differently if they were
the care giver
• Demonstrations of essential equipment or
techniques
The Challenges of Large Group Sim
• Coordinating the providers(actors)
• Takes many people to get the simulation to run
smoothly
• Dependent on technology to work
• Transportation of the high fidelity simulator and
all essential equipment: 3 laptops were needed
alone for the scenario presented and all of the
accessory equipment
• Large number of people in the room which
increases the potential for distraction or
interruption
Evaluation of Content Delivered
• A pre/post test was given
to participants.
• 23 Respondents for tests
• Questions were general
knowledge re: stroke and
TPA
Results
• Average Pre-test score of 52%
• Average Post-test Score of 90%
• Increase in scores of approx. 40%
Safety Concerns
• Several responses on the pretest indicated a
knowledge deficit in the nursing respondents
that might result in an error at the bedside
related to:
– TPA administration
– When anticoagulants could start after TPA
– Blood pressure control with Ischemic Strokes
#6 After the Initial IV bolus of rTPA, the remainder
of the infusion should be administered over
• Pre test response: 47.8% wrong responses
• Post test response: 0% wrong responses
#8 After administering rTPA, don’t
start heparin or aspirin for at least
• Pre test response: 56% with wrong response
• Post test response: 4% wrong response
# 9 For patients with ischemic stroke not treated
with rTPA, it is recommended that the blood
pressure be treated if it exceeds which of the
following levels?
• Pre test Response: 52% wrong response
• Post test Response: 17% wrong response
The future
• Development of other simulations
– based on needs identified by nursing staff and
the clinical nurse specialist or unit educator
• Record large group simulations for posting on
DHMC intranet