Timothy Lukovits, MD Dartmouth-Hitchcock Medical Center

Disclosures and conflicts of interest

DHMC Patient Safety Training Center

Some advantages of simulation lab training for neurologic diseases

• teachers can watch errors being made without patient harm and with less trainee embarrassment

• assessment seems more valid when more standardized clinical situations are used

• content can be designed to match educational goals

• scenarios can be tailored to each participant's educational level/needs

• uncommon situations can be created as needed

Skills evaluated in 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

Debriefing

Introduction

We aimed to develop simulation lab training exercises that improve our residents' competency in managing acute stroke.

Medical simulation has rarely been used in Neurology resident education. The simulation lab can potentially be a better method of assessing residents' clinical abilities and providing constructive feedback.

Background

Between December of 2009 and September of 2011, stroke simulation scenarios were developed and implemented to enhance the training of neurology residents. Role playing was done by a live professional patient and stroke-fellowship trained attendings. SimMan software (Laerdal Medical AS) was used to simulate and display alterations in vital signs. Two standardized scenarios were used: one with a typical patient with an ischemic stroke eligible for intravenous thrombolysis and another with a progressive cerebellar hemorrhage needing evacuation. Goals including the identification of stroke mimics, proper administration of the NIH Stroke Scale, correction of hypoglycemia, treatment of acute hypertension, discussion of the risks and benefits of thrombolysis, correction of coagulopathy, interpretation of head computed tomographic scans, prioritizing simultaneous outside telephone calls, and communication with nursing staff and other consultants were re-enforced. All sessions were videotaped. For each scenario, a checklist based on these goals was used to calculate the percentage of items done satisfactorily ("score"). A survey for residents to critique the exercises was used in debriefing sessions.

Methods

Conclusion

Medical simulation appears to be a feasible and useful method for training neurology residents in the management of acute ischemic and hemorrhagic stroke. This work used live professional patients and role-playing and emphasized cognitive and communication skills rather than procedures, unlike other simulation lab training. Future work will focus on the development of additional scenarios, refinement of the debriefing process, and expansion of this training to regional emergency medicine providers.

Novel Simulation Lab Exercises for Training Neurology Residents How To Manage Acute Stroke Timothy G. Lukovits, M.D.; Richard P. Goddeau, D.O.

Cerebrovascular Disease and Stroke Program, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire

Neurology Department, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire

References 1. Neuro-critical care skills training using a human patient simulator. Musacchio MJ, et al. Neurocrit Care 2010, 13(2):169-175. 2. Stroke and TIA assessment training: a new simulation-based approach to teaching acute stroke assessment. Garside MJ, et al. Simul Healthc 2012, 7(2): 117-122. 3. Simulation training for hyperacute stroke unit nurses. Roots A, et al. Br J Nurs 2011, 20(21):1352-1356. 4. Stroke training of prehospital providers: an example of simulation-enhanced blended learning and evaluation. Gordon DL, et al. Medical Teacher 2005,27(2):114-121.

All materials: Copyright Lukovits, Goddeau 2012

Results To date, 25 sessions have been completed and analyzed. The median, average, range and standard deviation for the scores on scenario 1 (ischemic stroke/thrombolysis were: 64%, 62%, 32-77%, and 12.5. The median, average, range and standard deviation for the scores on scenario 2 (cerebellar hemorrhage) were: 85%, 86%, 80-100%, and 6.7. Residents' evaluation of the exercise was consistently very positive. We were unable to show any relationship between year of training and performance.

DHMC Cerebrovascular Disease and Stroke Program Mock Stroke Alert Exercise 1 Resident: Date of exercise: Date of debriefing: Goals Met Washes hands prior to encounter Identifies patient by name band Rapidly identifies and corrects hypoglycemia Obtains bloodwork within 10 minutes Expediently responds to hypertensive urgency, administers labetalol or nicardipine within 15 minutes Obtains and views head CT within 25 minutes Moves to nicardipine or labetalol infusion within 30 minutes

DHMC Cerebrovascular Disease and Stroke Program Mock Stroke Alert Exercise 2 Resident: Date of exercise: Date of debriefing: Goals Met Washes hands prior to encounter Identifies patient by name band Rapidly contacts attending for stroke alert within 15 minutes Is aware of and can use the eDH order sets for ED alert and ICH admission Rapidly obtains blood work within 10 minutes Obtains and views head CT within 15 minutes and recognizes intracerebral hemorrhage and can describe size and location of ICH Gets focused history from patient while treating patient with professionalism and respect

Figure 1. Image from scenario 1 exercise in ER bay in simulation lab.

Figure 2: Excerpt from Assessment Checklists used for scenarios 1 and 2.

The future

• Development of other simulations – status epilepticus, spinal cord compression,

thunderclap headache – Exercises for ER staff, other residency programs, and

outside providers • Team simulations • Refinement of the debriefing and measuring

effect of exercise • Simulated telemedicine evaluations • Mini simulations/role playing on phone calls

• You Tube