Fawaz Al-hussain Assistant Professor Stroke Neurologist For Internal Medicine Round.
SIMULATION CODE STROKE - Helping San Mateo County ...Stroke neurologist trained actor to a play a...
Transcript of SIMULATION CODE STROKE - Helping San Mateo County ...Stroke neurologist trained actor to a play a...
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SIMULATION CODE STROKEWaimei Amy Tai, MDClinical Assistant ProfessorStanford Stroke CenterSMC Stroke Symposium: November 1, 2013
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• No financial disclosures• Off label use-tpa within 4.5 hours of symptom onset
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You receive this patient in the ED• A 61 year old woman who was brought from the shopping
mall when she had acute onset slurred speech and left arm weakness
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Credit: Robert Gauthier / Los Angeles Times
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What do neurology residents think about stroke codes?
“This is a high stress situation”
“It’s like they just dump you in the situation”
“It’s scary to be alone at night.”
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Why Use Simulation for Acute Stroke• High acuity patient• Large number of team members• Complex decision making
• Time sensitive treatments available• Rapid decision making required• Multiple factors in patient history, exam, radiologic studies needed
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Why Use Simulation for Acute StrokeNovice neurology residents
+High acuity patient, multiple team members, complex
decision making=
High risk for delays in treatment, decision errors
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So what?High risk for delays in treatment, decision errors this can lead to
• Poor patient outcomes• Decreased satisfaction of experience for patients and
providers• Increased cost burden to society with more disabled patients
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All the pieces of the puzzle.
Radiology
Page operators
MDsEMS
transport
MDs
laboratory
nurses
pharmacy
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Acute Stroke Code FlowchartRN 1
RN 2
Team Member
Neuro Fellow/Attdg
Neuro Res
Stat labs, iv startsAccurate weight
CT: Clear tableRads- protocols
Arrive at CT to review scanIf coming from home,Can make tpa decision on phone
Hx, exclusionNIHSS, go to CTCall fellow, family
Goal: CT <25minGoal: Order for tpa placed <40min Goal: tpa bolus <60min
Monitor vitalsIn CT, give prn meds
Review CTNo bleed- tell RN/ED MD to order tpa
If BP ok, hx/criteria ok, verbally verify tpa order to start bolus
If tpa ordered, prepare tpa pump, iv tubes
PharmD: stand by for orders, mix and deliver
If BP ok, hx/criteria ok, verbally verify tpa order to start bolus
Prepare pump, Start bolus
20’ 40’
Rads: reads scan, call MDs
Insert foley
ED MD: orders, screening
hook to transport monitorNIHSS with neuroMD
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Simulation for Neurology Residents
•Learning objectives• abbreviated history• use NIHSS as tool for physical exam• Interpretation of non-contrast head CT• calculate tpa dose• write tpa order set• courteous yet efficient manner with patient• Coordination with other care providers
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Methods1. Stroke neurologist trained actor to a play a standardized
patient 2. A stroke nurse interacted with trainees and carried out
nursing duties. 3. 6 residents attended a 4 hour training session with 2
scenarios 4. Trainees communicated with the stroke attending and RN
during scenario5. Debriefing occurred after each scenario6. Trainees completed evaluations after the simulation
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Types of Scenarioswarfarin-associated intracranial hemorrhage requiring coagulopathy reversal
ischemic stroke requiring i.v. tPA
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EPIC TPA ORDER SET
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0 1 2 3 4 5
quality of teaching
learning from scenario
overall organization
facilities
overall evaluation
Evaluation of Experience by Trainees
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Post Stroke Simulation Knowledge• Average score of 9/10 in post stroke knowledge
assessment• Included array of multiple choice questions covering
clinical content• And crisis resource management
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Feedback by Trainees•“Having a real life actor was really helpful to learn how to act quickly during an emergency.”
•“Realistic situation without risk- this is great for learning.”
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Expansion•Work with ED RNs in multi-disciplinary teams in simulation
•Expansion to other acute neurologic emergencies (herniation syndrome)
•Simulations for use in process flow improvements
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Multi-disciplinary teams in stroke simulation
• Work with new ED RN trainees to help train RN roles
• Had neurologist participate to reinforce CRM training
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Acute herniation syndrome• Used mannequin as patient• Operationalized technical skills including intubation, interpreting scans, administering acute medical therapies
• Coordination of care with other care providers and consultants
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In situ simulations• In a performance improvement project
• Tested alternative work flows to identify pitfalls and equipment and personnel needs
• Used simulation with standardized patient (volunteer) to practice new work flows prior to real world execution
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Opportunities
•Better team based care•Process improvement•Core clinical and technical proficiencies