Abstract WP295: Improving Resident Confidence and Efficiency During Stroke Alerts Through Simulation Training

Background: Prior studies reported that only half of stroke patients arrived at emergency departments (ED) via emergency medical services (EMS). We sought to assess predictors of ED mode of arrival and its effects on acute stroke care and inpatient outcomes in a large racial-ethnically diverse cohort. Methods: In 2016, we launched a system-wide standardized telestroke program for 21 certified stroke centers. Non-cancelled stroke alerts included those patients who were potential candidates for further workup for acute ischemic stroke treatment. This study cohort included non-cancelled stroke alerts seen by Telestroke in 2021. Assessment included demographics, ED arrival mode , initial NIH Stroke Scale (NIHSS), neuroimaging results, IV thrombolytic, door-to-needle (DTN) time, large vessel occlusion (LVO), thrombectomy referral, hospital length of stay and discharge disposition. Clustered logistic regression was used to evaluate ED arrival mode’s effects on short-term outcomes. Results: Of the 7744 stroke alerts seen by Telestroke in 2021, 3264 (42.2%) were non-canceled. Among these, 2014 (61.7%) were in the early window (0-4.5 hours from last seen well). More of those arriving in the early window came via EMS compared to those seen in the extended window [1625 (80.7%) versus 729 (58.3%) respectively]. Among non-canceled ED stroke alerts, compared to patients who arrived via EMS, walk-in patients were younger, more Hispanic, had lower initial NIHSS scores, longer times for ED to contact Telestroke, slower DTN times, but less mortality [Table]. In multivariate analysis, walk-in patients were less likely to have a DTN time within 30 minutes (OR=0.37, 95% CI 0.25-0.34; p=<0.001). Conclusions: In our cohort, there were several differences between walk-in patients and those who arrived via EMS. Further research is needed to understand these differences, the reasons for choosing walk-in, and whether ED mode of arrival affects clinical outcomes.

Introducción:El manejo del ictus isquémico minor presenta desafíos significativos, debido a la variabilidad en la aplicación de protocolos de neuroimagen y tratamiento endovascular (TEV). La ausencia de consenso sobre la indicación de la angiografía por tomografía computarizada (angioTC) en estos casos subraya la importancia de investigar la prevalencia y las implicaciones clínicas de la oclusión de gran vaso en esta población.Metodología:Análisis del registro multicéntrico CODICT en pacientes con ictus isquémico minor (National Institutes of Health Stroke Scale (NIHSS) ≤5) atendidos en centros terciarios de atención al código ictus (CI) de la Comunidad Valenciana en el periodo 01/07/2020–30/11/2023. Se evaluó la frecuencia de oclusión de gran vaso (OGV), definida como oclusiones en carótida interna, arteria vertebral, basilar, y segmentos críticos de la arteria cerebral media (M1, M2), anterior (A1, A2) y posterior (P1, P2), mediante angioTC.Resultados:Se identificaron un total de 5473 activaciones de CI en el periodo de estudio. Un total de 833 pacientes sufrieron un ictus isquémico minor. El 17,5% (n = 146) de los ictus minor mostraron una OGV en el angioTC. El 48,6% (n = 71) de los pacientes con ictus minor y OGV fueron sometidos a TEV. Los vasos más frecuentemente ocluidos fueron la arteria cerebral media (ACM) en sus segmentos M1 y M2 ambos en el 35,6% (n = 52) de los casos. Sin embargo, el vaso más frecuentemente tratado mediante TEV fue M1 en el 29,5% (n = 43), seguido por M2 en el 10,9% (n = 16) de los casos.Conclusiones:Este estudio pone de manifiesto la importancia de la realización de angioTC en todo paciente que cumpla criterios de activación de Código Ictus, independientemente de la gravedad clínica. La presencia de OGV cambió el manejo clínico en casi la mitad de los pacientes con ictus minor y OGV.

Introduction: Even experienced teams can become overwhelmed with multiple simultaneous stroke alerts, especially when all require endovascular therapy. We describe a recent situation where three acute stroke alerts arrived to our comprehensive center within 36 minutes of each other and all needed endovascular therapy. We strategically handled the situation to ensure all patients were assessed and treated in an organized and timely manner. Methods: The stroke team conducted a detailed review of the three cases after treatment to identify areas of success and areas to improve. Results: EMS alerted our center for Case 1 at 11:47 followed by Case 2 at 11:51, FAST-ED scores of 4 and 7, respectively. Based on these scores, the interventional team was on standby because of the high likelihood of large vessel occlusion. As the stroke responder RN awaited the EMS cases, Case 3 arrived via triage at 12:00. The triage nurse immediately called a stroke alert for right facial droop, right weakness, and expressive aphasia, which activated a second stroke responder. Case 1 arrived at 12:19 and Case 2 arrived at 12:36. A third responder was activated so that all patients had a dedicated responder to facilitate initial assessment, rapid imaging, and coordination of care up to endovascular procedure start. Case details can be found in the table below. Discussion: With three stroke alerts arriving within 36 minutes of each other and all needed endovascular intervention, there was an initial strain on our stroke alert process. However, our center’s standard is to have a primary and secondary stroke responder, as well as multiple other nurses trained in rapid stroke response. In this way, we ensured that all patients were assessed and treated rapidly and efficiently.

Introduction: The AHA-ASA Target:Stroke Program calls for innovative approaches to prehospital stroke care. We previously showed that mobile videoconferencing during ambulance transport is technically feasible in a rural EMS setting using an iPad-based telemedicine system. We now hypothesize that this mobile telestroke system is clinically feasible as measured by agreement of the NIH Stroke Scale (NIHSS) between face-to-face (FTF) and remote ambulance-based assessments (iTREAT). Methods: The iTREAT system comprises an Apple iPad® with retina display, high-speed 4G LTE modem, Cisco Jabber secure video conferencing application, mounting apparatus, and magnetic external antenna. We developed 4 unique stroke and 2 unique stroke-mimic scenarios to simulate prehospital stroke alerts. We recruited 3 standardized patients each assigned two scenarios, and randomly assigned each scenario to one of 6 major ambulance routes triaging to UVA Medical Center. To eliminate bias, we alternated the order of FTF and iTREAT evaluations. Statistical measures were inter- and intra-rater correlation coefficient for the NIHSS and audio/visual(AV) quality ratings on a 6-point scale (>4 indicating “good” or “excellent” connectivity). Results: For the 12 iTREAT and 10 FTF evaluations (two FTF missing data), intra-rater correlation of NIHSS scores was consistently >0.91 (mean=0.96). Inter-rater correlation for FTF evaluations was >0.89 (mean 0.96), and inter-rater correlation for iTREAT evaluations was >0.84 (mean=0.94). AV quality ratings during all iTREAT evaluations were deemed “good” or “excellent” (audio mean=5.3, median=5.5; video mean=4.67, median=4.5). Both NIHSS correlation and AV quality rating increased over the study period. Conclusion: In this pilot feasibility study, NIHSS scores obtained via ambulance using our iPad-based mobile telestroke system correlated well with in person assessments. These results support further research to determine feasibility and efficacy of this low-cost mobile telestroke system in prehospital stroke care.

Background: With increasing demand for neurologists, nontraditional health care delivery mechanisms have been developed to leverage this limited resource. Introduction: Telemedicine has emerged as an effective digital solution. Over the past three decades, telemedicine use has steadily grown; however, neurologists often learn on the job, rather than as part of their medical training. The current literature regarding telestroke training during neurology training is sparse, focusing on cerebrovascular fellowship curricula. We sought to enhance telestroke training in our neurology residency by incorporating real-life application. Materials and Methods: We implemented a formal educational model for neurology residents to use telemedicine for remote acquisition of the National Institutes of Health Stroke Scale (NIHSS) for patients with suspected acute ischemic stroke (AIS) before arrival at our comprehensive stroke center. This three-phase educational model involved multidisciplinary classroom didactics, simulation exercises, and real-world experience. Training and feedback were provided by neurologists experienced in telemedicine. Results: All residents completed formal training in telemedicine prehospital NIHSS acquisition and had the opportunity to participate in additional simulation exercises. Currently, residents are gaining additional experience by performing prehospital NIHSS acquisition for patients in whom AIS is suspected. Our preliminary data indicate that resident video encounters average 10.6 min in duration, thus saving time once patients arrive at our hospital. Discussion: To our knowledge, this is the first report of a telestroke-integrated neurology residency program in a comprehensive stroke center resulting in shortened time to treatment in patients with suspected AIS. Conclusions: We present a model that can be adopted by other neurology residency programs as it provides real-world telemedicine training critical to future neurologists.

The purpose of the study: is to investigate the efficiency of the developed physical rehabilitation program in the late rehabilitation period after ischemic stroke with a personalized approach with the priority use of the "OSNOVA" device for the restoration of locomotor functions. Material & Methods: to implement a physical rehabilitation program in the late rehabilitation period after ischemic stroke with a personalized approach with the priority use of the "OSNOVA" device for the restoration of locomotor functions, 10 patients diagnosed with ischemic stroke in the late rehabilitation period after undergoing sanatorium treatment were involved. Because the patients differed in pathogenesis (flaccid and spastic paralysis, left or right-sided), a personalized physical rehabilitation program was applied to each patient, but with elements of correction depending on the patient’s dynamics. All participants signed an informed consent form to participate in the study. The study used general and clinical methods of examination (medical history, patient examination), the NIHSS (National Institutes of Health Stroke Scale) scale, which allows an objective approach to the patient's condition after a stroke and assesses neurological status, and the MMSE (Mini Mental State Examination) scale, which assesses mental state and cognitive function. Also, to implement the developed program, a device for restoring locomotor functions – "Osnova" – was developed. Results: a program of physical rehabilitation in the late rehabilitation period after ischemic stroke with a personalized approach with the priority use of the device "OSNOVA" was developed, which was conducted for three weeks and included three stages and the volume of training hours – 90. A "success diary" was introduced to motivate and monitor the workload during training. The data obtained showed that the average Barthel scale score is 77.1 against the initial value of 64. It should be noted that the scores increased by 17%. The NIHSS scale is 13.9 against the initial value of 10.1. We note that the scores have increased by 27%. Conclusions: the results obtained showed positive dynamics, but the development of a standard rehabilitation protocol is an open question, as there is currently insufficient data to determine the optimal duration of procedures and their intensity.

The Rapid Response Team (RRT) system at Memorial Sloan Kettering Cancer Center led by critical care medicine (CCM) advanced practice providers (APPs) expanded exponentially between 2009 and 2021. CCM-APPs are trained for care of critically ill patients as well as to oversee rapid response calls. The RRT is composed of a CCM-based RRT-APP, respiratory therapist, RRT-RN, and nursing supervisor. Since program inception, 11 RRT pathways and interventions have been developed and adjusted to improve multidisciplinary patient management. Pathways vary in complexity and require multidisciplinary collaboration. In some circumstances, the RRT patient may require transfer to outside facilities for services not provided at our oncology-based facility. RRT data are tracked across the hospital continuum with on-line reporting through RRT website dashboards. 2021 RRT data on electronic sepsis alerts, behavioral RRT and stroke alerts are presented. The RRT program is monitored through robust quality assurance. The APP-led RRT system's scope of care has been continuously expanded through the creation of RRT pathways to meet the increasingly complex medical needs of our patients.

IntroductionThe ability to utilize the electronic health record (EHR) without compromising the doctor-patient relationship (DPR) is an essential skill of all physicians and trainees, yet little time is spent on educating or assessing learners on needed techniques. To address this gap, we developed a conventional OSCE station coupled with a simulated patient chart within the Epic program in order to assess our students' skills utilizing the EHR during a patient encounter.MethodsOf third-year medical students, 119 were given full access to the patient's simulated chart 24 hours in advance of their OSCE to review clinical data. During an in-person OSCE with a standardized patient (SP), students performed a focused history and physical, using the EHR to verify allergies and medications. Students completed an electronic patient note graded by faculty. SPs evaluated the students on communication and interpersonal skills with specific rubric elements. Faculty graded the students' notes to evaluate their expression of clinical reasoning in the assessment and plan.ResultsTraining SPs and faculty to assess students on EHR skills was feasible. After implementation of a comprehensive curriculum focused on EHR and DPR, there was a significant difference on EHR-related communication skills (M = 76.4, SD = 17.6) versus (M = 37, SD = 28.9) before curriculum enhancement t (117.9) = −12.4, p <.001.DiscussionThe EHR OSCE station provided a standardized method of assessing students' EHR skills during a patient encounter. Challenges still exist in the technological requirements to develop and deliver cases in today's EHR platform.

Background: Timely evaluation and treatment are essential to optimizing outcomes in ischemic and hemorrhagic stroke. National guidelines emphasize rapid provider response and multidisciplinary coordination. In complex settings such as inpatient units, delays in decision-making and care coordination can hinder time-sensitive interventions, including thrombolysis and thrombectomy. Purpose: As part of a broader institutional focus on continuous quality and process improvement (QI/PI) in stroke care, this project evaluated treatment time trends following integration of Advanced Practice Providers (APPs) into the acute stroke response workflow at a Comprehensive Stroke Center (CSC). The analysis focused on door-to-needle (DTN) and door-to-device (DTD) times for stroke alerts in inpatient units and the Emergency Department (ED). Methods: In Fiscal Year (FY) 2021, eight APPs were incorporated into the hospital-wide stroke response team. APPs were trained in acute stroke protocols and began responding in real time to stroke alerts across all hospital settings, assisting with rapid triage, examination, imaging review, and coordination with interventional teams. In FY24, three additional APPs joined the inpatient team, increasing coverage from 64% to 86%. Time metrics for ED and inpatient stroke activations were compared pre- and post-APP integration and monitored annually as the APP team expanded. Descriptive statistics were used to evaluate changes in treatment intervals. Results: Among inpatients, median DTN for thrombolysis decreased by 33 minutes and median DTD for thrombectomy by 37 minutes. For ED patients, median DTN decreased by 4 minutes and DTD by 34 minutes. Adherence to Get With The Guidelines (GWTG) target stroke measures also improved across all settings. The most significant improvements were seen in inpatient cases, where delays were historically greatest. Conclusions: As part of broader institutional efforts to enhance stroke care quality and efficiency, integration of APPs into the acute stroke response workflow was associated with improved key treatment time metrics. While not the sole intervention, APP integration did not extend and may contribute to reduced time to evaluation and treatment, particularly in complex inpatient settings. This experience provides valuable insights for health systems seeking to enhance multidisciplinary stroke care through scalable, team-based innovations.

Changes to Training Practices during a Pandemic - The Experience of the Irish National Trauma & Orthopaedic Training Scheme

Use of a simulation-based mastery learning curriculum for neurology residents to improve the identification and management of status epilepticus

Screening patients admitted with stroke symptoms for risk of aspiration is often the responsibility of registered nurses (RNs). Simulation technology has become a widely used evidence-based form of training for healthcare professionals. The purpose of this study was to determine if the use of medical simulation mannequins as a training component is feasible when training and evaluating nurses administering swallowing screenings to stroke patients. A total of 32 RNs were divided into one of two training groups: didactic training only or didactic training plus simulation. Acquisition of skills was assessed immediately post-training and compared between the groups revealing significant differences between simulation group and didactic-only group for interpretation (p=0.01) and administration (p=0.05) accuracies. Following training to 100% accuracy for post-training baseline competency, maintenance of skills across participants was assessed three more times over 6weeks with the third follow-up screening completed with a standardized patient (live patient actor). While interpretation performance at each subsequent trial never equaled the baseline 100% post-training accuracy (p=0.001), steady improvement in performance was observed with each follow-up assessment. For screening administration, no significant differences in skills were evident between post-training baseline competency and the 6-week follow-up (p=0.269) further confirming improvement in skills over time. Extension of screening administration and interpretation skills to the standardized patient was evident. Findings indicate that simulation training using medical mannequins can be used to train and evaluate nurses for obtainment and maintenance of swallowing screening competency.

Objective To investigate the predictive value of thromboelastography for the occurrence of early neurological deterioration (END) in patients with primary acute cerebral infarction (ACI). Methods 150 patients who were hospitalized in the department of neurology of our hospital from September 2020 to September 2021 and were clearly diagnosed with primary ACI by head CT and head magnetic resonance imaging (MRI) were selected and divided into END and non-END groups according to the change in National Institute of Health Stroke Scale (NIHSS) score within 72 h of admission. The general baseline data and laboratory indexes of the first examination at admission were compared between the two groups, and the factors that may affect the occurrence of END were determined by univariate analysis and multivariate logistic regression analysis, and the predictive value of thromboelastography on the occurrence of END after ACI was analyzed by applying the receiver operating characteristic (ROC) curve. Results Time to onset, baseline NIHSS score, percentage of diabetes, white blood cell (WBC) levels, C-reactive protein (CRP), and apolipoprotein B (Apo B) levels were higher in the END group than in the non-END group (P < 0.05); coagulation reaction time (RT) (3.97 ± 1.16 vs. 5.49 ± 1.03) and kinetic time (KT) (1.32 ± 0.67 vs. 1.82 ± 0.58) were lower in the END group than in the non-END group (P < 0.05). Inthe END group (P < 0.05) diabetes, baseline NHISS score, CRP level, Apo B level, and RT were independent risk factors for the development of END in patients with ACI (P < 0.05). The AUC of RT to predict the occurrence of END in patients with ACI was 0.855 (95% CI: 0784 to 0925, P = 0.001), with a sensitivity of 81.70% and specificity of 78.00% when the optimal cut-off value was 0.597. Conclusion NIHSS score at admission, CRP, apolipoprotein B, RT shortening, and diabetes mellitus were independent risk factors for the development of END in ACI patients; RT shortening in TEG was predictive of END in ACI patients.

State University of New York Upstate Medical University College of Medicine

IntroductionChild neurology has unique challenges in communication due to complex disorders with a wide array of prognoses and treatments. Effective communication is teachable through deliberate practice and coaching. Objective structured clinical exams (OSCEs) are one method of providing practice while assessing communication skills. Yet OSCEs have not been reported for child neurology residents.MethodsWe developed simulated clinical cases centering on communication skills for child neurology residents, all with challenging clinical scenarios (e.g., disclosure of a medical error, psychogenic nonepileptic events). Standardized patients (SPs) portrayed the parents of pediatric patients and, in some scenarios, an adolescent patient. We used a modified Gap-Kalamazoo Communication Skills Assessment Form to assess communication skills. The assessment was completed by faculty, SPs, and the resident, and we measured agreement among raters. Residents were surveyed afterward regarding their experience.ResultsNine cases were developed and piloted. A total of 27 unique resident-case encounters with 16 individual trainees occurred over three annual implementations. Scores on the 360-degree assessment of communication skills showed that residents overwhelmingly underassessed their skills compared to other rater groups. Among 18 responses on the post-OSCE survey, the majority (77%) found the experience useful to their education and felt that the feedback from the SPs was helpful (61%) and the case portrayals were realistic (89%).DiscussionWe implemented simulated cases for assessment and formative feedback on communication skills for child neurology residents. We provide a blueprint to develop this educational activity in other programs.