Setting Up a Stroke Team Algorithm and Conducting Simulation-based Training in the Emergency Department - A Practical Guide

In acute stroke care, faster treatment directly leads to better patient outcomes. This team based stroke algorithm helps to deliver thrombolysis as fast and safely as possible to rapidly evaluate patient eligibility for a thrombectomy. Since the effect of acute stroke therapies is highly time dependent, every minute counts.

Therefore, strategies are needed to shorten the time to treatment without putting the patient's safety at risk. The combination of a team based algorithm and regular training with the entire interdisciplinary team shortened the time to treatment in our center. We developed this algorithm when we noted that a large share of fatal errors were not due to a lack of knowledge, but due to deficits in communication, interaction and decision making.

Acute stroke is a high fidelity situation which requires dedicated teamwork. Clear communication, cooperation, decision making and management of stress. Our composite intervention focuses on the importance of interdisciplinary teamwork and it's easily transferrable to other hospital settings.

Joining us in this demonstration will be Ana Lawa, a newer radiology resident, and Tanya Herzinger, a radiology technician. When the alarm is heard, the ED nurse goes directly to the computer to check the information on the incoming patient. Hypothetically, the system announces a male patient with a tentative diagnosis of a stroke within at least six hours, arriving soon by ambulance.

When the paramedics enter the ED with a patient on a stretcher, they immediately report to the stroke nurse and SU resident. Next, the resident performs an initial check that includes the fast test. The resident then asks about the characteristics and evolution of the symptoms, in order to exclude very obvious stroke mimics, and exclude patients that present beyond a therapeutic time window.

The nurse must now trigger the stroke team alert using a speed dial collective call, which simultaneously informs all members of the stroke team via their institutional mobile phones. When the stroke team members answer their phones, they get an automated message indicating that there is stroke within time window. Now, the ED resident, SU resident and senior neurologist, all meet at the ED.The laboratory technician should got to the laboratory and prepare to analyze the stroke patient's blood sample.

And the radiology resident and technician should meet at the CT scanner. Next, the ED resident should take blood samples by using an adaptor or a butterfly cannula. Three milliliter citrate plasma sample is needed to determine the coagulation parameters, including the prothrombin time and international normalized ratio, the activated prothrombin time, and the thrombin time.

If possible, the resident now informs the patient of the suspected acute stroke, and then collects information on symptom onset, symptom evaluation, prior disabilities, and current medication, with a focus on blood thinners, allergies, and any preexisting conditions. The resident must then perform a focused neurological exam, on the basis of the NIH stroke scale. Next, the senior neurologist reviews the case and decides on an imaging modality.

CT scanning is a strong choice for patients with unequivocal stroke systems, and stroke onset that is clearly within the therapeutic time window, because of speed and easy access. Also, it allows select patients for mechanical recanalization. At the lab, the analyses are performed on an automated hemostasis analyzer, an automated hematology system, and an automated analyzer for clinical chemistry.

This requires 15 to 20 minutes. Meanwhile, bring the patient on the ambulance stretcher to the CT scanner. With the patient are the paramedics, the residents from the ED, the stroke unit residents and the senior neurologist.

At the CT scanner, the team is joined by a neuroradiology resident and a radiology technician. The patient is then moved to the CT and connected to an infusion line to deliver the contrast agent. The paramedics are relieved.

Meanwhile, the ED nurse arrives with a new stretcher, a thrombosis kit, monitoring equipment and portable oxygen. Now, the technician performs a cranial CT to exclude intercranial hemorrhage. The scanning is unenhanced with a slice thickness of five millimeters.

Once taken, the scans are immediately reviewed by the neuroradiologist. Then, the senior neurologist decides if intravenous RTPA should be administered. If the patient confirm no use of blood thinners or other hemostasis issues, do not wait for the blood lab values and directly proceed with administering the RTPA bolus.

Consulting a table of body mass to dose, the nurse prepares the RTPA bolus, then calls colleagues in the ED to prepare the remaining 90 percent of the dose. The stroke unit resident then administers the bolus of RTPA over one minute. Now, a CT angiography is performed to screen for LVO.

Both the neuroradiologist and senior neurologist examine the stand. If LVO is present, the department of anesthesiology is immediately notified. After scanning, the stroke team takes the patient back to the ED, or directly to the angiography suite, in case of LVO.

Around this time, the laboratory phones the stroke unit resident and discloses the coagulation data. When the patient is back at the ER or suite, the remaining 90 percent of the RTPA is set up to infuse over one hour. Then, the patient's blood pressure, heart rate and oxygen saturation are put up on a monitor.

Every 15 minutes, the patient's neurological function is assessed on the NIHSS. For a training session, first conduct an oral presentation covering the most frequent stroke symptoms in your hospital's acute stroke workflow. Then practice the stroke team algorithm on a mannequin while one of the stroke team trainers notes the procedural times and positive and negative elements of the performance.

Following the simulation, have a feedback session with an active dialogue. Start the discussion with the door to needle time recorded during the training session. Then conduct three rounds of feedback, including every team member in each round.

The implementation of the stroke team algorithm in 2012, accompanied by regular simulation based stroke team trainings, led to a relevant increase in the patients treated with a door to needle time below 30 minutes and an increase in thrombolysis rate. The course was evaluated by questionnaires. 16 physicians, 11 ED nurses and radiology technicians, and 18 medical students responded.

Regarding their ability to safely treat acute stroke patients, the participants reported significantly greater confidence after the course. A binding stroke team algorithm and regular simulation based stroke team trainings can lead to a long term reduction of the door to needle time. This is the key benchmark process time for acute stroke treatment.

This algorithm starts at the doorstep of the hospital and is easily transferrable to other hospitals without specific infrastructural prerequisites. It emphasizes the role of teamwork and is straightened to teach non technical skills. Recognizing errors early, communicating them and correcting them have a tremendous effect on patient safety.

Therefore, it is important to create a sense of shared responsibility and a flat hierarchical structure to allow open communication. Bring this to practice during simulator based team training sessions. In non medical high fidelity situations such as aviation, concept called crew resource management, CRM, has proven to be highly effective.

CRM emphasizes the importance of non technical skills, such as clear communication, teamwork, situation awareness, decision making, leadership, and the management of stress. As similar concepts have already been successfully implemented in cardiovascular life support, anesthesiology or surgery, we believe that a basic education in CRM and regular simulation based trainings offer ways to improve acute stroke care in high fidelity situations.