Simulation-Based Assessment of Graduate Neurology Trainees' Performance Managing Acute Ischemic Stroke

Abstract

Background and ObjectivesMultidisciplinary acute stroke teams improve acute ischemic stroke management but may hinder trainees’ education which in turn may contribute to poorer outcomes in community hospitals upon graduation. Our goal was to assess graduate neurology trainee performance independent of a multi-disciplinary stroke team in the management of acute ischemic stroke, tissue plasminogen activator (tPA)-related hemorrhage, and cerebral herniation syndrome.MethodsIn this prospective, observational, single-center simulation-based study, participants (sub-interns to attending physicians) managed a patient with acute ischemic stroke followed by tPA-related hemorrhagic conversion leading to cerebral herniation. Critical actions were developed by a modified Delphi approach based on relevant American Heart Association guidelines and the Neurocritical Care Society’s Emergency Neurological Life Support protocols. The primary outcome measure was graduate neurology trainees’ critical action item sum score. We sought validity evidence to support our findings by comparing trainees’ performance across four levels of training.ResultsFifty-three trainees (including 31 graduate neurology trainees) and five attending physicians completed the simulation. The mean sum of critical actions completed by graduate neurology trainees was 15/22 (68%). Ninety percent of graduate neurology trainees properly administered tPA, 84% immediately stopped tPA infusion following patient deterioration, but only 55% reversed tPA according to guidelines. There was a moderately strong effect of level of training on critical action sum score (level 1 mean score [standard deviation (SD)] = 7.2 (2.8) vs. level 2 mean score (SD) = 12.3 (2.6) vs. level 3 mean score (SD) = 13.3 (2.2) vs. level 4 mean score (SD) = 16.3 (2.4), p < .001, R2 = 0.54).DiscussionGraduate neurology trainees reassuringly perform well in initial management of acute ischemic stroke, but frequently make errors in the treatment of hemorrhagic transformation after thrombolysis, suggesting the need for more education surrounding this low frequency, high-acuity event. High-fidelity simulation holds promise as an assessment tool for acute stroke management performance.

Curriculum Innovations: High-Fidelity Simulation of Acute Neurology Enhances Rising Resident Confidence

“…7 Neurology physicians in training have reported educational benefit with acute ischemic stroke (AIS) simulation. 8 In addition to refining these cognitive skills, simulation may also help with teaching communication and professionalism skills. 9 A gap remains in neurology education for a comprehensive acute neurologic emergency simulationbased training curriculum for rising neurology residents.…”

Author Response: Simulation-Based Assessment of Graduate Neurology Trainees' Performance Managing Acute Ischemic Stroke

“…We appreciate Dr. Das's comments on our study. 1 The idea of using peer education is particularly exciting and applicable to the diverse backgrounds of critical care fellows that rotate through our neurocritical care unit.…”

“…In our study, we found that few trainees performed a comprehensive neurologic examination (including the NIH Stroke Scale), likely due to the ease of identifying a large left middle cerebral artery stroke syndrome in conjunction with the technologic limitations of replicating findings with current simulator technology. 1 Thus, we worry that current simulation technology may fall short in assessing and teaching the neurologic examination.…”

Reader Response: Simulation-Based Assessment of Graduate Neurology Trainees' Performance Managing Acute Ischemic Stroke

“…Pergakis et al 1 reported results from their institutional use of simulation to assess graduate trainees' performance in acute ischemic stroke management. This is important given the increased emphasis on the role of simulation, especially in endovascular stroke training and multidisciplinary team training during acute stroke codes.…”

“…The authors assessed trainees across subspecialties and reported a disparity in the performance on specialty-specific critical action items. 1 For example, trainees from critical care performed well in airway actions, and those from neurology performed well on stroke actions. This is a potential educational opportunity to use peer coaching strategy in neurocritical care fellowships that will improve the utility of learning compared with more traditional didactic-based continuing medical education initiatives.…”