Simulation Methods in Acute Stroke Treatment

HomeStrokeVol. 51, No. 7Simulation Methods in Acute Stroke Treatment Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toSupplementary MaterialsFree AccessResearch ArticlePDF/EPUBSimulation Methods in Acute Stroke TreatmentCurrent State of Affairs and Implications Martin W. Kurz, MD, PhD, Johanna M. Ospel, MD, Rajiv Advani, MD, PhD, Else Charlotte Sandset, MD, PhD, Anne Hege Aamodt, MD, PhD, Bjørn Tennøe, MD, Hege L. Ersdal, MD, PhD, Lars Fjetland, MD, PhD, Soffien Ajmi, MD, Kathinka D. Kurz, MD, PhD and Mayank Goyal, MD, PhD Martin W. KurzMartin W. Kurz Correspondence to: Martin W. Kurz, MD, PhD, Department of Neurology, Stavanger University Hospital, Postboks 8100, 4068 Stavanger, Norway. Email E-mail Address: [email protected] https://orcid.org/0000-0001-8853-4450 Department of Neurology (M.W.K., S.A.), Stavanger University Hospital, Norway. Neuroscience Research Group (M.W.K., R.A., S.A.), Stavanger University Hospital, Norway. Department of Clinical Science, University of Bergen, Norway (M.W.K.). , Johanna M. OspelJohanna M. Ospel Department of Clinical Neurosciences (J.M.O.), University of Calgary, Alberta, Canada. Department of Radiology, Universitätsspital Basel, Switzerland (J.M.O.). , Rajiv AdvaniRajiv Advani Neuroscience Research Group (M.W.K., R.A., S.A.), Stavanger University Hospital, Norway. Department of Neurology, Stroke Unit (R.A., E.C.S.), Oslo University Hospital, Norway. , Else Charlotte SandsetElse Charlotte Sandset Department of Neurology, Stroke Unit (R.A., E.C.S.), Oslo University Hospital, Norway. Department of Research and Development, The Norwegian Air Ambulance Foundation, Oslo, Norway (E.C.S.). , Anne Hege AamodtAnne Hege Aamodt Department of Neurology (A.H.A.), Oslo University Hospital, Norway. , Bjørn TennøeBjørn Tennøe Department of Radiology and Nuclear Medicine, Division of Diagnostics and Intervention (B.T.), Oslo University Hospital, Norway. , Hege L. ErsdalHege L. Ersdal Department of Anesthesiology and Intensive Care (H.L.E.), Stavanger University Hospital, Norway. Faculty of Health Sciences (H.L.E.), University of Stavanger, Norway. , Lars FjetlandLars Fjetland Department of Radiology (L.F., K.D.K.), Stavanger University Hospital, Norway. SMIL Stavanger Medical Imaging Laboratory (L.F., K.D.K.), Stavanger University Hospital, Norway. , Soffien AjmiSoffien Ajmi Department of Neurology (M.W.K., S.A.), Stavanger University Hospital, Norway. Neuroscience Research Group (M.W.K., R.A., S.A.), Stavanger University Hospital, Norway. , Kathinka D. KurzKathinka D. Kurz Department of Radiology (L.F., K.D.K.), Stavanger University Hospital, Norway. SMIL Stavanger Medical Imaging Laboratory (L.F., K.D.K.), Stavanger University Hospital, Norway. Department of Electrical and Computer Engineering (K.D.K.), University of Stavanger, Norway. and Mayank GoyalMayank Goyal Diagnostic Imaging (M.G.), University of Calgary, Alberta, Canada. Department of Clinical Neurosciences (M.G.), University of Calgary, Alberta, Canada. Originally published17 Jun 2020https://doi.org/10.1161/STROKEAHA.119.026732Stroke. 2020;51:1978–1982is related toStroke Systems of CareEssential Workflow and Performance Measures for Optimizing Acute Ischemic Stroke Treatment in IndiaPath From Clinical Research to ImplementationOptimization of Endovascular Therapy in the Neuroangiography Suite to Achieve Fast and Complete (Expanded Treatment in Cerebral Ischemia 2c-3) ReperfusionOptimal Imaging at the Primary Stroke CenterLeaving No Large Vessel Occlusion Stroke BehindSee related articles, p 1928, p 1932, p 1941, p 1951, p 1961 and p 1969If left untreated, the natural course of acute ischemic stroke is devastating, with high rates of morbidity and mortality, particularly if the stroke is caused by a large vessel occlusion.1 Endovascular thrombectomy is a highly effective treatment for large vessel occlusion stroke with a number needed to treat of 2.6.2,3 As the effect of endovascular thrombectomy rapidly decreases with increasing time to treatment, instantaneous symptom recognition and triage, fast patient transfer, and treatment are keys to achieve good outcomes.4–6 Fast and complete reperfusion is also beneficial from an economic standpoint, since it decreases the long-term costs by avoiding poststroke morbidity.7 Both clinical and economic outcomes depend not only on the speed but also on the quality of reperfusion.8,9 These are determined by individual operator skills and the ability of the medical professionals involved to act effectively as a team. Even small improvements in every part of the acute treatment cascade can accumulate and then have a substantial impact on patient outcome.10 Simulation techniques offer the potential to improve both individual operator skills and team tasks that require interpersonal coordination. In this systematic review, we provide an overview about simulation-based interventions in acute stroke treatment and how they can be used to improve performance of individuals and the collaboration across different members of the medical team.Classical Teaching Concept in Neurointervention and Its LimitationsTraditionally, the most commonly used strategy in medical training has been based on graded and progressive responsibility of residents under supervision.11,12 As residents gain experience and skills, the learning curve improves further as they start to work with greater independence. Medical trainees acquire their procedural skills in vivo, that is, while performing procedures on a patient under supervision. With increasing experience, the trainee is given rising procedural responsibility, until they eventually perform the task independently. Particularly in low-volume centers, it can be challenging for trainees to achieve a sufficient skill set.13–15 This might seem bizarre to a layperson at first glance, and it is particularly precarious in the field of stroke neurointervention, where patients' lives are at risk and neurons are dying at a rapid pace. In such a setting, nothing less than the highest level of expertise should be adequate.This idealistic view clearly conflicts with current teaching concepts in stroke neurointervention. The traditional training methods as they are used today have several important drawbacks16,17:Lack of patient safety and suboptimal quality of care: imposing the learning curve especially of new trainees solely on patients may cause more complications and lead to poorer outcomes as compared with expert-level care.Lack of teaching standardization: each trainee learns the skill set from her or his supervisor. Thus, individual preferences are taught, not necessarily representing evidence-based state-of-the-art treatment.Lack of structured feedback: during the procedure, there is no time for structured trainee feedback owing to the time-sensitive nature of the task. After the procedure, time constraints in hospitals make timely feedback difficult, and sometimes, feedback is simply forgotten.Lack of objective criteria to assess progress: since all procedural training takes place in the human body with unique anatomic variation, it is challenging to assess skills and progression both between individual trainees and for one trainee over time.Lack of standardized learning/teaching outcomes: learning outcomes for medical trainees differ internationally and, in some cases, nationally. The lack of standardization means that a person qualified to perform a procedure in one country or region might not fulfill the requirements to perform the same procedure elsewhere.Potential Solution: Introducing Simulation Methods Into Stroke MedicineThe problems we are facing in acute stroke neurointervention today are similar to the ones the commercial aviation industry was confronted with in the 1950's.18,19 They dealt with it by introducing highly standardized training programs for pilots, in which simulation training plays a major role: every pilot has practiced a flight path hundreds of times on a simulator before flying it in real life. As a result, airlines have been able to minimize incidences due to human error.20 Nowadays, when boarding an aircraft, passengers do not have to worry about where the pilot was trained or who their supervisor was. In acute stroke care, we are not there yet. There are several differences between aviation and medicine (stroke care in particular), mostly related to the emergent nature of the disease, which makes it harder to establish simulator training in stroke management (Table).Table. Key Characteristics and Differences Between Aviation and Stroke MedicineAviationStroke MedicineTarget populationHealthy, independent passengersPotentially severely disabled stroke patientsAvailable background informationDetailed information on each passenger (passport information, fingerprints, health data), high-risk passengers are not allowed to boardLittle/no background information (often no family history, no medical history, unknown risk profile)Nature of the procedureElective flight, can be rescheduled if necessaryEmergent procedure, no rescheduling alternativePotential loss in case of procedure cancelationMinimal (need to reimburse passengers, reschedule flights)Devastating (patient's lives are at risk, the affected brain tissue may be irreversibly lost)Tolerance to failureZero tolerance (the passengers and staff have an expectation of complete safety: an adverse event makes world headlines)Acceptance of suboptimal outcomes according to given circumstances (it is expected and accepted that some acute stroke patients will experience bad outcomes or even die). Thus, a bad outcome is not necessarily perceived to be the operator's faultDespite these difficulties, numerous studies have recently evaluated simulator and team training in the setting of acute ischemic stroke treatment and reported promising results. Especially in small volume centers lacking didactic resources, the introduction of simulation concepts could increase the learning curves of trainees distinctly. Broadly speaking, simulation can be used to (1) build and improve individual skills (task training) or (2) improve teamwork and communication within a medical team (team training). An overview of different studies on task training and simulation-based team training related to stroke is provided in Table I in the Data Supplement. Methods and findings are also presented. Basic procedural skills and training can be acquired through an improved educational curriculum and virtual reality simulation.21 Task simulation training can help to enhance procedural skills, save time, and reduce medical errors. Strikingly, this can be seen in the study by Spiotta et al,22 where 10 neurosurgical residents and 4 endovascular neurosurgery fellows performed simulation training for carotid angiography on a simulator. During 5 trial runs, both residents and fellows demonstrated significant successive improvements in procedural and fluoroscopy times. Residents even approximated the efficiency of fellows on the third and fourth runs. Based on the promising results of task training, Kreiser et al23 report the introduction of simulation training into the medical student curriculum and as mandatory part of the training of interventional angiographers. In commercial aviation, the importance of communication and effective management of human resources in teams has long been recognized.19 There, the introduction of crew resource management is commonplace. Adopting this team training model from aviation into health care can potentially enhance patient safety.24 Crew resource management has been successfully implemented in surgery, emergency medicine, and intensive medicine leading to a marked drop in mortality.25 Recently, simulation-based team training for multidisciplinary teams has become available (Table, team training). Pfeilschifter et al26 have implemented monthly interprofessional simulation-based stroke team training at the University Hospital in Frankfurt, Germany. As a result, workflow time intervals decreased significantly (door-to-computed-tomography time: 27 versus 12 minutes, P<0.001; door-to-needle time: 43 versus 23 minutes, P<0.001). Ajmi et al10 at the Stavanger University Hospital in Norway could confirm these results. They performed 2 clusters of weekly in situ simulation-based team training to practice the in-hospital stroke care pathway from door to needle. Median door-to-needle times in real-life treated patients (27 versus 13 minutes; P<0.001) and symptom onset to treatment time (110 versus 96 minutes; P=0.005) significantly decreased. More importantly, 3-month patient outcomes improved after the introduction of simulation-based team training with significant reduction of worst outcomes (modified Rankin Scale score 5 and 6 [12.2 % versus 3.5%; P=0.021] and mortality [9.1% versus 3.5%; P=0.049]).Problems to OvercomeSimulator-based task training has only recently been introduced into stroke medicine, and there are several obstacles to overcome. These are 2-fold: first, the acceptance of simulators in the stroke community. From being considered as a potential training tool for novices in the absence of experienced supervisors, they have to be accepted and developed as a lifelong training and preparation tool (Figure). Second, the current financial model is based primarily on the development of simulation modules to train physicians on a new device or technique. Often, the company that had developed the product ends up bearing the cost of the entire simulation experience. This is, however, a nonsustainable model. In this model, simulation-based training is limited to new devices and that too, for a limited period of time. Simulation training should be available throughout the lifetime of technical devices, to reduce the complication rate and to improve performance.Download figureDownload PowerPointFigure. Illustration (not based on published data) of current and simulation enhanced training in stroke neurointervention.A, Current structure of training in stroke neurointervention. Simulator training is not incorporated in the training curriculum, and the operator skills are exclusively acquired in the in vivo training phase. B, Simulation-enhanced stroke neurointervention training with a simulator-based pretraining phase. Part of the skills are acquired in vitro. C, Simulation-enhanced stroke neurointervention training with a simulator-based pretraining phase and continuing simulation cycles during the in vivo training phase. Continuous training increases the slope of the learning curve (black arrows) and allows the operator to achieve a high level of technical skills faster. D, Simulation-enhanced stroke neurointervention training with a simulator-based pretraining phase and continuing simulation cycles during the in vivo training phase that incorporate individual patient anatomy derived from cross-sectional imaging. This allows the operator to practice a procedure in an individual patient with its unique anatomic features in a simulation environment just before starting the actual procedure. The operator is then able to foresee and avoid problems that could arise due to anatomic variations, etc. This accelerates the learning curve further (black arrows), even in advanced training stages (dashed line). In addition, incorporating individual patient anatomy in a simulation environment beforehand can facilitate the choice of appropriate catheters and devices during the actual procedure, thereby reducing procedure cost and time.These obstacles can be overcome easier and faster if physicians (1) appreciate simulation as a useful tool that can help them to improve their skills, in all career stages rather than at a trainee level only and (2) there are policies in place to document continuous and recurrent demonstration of adequate skills (somewhat similar to the process of Continuing Medical Education (CME) credits that are in place in most jurisdictions). Physician feedback is crucial for improvement of the simulation content (which kinds of scenarios should be simulated that are particularly challenging for the medical team?) and haptic and audiovisual feedback (where does the simulation differ from a real-life scenario? What is different, and how can it be improved?). If we as physicians want an effective and useful training tool that serves our needs, we have no choice but taking part in its development ourselves. Other, minor problems include (1) unrealistic haptic feedback, (2) costliness of simulators that prevent them from being widely used, and (3) the limited number of clinical scenarios/anatomic variants that can be simulated. These are, however, second-level problems that can most likely be solved in the future as technology evolves.Need to Democratize Neurointerventional Stroke Training: a Call for ActionIn our opinion, simulator-based training should be an integral part of the curriculum in acute stroke care and particularly in neurointerventional stroke treatment. Task and team training can maximize patient benefit, the trainee's learning experience, and most importantly, avoid harming the patient. Analogous to a commercial pilot's training program, there should be a simulator training phase before the in vivo training phase for stroke physicians and neurointerventionalists as well. Ideally, simulation training should continue beyond the initial training phase and incorporate individual patient anatomy, to allow for targeted preparation of particularly challenging cases (Figure).Indeed, several professional societies have recognized the need for standardization of neurointerventional training programs and the potential benefits of simulation training in this regard. In their official document on training standards in neuroendovascular surgery, the society of Neurological Surgeons, for instance, states that "The practical endovascular training aspect can be significantly buttressed by incorporating simulation-based modules."27 The World Federation of Interventional and Therapeutic Neuroradiology goes even further and recommends using simulation for basic training in neurointervention. It also encourages the development of new applications, covering all aspects of neurointerventions.28 This can especially help more inexperienced and low-volume centers to maintain a high quality, independent of the individual involvement of neurointerventional experts.Optimal training frequency and intensity depends upon the expertise of the neurointerventionalists and procedure volume. Simulator training can compensate for low volume as interventional radiologists can train on cases where experience is lacking. This concept is currently being tested in Norway.ConclusionsIn summary, current training concepts in acute stroke care, and particularly in stroke neurointervention, are suboptimal, as trainees acquire most of their skills by performing procedures in real patients, which leads to unnecessary complications and adverse outcomes. Simulation-based training has been implemented in other fields such as commercial aviation for many decades and has recently entered the field of stroke medicine. The preliminary results using different simulation training techniques for acute stroke treatment are encouraging. Simulation training might help to transform acute stroke care in general, and neurointervention in particular, into a more standardized and reproducible routine rather than the nerve-racking, operator-dependent task it is today.Sources of FundingNone.DisclosuresDr Ospel is supported by the University Basel Research Foundation, Julia Bangerter Rhyner Foundation, and Freiwillige Akademische Gesellschaft Basel; Dr Advani has received payments for lectures from Bristol-Myers Squibb, Pfizer, and Bayer; Dr Sandset has received payments for lectures from Bayer and Novartis; Dr Ajmi is a research fellow funded by a Safer Healthcare Grant (University Research Fund); Dr Kurz got a research grant from the Laerdal Foundation; Dr Goyal is a consultant for Medtronic, Stryker, Microvention, and Mentice. The other authors report no conflicts.FootnotesFor Sources of Funding and Disclosures, see page 1982.The Data Supplement is available with this article at https://www.ahajournals.org/doi/suppl/10.1161/STROKEAHA.119.026732.Correspondence to: Martin W. Kurz, MD, PhD, Department of Neurology, Stavanger University Hospital, Postboks 8100, 4068 Stavanger, Norway. Email martin.[email protected]noReferences1. Malhotra K, Gornbein J, Saver JL. Ischemic strokes due to large-vessel occlusions contribute disproportionately to stroke-related dependence and death: a review.Front Neurol. 2017; 8:651. doi: 10.3389/fneur.2017.00651CrossrefMedlineGoogle Scholar2. Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, McTaggart RA, Torbey MT, Kim-Tenser M, Leslie-Mazwi T, et al.; DEFUSE 3 Investigators. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging.N Engl J Med. 2018; 378:708–718. doi: 10.1056/NEJMoa1713973CrossrefMedlineGoogle Scholar3. 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Stroke. 2020;51:1961-1968Optimal Imaging at the Primary Stroke CenterBruce C.V. Campbell,Stroke. 2020;51:1932-1940Leaving No Large Vessel Occlusion Stroke BehindRyan A. McTaggart, et al. Stroke. 2020;51:1951-1960 July 2020Vol 51, Issue 7Article InformationMetrics Download: 1,100 © 2020 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.119.026732PMID: 32568639 Originally publishedJune 17, 2020 KeywordsphysicianshumansteachingstroketherapeuticsPDF download SubjectsCerebrovascular ProceduresIschemic StrokeCerebrovascular Disease/Stroke