Simulation training programs for acute stroke care: Objectives and standards of methodology

First step: Analysis of the context

The healthcare systems show heterogeneity according to the political and regional healthcare administration. Differences in organizational aspects of education and training in Medical School, in post-graduate training and continuous medical education, would benefit including simulation methodology, complementary to the traditional ones, in order to target and tailor programs, according to local differences and specific needs. Each program should take into account the peculiarities and the Country and/or center-specific requirements. In order to efficiently address the local implementation of simulation training in stroke care, a preliminary analysis of the specific setting should be performed. It consists of identifying and describing the actual stroke care management and related issues focusing on areas of interest and critical local needs.

These elements include the following key points:

identification and description of the pre-hospital and in-hospital phase of the stroke pathway and its environment;

In particular, in stroke care, the analysis should be focused on identifying the strengths and weaknesses of the local stroke pathway (pre- and intra-hospital, Figure 1). All members of the stroke team should be surveyed to before implementation in order to focus on what they would like to improve. This preliminary step is essential for designing the simulation program for local implementation.

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Figure 1.

Stroke pathway.

Second step: Definition of the simulation training objectives

The second step for building a simulation training program is the definitions of the objectives, i.e., learning goals of the program.

General and educational objective(s) should be preliminary identified and clearly stated. A maximum of 2–3 goals for the program is highly recommended. For instance, improving technical skills, testing the communication attitudes, and the efficiency of the stroke pathway in a hospital setting are all worthy objectives. However, each of them requires a dedicated simulation pattern, with specific rules. Eventually, in an advanced simulation program, more than one aspect, behavioral, environmental, and technical, can be addressed in the simulation setting and reviewed in the debriefing sessions.

Some examples of objectives for simulation stroke programs are detailed in Box 1. These objectives can be applied in progressively more complex situations. Box 1

Examples of objectives for stroke simulation programs.

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• Pre- or in-hospital workflow improvement;

• Improve patient’s management by reducing delays, to improve the patient's outcome;

• Improve patient’s management by increasing knowledge on indication/interpretation of diagnostic tools and second-level neuroimaging techniques;

• Improve crew-resource management strategies, by training interdisciplinary team-based algorithm, implementing standardized in-team communication (Willems L, Practical Neurology 2018).

• Carrying out emergency protocols for acute ischaemic stroke/intracerebral haemorrhage treatment, accordingly to international/national recommendations (indications/contraindications for rtPA, mechanical thrombectomy, early arterial blood pressure control, anticoagulant reversal protocols);

• Improve monitoring and management of treatment complications (management of rtPA complications such as acute angioedema or neurological worsening)

• Improve technical skills by procedural simulations for mechanical thrombectomy or drug administration.

Third step: Definition of simulation training techniques and settings

Simulation stroke programs include different techniques of interventions, depending on the objectives of the training. All simulation techniques/settings have advantages and disadvantages, and they should be chosen accordingly to the objectives of the training.

Several approaches can be selected, either alone or combined, depending on the educational objectives and may be applied at different phases of the stroke pathway:

improving technical skills (i.e., mechanical thrombectomy, administration of rtPA);

The simulation techniques should be systematically adapted to the educational objectives and approaches. In particular, different simulation techniques can faithfully recreate both clinical scenarios for training purposes (i.e., role-playing simulation) and procedural “hands-on” training in performing time-critical procedures (i.e., procedural simulation), without exposing patients to harm during the learning process. ¹⁴

Descriptions of the simulation technique (or ‘dimensions’) can also be based on devices or places for simulation implementation. ¹⁵ For instance, high fidelity simulation refers to the simulation of case scenarios conducted on high fidelity mannequin, often in a simulation center. In stroke setting, this technique can be useful to train on the emergency situation, such as complications of intravenous thrombolysis (e.g., angioneurotic edema or neurological worsening), where the stroke team has to manage in frontline a specific, rare, medical emergency. In the simulation center, scenarios can also be played in high fidelity with environmental reality, such as the neuroimaging room for training on the diagnostic workflow of acute stroke diagnosis. Contrasting with simulation center simulation or on-site, the in-situ simulation technique is conducted in the real clinical context.

The benefits of performing simulation training in specialized simulation environments or centers are that trainers and equipment can be concentrated in one location, and the spaces allow the participants to focus on the learning tasks (for instance, dedicated debriefing rooms). However, simulation centers also have disadvantages. These protected spaces can represent a barrier for the transfer of skills and knowledge to every-day practice because trainees remain unfamiliar with the equipment, environments, procedures, and teams in the real-word. On the other hand, in-situ simulation training allows removal of these barriers and represents the “stress-test” for the real work context, thus showing any potential bias or system pitfall.^16–21 In order to guide in the decision of what simulation technique is more suitable for a specific purpose, the specific objectives of the simulation training should be previously settled (Box 1).

Technique 1: Role-play simulation

Role-playing, both low- and high-fidelity simulation, provides the opportunity for training on case management and communication skills during a routine clinical scenario, based on direct observation and feedback. This technique can be applied to every health professional at all stages of training and practice. It has relevant interest across cognitive, communication, and teamwork domains. A role-play simulation scenario runs with a standard diagram composed of 3 phases: the briefing, the scenario, and the debriefing (Figure 2). The first is the briefing, which allows the instructor to specify the framework of the session and specific objectives. Therefore, the rules of the role-playing are clearly presented, such as the confidentiality of exchanges and the absence of judgment attitude. The duration of the scenario is established, with specific starting and ending points (e.g. “the scenario starts when the neurologist receives the call from the Emergency Department for a stroke code and it finishes when the neurologist takes its therapeutic decision”), in order to set the “fiction window”. Generally, the duration of the role-playing should be about 1/3 of the length of debriefing, leading to a reasonable duration for each scenario of about 20 minutes. During the simulation, the trainees are immersed in the situation in a totally safe environment. The instructor coordinates the scenario and observes the trainees focusing on the specific objectives of the simulation program. Using records and forms for the continuous evaluation of trainees helps to address the debriefing phase. Post simulation debriefing is one of the most effective components of simulation-based education: different techniques exist, but there are essential rules that should be followed in the debriefing arena, for the effectiveness of the simulation session. ²² Ensuring psychosocial safety and a supportive climate, by highlighting the need to ‘‘behave or perform without fear of negative consequences to self-image, social standing, or career trajectory”, is essential. Indeed, training facilitators in debriefing techniques are critical to ensure the effectiveness of the simulation program.

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Figure 2.

Schematic representation of the simulation session.

Fourth step: Set up the simulation training – Description of case scenarios

The goal of simulation in the acute stroke setting is to reproduce scenarios for technical learning in a realistic environment with immediate feedback and learning goals assessment. Real-life clinical and/or professional situations, simple or complex, usual or exceptional, serve to support the construction of the clinical scenarios. The scenarios follow a plan to according to the objectives of the programs and to the experience of the instructors. They have one or two educational objectives and could carry on a different level of complexity. It is essential to test the scenarios before using them with learners in order to check out their feasibility and relevance. In addition, they must be fully understood by the trainers to ensure good interaction with the learners.

Each scenario should describe:

the target trainees;

The description of the scenario varies according to the simulation approaches and techniques used. A simulation training program can include one or more simulation sessions. Each simulation session takes place according to a pre-established standardized sequence and includes three distinct phases (Figure 2). The sequence has been described in the paragraph “technique 1: role-play simulation” and it is applied as well for other simulation techniques. The optimal number and time course of simulation sessions maximizing the learning curve should be anticipated, and decided accordingly to the type of simulation technique, the setting, the learning objectives, and the available human resources.