INTRODUCTION
Simulation techniques in medical education are gaining recognition and popularity
due to their capacity for training clinical skills in a practical and realistic way,
without putting patients or participants at risk[1 ]. Simulation scenarios allow students to repeatedly practice their abilities and
improve their efficiency, decision making, leadership and communication skills in
a time-pressure environment[1 ],[2 ],[3 ]. The longstanding experience of simulation-based learning in anesthesiology training
is well known for its positive results[4 ], but there are few data on the current use of simulation techniques in neurology
training[5 ].
Stroke is a leading cause of mortality and morbidity worldwide[6 ]. Proper acute stroke management must be fast, well coordinated and effective[7 ]. The need for quick and effective stroke care is widely recognized in the literature
and is represented by the aphorism "time is brain". On the other hand, a large scale
of fatal errors is mainly caused by deficits in communication skills, interaction
and decision making by the care team[7 ]. Furthermore, acute stroke is an emergency and there is a limitation of practical
teaching to the observation and demonstration of care by the fully trained professional[8 ]. As such, acute stroke training is a promising candidate for realistic simulation
approaches.
In this study we aimed to determine the impact of a stroke realistic simulation course
on the self-perception of confidence by clinicians in the management of acute stroke
care as compared with other neurology courses. We also aimed to describe the structure
of this didactic resource and to evaluate the acceptance of the training amongst participants.
METHODS
Study description
This was a pilot-controlled, before-after study.
Study population
We enrolled 55 healthcare professionals and medical students attending the XI Brazilian
Congress of Cerebrovascular Diseases on October 8th , 2017.
The inclusion criterion was participation in one of the courses described below. Participants
were excluded if they did not consent to participate.
Seventeen subjects were submitted to the intervention and participated in the stroke
realistic simulation course.
As controls, 18 participants of the Emergency Neurological Life Support (ENLS) course
and 20 participants of the Neurosonology course were chosen from a convenience sample.
Both courses were conducted during the congress. We chose to include controls from
both of these because that would enable us to compare the intervention with an “active
control arm” (i.e., the ENLS, which focuses on neurologic emergencies, including stroke)
and a “placebo arm” (i.e., the Neurosonology course, which does not address stroke
management).
Outcomes and definitions
Our primary outcome was a variation in the self-perception of confidence when treating
acute stroke patients before and after the courses. This was measured with the use
of pre- and post-test questionnaires, comprising 11 questions, translated and adapted
from previously validated versions[7 ].
The questionnaires were provided 30 minutes before and after the courses, with answers
adding up to a score between 10 and 50. The first 10 questions consisted of a Likert
scale varying between 1 (complete disagreement) to 5 (complete agreement), and the
last question had two options as possible answers. Information was also collected
on age, gender, occupation and whether the subject had already participated in other
realistic simulation courses on acute stroke care. The questionnaires were self-administered
and participants had 30 minutes to answer it both before and after the courses.
Description of the intervention
The stroke realistic simulation course consisted of two main parts. Firstly, participants
were introduced to the institutional acute stroke management protocol of São Rafael
Hospital (HSR) and watched the “Acute stroke aid” movie, which includes every step
of the protocol assistance and was recorded in the same institution. The movie portrays
the ideal care given to acute stroke patients, emphasizing critical points such as
the contraindications to thrombolysis and the importance of an integrated and well-trained
multidisciplinary team.
Then, professionals were split in three groups of six persons per instructor. Each
team was composed of six participants, role-playing one nurse, one nursing technician,
two emergency physicians, one observer and one reporter. Before the simulations, all
participants were introduced to their functions according to their roles. The observer
used a white board to draw an impartial timeline of all events occurring during the
simulation sets.
There were three stroke realistic simulation sets per group. The first covered a patient
with acute stroke and contraindications for thrombolytic therapy, the second had a
patient with acute stroke but out of the time window for thrombolysis and the last
involved a patient with acute stroke and hypertension.
Simulations took place in an environment fully equipped and faithfully adapted to
portray an acute stroke picture in the best way possible. It included a vital signs
monitor attached to an iPad (Apple, United States of America) broadcasting the content
of a Defibrillator Automatic Rhythm Training Simulator (DART) Sim App© (DART Sim Inc.),
a vital signs simulator controlled by the simulation instructor. Participants were
provided with a standardized kit containing: the “HSR Step-by-Step Guide for Assisting
Suspected Acute Stroke Patients”, elaborated according to the most recent stroke guidelines[9 ],[10 ],[11 ],[12 ]; the National Institute of Neurological Disorders and Stroke Scale (NIHSS), translated
and adapted into Portuguese[13 ]; a list of eligibility criteria for thrombolysis therapy[9 ],[10 ],[11 ],[12 ]; and a list of the amount of alteplase/body weight to be infused in each patient.
A thrombolysis kit was also included, with two alteplase ampoules, infusion pump equipment,
a puncture kit, a tourniquet, a calculator, gloves, plasters, a bolus syringe, a peripheral
intravenous catheter, a spatula and 0.9% 10 mL saline solution ampoules.
There was also a bioimaging station providing all necessary information to participants,
such as computed tomography (CT) and magnetic resonance imaging (MRI) results and
their follow-up images.
After each simulation, a feedback and debriefing session of highlights, improvements
needed and key points was conducted.
No specific interventions were made in the control groups, other than having them
respond to the questionnaire. Courses were taught as usual[14 ],[15 ].
Statistical analysis
Continuous variables were reported as mean and standard deviation or median (interquartile
range - IQR), and the categorical variables were reported as counts and frequencies
(percentage).
Categorical variables were compared with the chi-square test. Continuous variables
were evaluated using the Friedman's two-way analysis of variance by ranks to evaluate
which group had the most significative variation when comparing pre- and post-test
results. After this the Wilcoxon’s signed rank test was conducted on the data to follow
up this finding and evaluate the features of variation in each group. Groups were
compared independently.
Variation between pretest and post-test scores was also assessed as a binary variable,
with an increase in post-test scores being labeled as “positive variation”, while
neutral or negative variations in post-test scores being labeled as “non-positive
variation”. Multivariable logistic regression analysis was performed for adjustment
for potential confounders. Variables were selected for the final model based on the
theoretical association with the outcome of interest. Goodness-of-fit was assessed
with the Hosmer-Lemeshow test.
Statistical analyses were conducted with the IBM Statistical Package for the Social
Sciences (SPSS®, Chicago, IL, USA) 25.0, R (R Programming Language) and Microsoft
Excel® 2016 software. Values of p<0.05 were considered statistically significant.
Ethical concerns
This study was submitted and approved by the Ethics Committee in Human Research of
São Rafael Hospital, and all participating subjects signed a written consent form.
RESULTS
Characteristics of the participants
Of the 55 participants, 46 (83.6%) completed the pre- and post-test questionnaires,
with the following distribution: 14 subjects (30.4%) from the stroke realistic simulation
course (intervention group), 18 (39.1%) from the Neurosonology course and 14 (30.4%)
from the ENLS course (control groups), as shown in [Figure 1 ].
Figure 1 Flowchart of participants included in the study.
The participants’ characteristics are shown in [Table 1 ]. Overall, most subjects (30 or 65.2%) were neurologists or neurology fellows and
the mean age was 30.9±6 years.
Table 1
Characteristics of participants (n=46).
Characteristics
Stroke Realistic Simulation Course (n=14)
ENLS (n=14)
Neurosonology course (n=18)
p-value
Male gender, n (%)
7 (50)
7 (50)
7 (46.7)
0.486
Age (years), mean±SD
30±7.4
34±7.1
28±3.4
Previous participation in stroke simulation, n (%)
13 (92.9)
7 (50)
10 (55.6)
0.032
Occupation, n (%)
0.137
Nurse
1 (7.1)
0 (0)
0 (0)
Medical student
4 (28.6)
0 (0)
3 (16.7)
Physician
9 (64.3)
14 (100)
15 (83.3)
Physician specialist in neurology, n (%)
5 (35.7)
11 (78.6)
14 (77.8)
0.021
ENLS: Emergency Neurologic Life Support.
Impact of the intervention on the self-perception of confidence in the management
of acute stroke
There was an increase in the subjects’ self-perception of confidence in the management
of acute stroke of participants in the stroke realistic simulation course (intervention),
but not in the control groups, i.e., the Neurosonology and ENLS groups ([Figure 2 ]). Post-test scores were higher than pretest scores in the stroke realistic simulation
course group [pretest median (IQR): 41.5 (36.7-46.5) and post-test median (IQR): 47
(44.7-48); p=0.033]. This was not true for the Neurosonology [pretest median (IQR):
46 (44-47) and post-test median (IQR): 46 (44-47); p=0.739] and ENLS [pretest median
(IQR): 46.5 (39-48.2) post-test median (IQR): 47 (40.2-49); p=0.317] groups.
Figure 2 Variation between pretest and post-test results in the Stroke Realistic Simulation
Course (Graph a), Emergency Neurologic Life Support (Graph b) and Neurosonology (Graph
c) groups.*p=0.033 for comparison between pretest and post-test.
Overall, median (IQR) variation in the pre- and post-test scores was 0 (-0.25 to +4.25),
ranging from -16 to +15. Twenty-one (45.7%) participants had a positive variation
in the scores, distributed as 11 (78.6%) in the stroke realistic simulation course,
six (42.9%) in the ENLS group and four (22.2%) in the Neurosonology group, p=0.006.
After adjustment for neurology specialization and previous participation in stroke
simulation courses, allocation to the stroke realistic simulation group was associated
with a positive variation between pretest and post-test scores [OR (95%CI)=10.6 (1.68-67.35);
p=0.012), as shown in [Table 2 ].
Table 2
Multivariable analysis for association with positive variation between pretest and
post-test scores.
B
p-value
OR*
95%CI*
Lower
Upper
Study group (Neurosonology as reference)
0.041
ENLS course*
0.987
0.22
2.683
0.554
12.988
Stroke realistic simulation course
2.367
0.012
10.662
1.688
67.354
Physician specialized in neurology
-1.054
0.171
0.349
0.077
1.574
Previous participation in stroke simulation
0.367
0.642
1.444
0.307
6.781
*OR: Odds Ratio; 95%CI: 95% confidence interval; ENLS: Emergency Neurologic Life Support; Hosmer-Lemeshow
test=0.585.
Acceptance of the stroke realistic simulation course among participants
All 14 participants (100%) in the stroke realistic simulation course acknowledged
its contribution to amplify their knowledge and skills on acute stroke care, agreed
that the simulated situations were realistic and recognized their applicability to
the medical routine.
DISCUSSION
Our research has shown that a high-fidelity simulation course on stroke care was associated
with an improvement in the level of confidence involved in the management of this
situation.
The course structure ensured that subjects had close contact with the most current
stroke guidelines/recommendations. The main concepts regarding the initial treatment
and management of acute stroke were transmitted in a repetitive and accessible way.
The importance of providing adequate conditions for training in neurological emergencies
is widely acknowledged among the academic community[2 ],[16 ],[17 ]. High-fidelity simulation training not only improves knowledge, but also allows
for a refinement of the care protocols[16 ],[17 ],[18 ]. Besides, a structured simulation setting enables interactive and standardized scenarios[5 ], which, along with a debriefing session conducted by experienced physicians after
each scenario, promotes an active way of learning, resulting in the consolidation
of the content[4 ],[19 ].
Our course may be an effective tool for the training and institution of an acute stroke
care algorithm in the emergency department. The protocol is presented theoretically
at the beginning of it and repeatedly practiced through each scenario.
Training with realistic scenarios can also lead to a decrease in the error rate of
these subjects when treating acute stroke[17 ],[20 ]. Our interventional, controlled design made it possible to correlate the intervention
with an increase in healthcare professionals’ self-perception of confidence.
However, the study had some limitations. Its small sample size may hamper the generalizability
of our findings. However, we analyzed participants in a national congress with different
backgrounds, so our results may apply to similar settings. Moreover, the short duration
of our observation of the subjects makes it difficult to infer the long-term effects
of the intervention; therefore, the course’s impact on participants may be over- or
underestimated. Nevertheless, because this was a pilot study, its long-term effects
were not our primary endpoint. Furthermore, even though we had a control group, which
strengthens our findings, the non-randomized design of the study made it prone to
confounding factors that may not have been accounted for. Nevertheless, our results
were sustained after multivariable analysis adjusting for potential confounders. In
addition, we analyzed the self-perception of confidence, but not the improvement of
actual skills in acute stroke management.
This realistic simulation training was associated with an increase in confidence in
the management of acute stroke patients. The course was highly accepted by the subjects
and was relatively easy to follow.
