Muhammad Rizwan Husain, MD, and Muhammad Taimoor Khan, MD

Kurz MW, Ospel JM, Kurz KD, Goyal M. Improving Stroke Care in Times of the COVID-19 Pandemic Through Simulation: Practice Your Protocols! Stroke. 2020.

The COVID-19 pandemic portends a risk to healthcare staff dealing with acute stroke emergencies, and many institutions have developed new protocols to help reduce exposure. On a typical day, acute stroke management progresses through a well-defined algorithm, developed by institutions to provide rapid and timely intravenous thrombolysis and mechanical thrombectomy (MT), with healthcare providers having their own well-defined roles. The COVID-19 pandemic has now required enforcement of strict infection control practices such as use of PPE, methods to minimize exposure to patients and staff during imaging and transport and while providing thrombolytic treatment or MT. However, despite these new well-defined protocols and standards of infection control safety in place, there is still a risk of exposure to healthcare workers, who might not be used to adapting quickly to a new system of management, again risking unwarranted exposure, which further leads to increased anxiety among the front line staff.

In this article, the authors describe how practice simulations catered to help staff adapt to the new standards have helped streamline the process of acute stroke emergencies, reduce staff anxiety and, at the same time, identify potential unknown sources of exposure, as well.

As part of standard training to help triage and treat acute stroke cases, a health care facility in Stavanger, Norway, utilized simulation-based learning for its health care staff. In the current era of the COVID-19 pandemic, the facility revised its stroke simulation to include the new changes. All staff that would respond to an acute stroke were trained on the use of personal protective equipment (PPE) and new infection control policies. The typical simulation, which ran daily for one week, included a patient who would present to the hospital with signs of an acute large vessel occlusive ischemic stroke, and the staff would now manage the patient with the new standards in place.

What the authors noted during the simulation was that there were still potential areas of healthcare staff exposure, such as lack of screening respiratory status in the patient, which is not the norm in acute stroke care; early communication between staff for COVID-19 patients; time delays for intubation; and risk of exposure during imaging or while administrating intravenous thrombolytic. These pitfalls, once identified, helped revise the standard protocols that were then implemented in the simulations. All healthcare workers had to undergo at least one simulation training. Due to staff concerns of being on the frontline managing potential COVID-19 patients with a stroke, only 15% of staff felt comfortable doing so prior to the simulation, whereas after one simulation, 80% felt comfortable with adapting to the new set protocols.

The authors concluded that: 1) these simulations help identify potential pitfalls in the workflow, which can then be readdressed to reduce virus exposures; 2) the healthcare staff were much better trained and thus less stressed and well adapted to manage COVID-19 stroke patients; and 3) they strongly encourage other institutions to set similar simulations in place.

While simulations have indeed proved to be useful to train healthcare staff, e.g., Advanced Cardiac Life support (ACLS) and Basic Life Support (BLS), it is unlikely that there can be one standard simulation protocol applicable to all facilities, as individual hospitals will have to address and cater to their own workflow that might not be generalizable. Furthermore, this facility had been carrying out acute stroke care simulations for the last three years and had to modify it to the current pandemic. Many institutions do not have acute stroke simulations as standard of practice and during the ongoing peak of the pandemic, with limited resources, might find it challenging to adapt quickly, should they wish to establish similar simulations at their institutions.