1. Park, Chan W. MD, FAAEM
  2. Holtschneider, Mary Edel MPA, BSN, RN-BC, NREMT-P, CPLP

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"Adoption of a conceptual model of interprofessional education (IPE) to guide future study designs would focus related research and evaluations on patient, population, or system outcomes that go beyond learning and testing of team function. Visualizing the entire IPE process illuminates the different environments where IPE exists[horizontal ellipsis]" (Institute of Medicine, 2015, p. 4).


In our previous column, we introduced the concept of viewing interprofessional (IP) simulation training from the patient's point of view. We discussed how this framework helps promote patient centeredness for both educators and learners. In this column, we will explore another creative way to integrate interprofessional education (IPE) and IP goal setting in our simulation arena, using the framework for Stroke Emergency Response Team training.


Many of us work with patients with strokes and are familiar with the American Heart Association Get With the Guidelines for Stroke. Despite our familiarity with the stroke lexicon, "National Institutes of Health (NIH) Stroke Scale," "Door to Needle Time," and "Time is Brain" (Jauch et al., 2013), some providers and facilities fail to realize the importance of activating the full stroke emergency response to see how personnel, process, and systems issues impact the ability to provide optimal patient care. Given no two hospital systems are exactly alike, it is advisable for the nursing professional development (NPD) practitioner to consider systems integration and process flow testing of any "best practice" measures at the local facility before adopting any protocols.


One of the main goals of stroke treatment is to optimize all aspects of the detection, diagnosis, and management process. For example, if the patient with stroke symptoms is a thrombolytic candidate, the time measured from presentation to thrombolytic administration (Door to Needle Time) should be less than 60 minutes. This is not to be confused with the 4.5 hours, which is the recent expanded cutoff time from the time of symptom onset to when a thrombolytic can be administered under the American Heart Association guidelines (Jauch et al., 2013). Yet, how many of us who work in a designated "stroke center" regularly rehearse our stroke activation across the continuum of care to include the entire IP team of nurses, physicians, patient transporters, radiologists, computed tomography technicians, pharmacists, and quality management personnel?


Some facilities make the assumption that, once a standard operating procedure has been reviewed and signed off by the subject matter experts, everything will occur as written. Yet, how many of us can attest to the fact that, in the real world, this is not the case? If nothing else, it is a vulnerability and could be a possible disaster waiting to happen. Studies have shown that variance in the quality of care exists depending on factors such as day of the week, weekends, holidays, and even the time of the shift (McKinney, Deng, Kasner, Kostis, & Myocardial Infarction Data Acquisition System [MIDAS 15] Study Group, 2011).


Knowing this, how confident are we that all of our staff can immediately recognize the signs and symptoms of a stroke, swiftly activate the emergency response system, and subsequently implement definitive care for the patient with stroke based on national metrics? Is it fair to say that there are many staff who work in our medical facility who have not yet experienced a systems-wide activation of a stroke code and do not know the challenges involved? For those who can say "yes" to the preceding question, what obstacles have prevented your facility from rehearsing the whole stroke response and management process from beginning to end, that is, from the time the patient enters the facility to the time of thrombolytic administration?


In reality, many facilities practice this critically important but labor-intensive stroke response process on a localized and needs-based manner, that is, in silos. For example, the emergency department triage nurses practice the stroke detection, physicians practice documenting their National Institutes of Health (NIH) Stroke Scale score and write their orders, operators rehearse activating the stroke code, and radiologists read the study and communicate their findings. In other instances, a simulation exercise might be held on a medical/surgical floor that includes recognizing a patient with stroke signs and symptoms and appropriately activating the response team. Yet, because of time and personnel limitations, the training may prematurely conclude without actually testing to see how the entire system functions in concert.


Using a concert analogy, what type of performance would you expect from a philharmonic orchestra whose members have never rehearsed together? Moreover, is one rehearsal adequate to assure optimal performance? So, how is it that our facilities have so much confidence in the facility's stroke response readiness when it remains unrehearsed and unpracticed together?


At the facility level, had the whole process been rehearsed and practiced together, one could uncover a series of seemingly insignificant "mishaps" that, when taken as a whole, materially impact the quality of patient care. Simulation training is well suited to identify these types of "latent threats" that occur only during full immersive exercises. In other instances, for the sake of time and expediency, some facilities do not engage in any simulated practice at all. The stroke emergency response may remain an agenda item discussed at a staff meeting, and an email is sent out with the standard operating procedure and policy attached.


As you can see, creative integration of IPE can uncover many "blind spots" in healthcare provider knowledge, skills, and attitudes, and potentially dangerous assumptions we make in health care. Consequently, NPD practitioners are in position to help key stakeholders to appreciate the various nuances of systems issues that pose challenges to our healthcare providers and negatively impact patient care.


What are the practical considerations for the NPD practitioner with respect to stroke emergency response training? The true opportunity for the NPD practitioner here is to create a simulation where all of the healthcare providers can experience the immersive process of a stroke activation. To do so, the process should optimally be tested from start to finish and with all steps in between. This is how we help identify relevant educational issues and blind spots as well as identify latent system threats. Throughout the simulation, the NPD practitioner should carefully document important team dynamics, such as communication, leadership, and followership. Furthermore, to probe latent system threats, the NPD practitioner should carefully examine adherence to the code team paging protocol, pager functionality throughout the hospital, and other aspects such as the patient transport challenges, including elevator access, all of which impact the ability to provide optimal patient care.


Before simulating any hospital-wide activation system, three practical issues should be considered. First, the NPD practitioner must collaborate with the different IP teams and departmental leaders who are participants of the stroke emergency process. Second, proper support from the hospital leadership should be obtained before the planning. Third, the hospital leadership and departmental leaders should be notified of the exercise a day before and on the day of the simulation activation. The reason being, the activation process will require many healthcare providers and resources to remain offline for the duration of the process. This will ensure everyone is aware and has accounted for the inevitable impact on patient flow and patient care.


Once leadership support and collaboration have been achieved, consider using a standardized patient (SP) rather than a manikin for this type of hospital-wide activation. Unlike a manikin, an SP can portray emotional distress and show focal deficits, which are integral to creating a realistic environment. The use of the SP also helps evoke both an emotional and visceral response from the clinical staff, which adds to the depth of their learning experience (Pascucci, Weinstock, O'Connor, Fancy, & Meyer, 2014). As such, the SP needs to be well versed on the basics of stroke presentation, remain in character throughout the activation process, and be informed on how to respond to the providers as he or she is transported throughout the hospital. We recommend using an SP who is unfamiliar to the staff. This also helps promote urgency and heightens the emotional response to the simulation. From then on, you will likely experience dynamic teamwork as well as some level of stress as the healthcare providers quickly manage the patient's emergency while navigating many of the unanticipated systems-related obstacles. This realism provides the full immersive experience for everyone involved and is one of the many benefits of performing an in situ simulation. If you have the resources to add a second SP who could act as a family member, that would add even more realism to the scenario.


Whenever you are working with an SP, it is important to set ground rules for what the SP can and cannot be subjected to. This is to avoid any potential physical and psychological harm to our SP, that is, no undressing, genital examination, and so forth. The NPD practitioner must be present throughout the simulation to allow the healthcare providers to perform everything except invasive procedures, such as starting an intravenous therapy, exposing the SP to radiation in the computed tomography scanner, or administrating medications. Other than invasive procedures, everything else must be allowed to proceed spontaneously and naturally according to the established protocol, including charting on a simulated electronic medical record.


During the simulation, the NPD practitioner accurately documents key metrics, such as those shown in Table 1. From the time of patient entry all the way to thrombolytic administration, the NPD practitioner should observe the whole process and identify systems and educational issues. In addition to these metrics, your facility might have other areas of interest to assess, such as time to triage or time to emergency response team arrival. Once you have done several simulations, your institutional practice pattern will likely emerge that identifies both strong and weak areas. This will provide an excellent opportunity to work with the IP team members in addressing specific systems issues as well as staff-related limitations, barriers, and educational concerns.

Table 1 - Click to enlarge in new windowTABLE 1 Emergency Department Care Goals

As with any simulation, the realism and immersive experience is much greater if all parties act and behave as if the training were real. This is often referred to as a contract to suspend disbelief and is one of the basic premises of implementing a successful simulation. Educating the staff upfront on the goals and objectives of the simulation will help gain their cooperation and partnership. After the simulation, facilitating an effective debriefing that includes seeking their input on how to address the identified systems issues will help create a collaborative environment where ideas and concerns can be discussed freely and in a safe manner.


In this column, we have explored expanding the goals of IP simulations beyond IPE to include process improvement efforts and systems testing in the practice environment. NPD practitioners are in a unique position to facilitate these simulations and to ensure that all of the healthcare professionals involved in the care of the patient are actively involved in identifying issues and helping to solve them.


In our final column, we will conduct a simulated question and answer session with the authors of the current Interprofessional Simulation series. We will take several common questions sent in from our readers and share our individual and collective thoughts and answers.




Institute of Medicine. ( 2015). Measuring the impact of interprofessional education on collaborative practice and patient outcomes (prepublication). Retrieved from[Context Link]


Jauch E. C., Saver J. L., Adams H. P. Jr., Bruno A., Connors J. J., Demaerschalk B. M. Council on Clinical Cardiology. ( 2013). Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 44, 870-947. [Context Link]


McKinney J. S., Deng Y., Kasner S. E., Kostis J. B. Myocardial Infarction Data Acquisition System (MIDAS 15) Study Group ( 2011). Comprehensive stroke centers overcome the weekend versus weekday gap in stroke treatment and mortality. Stroke, 42, 2403-2409. [Context Link]


Pascucci R. C., Weinstock P. H., O'Connor B. E., Fancy K. M., Meyer E. C. ( 2014). Integrating actors into a simulation program: A primer. Simulation in Healthcare, 9, 120-126. [Context Link]