Role of Emergency Medicine Residents in Collaborative Care of Stroke Patients Within the Emergency Department
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Acute ischemic stroke (AIS) management is time-sensitive Co-management between Emergency Medicine and Neurology In-person neurology-based stroke team EM resident and attending Goal to develop a workflow where EM residents became active decision-makers in care of AIS patients
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Role of Emergency Medicine Residents in Collaborative Care of Stroke Patients Within the Emergency Department
- 1. Role of Emergency Medicine Residents in Collaborative Care of Stroke Patients Within the Emergency Department Lauren Mamer, Mallory Davis, Erika Kokkinos, Jessica Doan, Sarah Vermillion, Sarah Jamali, Sarah Balgord, Cemal Sozener University of Michigan Department of Emergency Medicine April 13, 2022
- 2. Background • Acute ischemic stroke (AIS) management is time-sensitive • Co-management between Emergency Medicine and Neurology • In-person neurology-based stroke team • EM resident and attending • Goal to develop a workflow where EM residents became active decision-makers in care of AIS patients
- 3. Methods Review of existing response to acute stroke activations Pre-survey assessing EM resident existing knowledge, attitudes and beliefs on AIS care New protocol developed with distinct roles and responsibilities for neurology and EM residents Badge card visual aid and brief educational interventions
- 5. Pre-Survey • 38 resident responses (response rate of 59.3%)
- 8. Conclusions/Next Steps • Gaps identified in required confidence/knowledge for AIS management • Targeted educational interventions given, acute stroke activation protocols redesigned to promote co-management of AIS management and enhance EM resident education experience • Next Steps • Repeat survey at 6-month mark • Additional educational interventions targeted to level of training • Neurology resident perspective
- 9. Acknowledgements • Faculty Mentor • Cemal Sozener • Acute Stroke Workgroup • Lauren Mamer • Mallory Davis • Erika Kokkinos • Jessica Doan • Sarah Vermillion • Sarah Jamali • Sarah Balgord
Editor's Notes
- Presenting on behalf of Acute Stroke Resident Workgroup
- Management of acute ischemic stroke (AIS) in the ED is time-sensitive. Involves complex diagnostic and therapeutic decision-making. At Michigan Medicine AES, patients presenting with concern for stroke are co-managed by EM and Neurology. Involves in-person evaluation by a neurology-based stroke team as well as an emergency medicine (EM) resident and EM attending Neurology primarily driving decision making. Distinct training environment as EM physicians practice in facilities without neurology coverage. Our goal was to develop a workflow where EM residents became active decision-makers in the care of these patients while taking full advantage of our stroke volume and Comprehensive Stroke Center to develop clinical judgment in acute stroke
- 1. The process for responding to acute stroke activations in our ED was reviewed by a group of EM residents. 2. Pre-survey was conducted regarding EM resident existing knowledge, attitudes, and beliefs about AIS care. 3. Roles and responsibilities for neurology and EM residents were established as part of a new AIS patient management system and discussed with EM and neurology residency leadership. Protocol shared with EM and neurology residents. Specifically for EM residents, goal to take over several concrete tasks and maintain active co-management of patients. 4. 3. A badge-card visual aid along with several brief educational interventions were deployed. New primary responsibilities for EM residents: 1. Initial screen for stability for scanner 2. Large vessel occlusion (LVO) screen for joint decision making about imaging (CT Head, CTA, CTP) 3. Early BP control (preferred agents labetalol, nicardipine) 4. ED resident remains with the stroke patient until the tPA decision is made and orders tPA. List of Resident Survey Questions: At what time interval from the patient’s onset of symptoms do you consider activating the stroke team or co nsulting with a stroke center? If you had to pick a minimum National Institutes of Health Stroke Scale (NIHSS) to give tPA what would it be? Assuming all other conditions are met. Do you perform a full assessment (initial assessment and NIHSS) on stroke patients? If you perform an NIHSS on your stroke patients, how confident to you feel in the accuracy of the score you assign? Are there any reasons why you would not activate the stroke team even with the onset of focal neurologic deficits within the intervention window? How comfortable would you feel giving tPA to a patient without a consultation from a neurologist or stroke specialist? How many times have you given tPA for an acute stroke? Existing science on tPA use in stroke is convincing. Are you reluctant to give tPA due to concerns of complications? How many times have your patients had life threatening complications related to administration of tPA? What year are you in training/practice?
- Badge reel resource distributed to all residents Encourage LVO screen, participation in imaging selection Encourage early blood pressure management, reminders for BP parameters
- 38 resident responses (response rate of 59.3%)
- 25/38 reported that they “always” or “often” personally performed NIHSS assessments. Only 3/38 respondents reported being “completely” confident with their NIHSS accuracy. 14/38 respondents reported that they would feel “extremely comfortable” or “comfortable” giving tPA without a consultation from neurologist or stroke specialist 26/38 respondents reported feeling somewhere between “neutral” and “extremely uncomfortable” in this setting. Majority of EM residents do not feel confident in NIHSS, most felt neutral to uncomfortable with decision to administer tPA
- Number of times tPA administered by residents increased by year of training Apart from the large number of PGY1 residents who had administered tPA 0 times, the number of complications observed was between 0 and 2 for all classes, and widely variable.
- Pre-survey results suggest the majority of our EM residents did not have confidence in their ability to score an accurate NIHSS, and most felt neutral to uncomfortable with the decision to administer tPA without neurology guidance. This is a gap in decision making needed for many common types of emergency medicine practice environments. Targeted educational interventions, and redesigned roles and responsibilities in the care of AIS patients were utilized to promote co-management with the existing neurology-based institutional stroke team with an overall goal to enhance EM resident knowledge and confidence in the diagnosis and management of AIS. Next Steps Mid-point auditing, repeat survey at 6 months Educational interventions targeted to level of training (ex intern orientation, PGY specific in comparison to delivering during whole residency didactics) Neurology resident perspective Limitations Single residency program study, at a program with three practice sites. Each site has a different stroke protocol and residence have a slightly different role. This project was focused specifically on the large academic tertiary care site. Experiences from other clinical sites may have influenced survey results. Fell short of goal 70% response rate did not reach our goal survey response rate (achieved 58% response rate).