Name: setting up a stroke team algorithm and conducting simulation-based training in the emergency department - a practical guide
Uploaded: 2017-01-15T14:00:00.000+00:00
Duration: 9 min 52 s
Description: Watch this Scientific Journal Video about Setting Up a Stroke Team Algorithm and Conducting Simulation-based Training in the Emergency Department - A Practical Guide at JoVE.com

The Stroke Team training was supported by a research grant of Boehringer Ingelheim to WP.

1. ED的预先通知<ol><li>急诊护士听到警报后，去电脑屏幕上立即生效。 </li><li>检查通过在线平台（ 如电子健康IVENA）7输入患者上述信息。发现系统宣布，一名66岁的男性患者，中风的时间窗口（中风&lt;6小时），与预计到达的时间内初步诊断。 </li><li>通过电话预先通知SU的居民。 </li><li>由于SU居民听到移动电话铃声，有苏居民采取电话。有SU居民进入ED的预计到达时间。 </li></ol> 2.病人到达的ED <ol><li>通过把医护人员病人的ED。有医务人员进入教育署在担架上，并报告行程护士和SU居民的病人。 </li><li> SU居民:执行第一次初步检查，包括快速测试8（F:面部下垂，A:手臂无力，S:言语困难，T:最后一次露面以及症状发作或时间的确切时间）。询问病人或有关血液稀释剂的摄入量的医护人员。了解有关的特点和症状演变，以排除出现超越了治疗时间窗或有明显的禁忌溶栓非常明显的中风模仿或病人。如果患者或医护人员不能回答这些问题，如果有接触的亲属。 注:初步检查发现，病人是溶栓治疗的候选人。 </li><li> ED护士:触发通过快速拨号集体呼吁，通过其体制的移动电话同时通知卒中小组的所有成员卒中小组警报。输入患者的保险数据到医院信息系统，并执行注册过程。检查病人是否在医院前已经处理并打印出最新的排放信和La从电子医院信息boratory值，并将其交给苏居民。 </li><li>让所有卒中小组成员回答他们的手机听到自动语音留言说:"行程时间窗口内"。是否所有卒中小组成员立即前往其工作地点由算法定义如下:ED居民，SU居民和资深神经科相约在急诊科，实验室技术人员进入实验室，放射居民，技术员相约在CT扫描仪。 </li></ol> 3.快速采血和临床考试<ol><li> ED驻地:获取静脉访问并执行血液采样，无论是通过一个适配器向静脉通路或与蝴蝶套管，对凝血参数INR（国际标准化比率凝血酶原时间），活化凝血酶原激酶时间（aPTT）和凝血酶时间（TT ）（3毫升，柠檬酸盐血浆），血液学（1.6毫升，EDTA血浆）和临床化学（7.5毫升，锂heparinate等离子）9。 </li><li> SU驻地:告知病人，他被检查为急性中风的怀疑。以一个简短的历史包括症状，发病时间，症状发展，残疾人之前，目前的药物摄入量（尤其是血液稀释剂），过敏和预先存在的医疗条件的问题。询问患者是否已经与造影剂前影像学检查。当病人不能回答这些问题，问什么时候亲属提供。 <ol><li>美国国立卫生研究院卒中量表（NIHSS）10的基础上进行集中神经学检查。在NIHSS的免费在线培训几种语言11可供选择。 </li></ol></li><li>资深神经科:查看病人的情况，并在适当的成像方式决定根据本病的症状和时间窗口的患者。明确优先在考虑计算机断层扫描（CT）的患者明确卒中症状及卒中发病因为速度和容易获得的治疗时间窗。优先考虑为超出治疗时间窗或与中风症状或患者未知发病与非典型的临床表现的患者的磁共振成像（MRI）。 </li><li>标记血液样本为"重要"粉红色编码帽带他们到实验室。储备中风病研究小组样本下一离心机。即在自动止血分析仪，一个自动血液系统，和自动分析仪，用于临床化学进行完整的分析，需要15-20分钟。 </li><li>使患者的CT扫描仪。患者仍躺在担架救护车并伴有医护人员，从ED，苏，并且从SU资深神经学家居民。 </li><li>在CT扫描仪，满足居民专门从事神经放射学和放射科技术员。 </li></ol> 4.头颅CT扫描和急性治疗<ol><li&gt;转移患者的CT和连接造影剂的线（ 例如，优维-300）的CT血管造影通过路厄锁合连接静脉接入。 </li><li> ED护士:到达CT扫描仪，并用溶栓试剂盒（含有适合于静脉内（IV）的应用10毫克的rt-PA +水性广告injectabilia，血压药物[ 例如 ，urapidile]，四抗呕吐沿担架带来药物[ 例如，格拉司琼]，四镇静剂[ 例如，劳拉西泮]，将10毫升注射器和0.9％NaCl溶液冲洗静脉接入），监控设备和便携式氧气。 </li><li>放射技师:执行头颅CT（以排除颅内出血）和CT血管造影（以屏幕LVO）。中风-CT包括为5毫米和CT血管造影层厚描绘大脑提供宫颈癌和颅内动脉CT平扫。 </li><li>神经放射:直接复查头颅CT。 CT平扫必须排除颅内hemorrhage和颅内肿瘤。对于机械性血栓，CT血管造影必须证明近端血管闭塞，并在CT平扫梗死核心不应该比艾伯塔省脑卒中程序早期CT得分（方面的问题）5 月12日大。 </li><li>资深神经科:语音治疗与IV RT-PA病人的决定。 <ol><li>如果患者能够可靠地排除血液稀释剂和以前问题的摄入量与止血，不要等待凝血参数和收购CT血管造影之前管理该RT-PA丸。 </li><li>在失语病人或活跃口服抗凝剂治疗的情况下，等待化验值（15-20分钟），并先进行CT血管造影。 </li></ol></li><li> ED护士:准备RT-PA推注的适当的剂量和呼叫同事在ED通过泵在1小时准备，其余90％的剂量输注。酶原激活剂的剂量为0.9毫克/公斤体重给予。有适当剂量的所有博表在5公斤准备防止计算误差离散的步骤40千克和"100 kg的DY权重。患者体重100公斤，更应该得到的90毫克总剂量。 </li><li> SU驻地:管理的rt-PA的丸药（总剂量的10％），直接在CT上表静脉经1分钟。 </li><li>卒中小组:病人转移到担架ED。 注:医务人员离开现场。 </li><li>化验员:调用SU居民和披露凝血参数，如国际标准化比值（INR），血小板，凝血酶时间（TT）和活化凝血酶原时间（APTT）。 </li><li>神经放射和SU高级神经学家:检查CT血管造影LVO。如果LVO存在，直接通知的神经放射，并计划干预麻醉部门。 </li><li>卒中小组:转移病人回ED或直接向血管造影套件LVO的情况。 </li><li>管理剩余的90％的在RT-PA在ED或血管造影术。显示器上的NIHSS血压，心脏率，血氧饱和度和神经功能，每15分钟，治疗与药物治疗IV（ 例如，乌拉地尔）严重升高的血压低于九十零分之一百八十五毫米汞柱的目标值。 </li><li> SU驻地:去一个电脑，检查在医院信息系统中剩余的实验室参数。 </li></ol> 5.基于仿真的行程队训练<ol><li>中风队教练（2）:邀请了参与护理急性卒中患者对卒中小组培训，这是提供每月一次的所有新工作人员。 </li><li>训练开始前，准备遥控假人。它连接到一个真正的显示器，用人造血液（无糖红茶为例）填充它。放置人体模型上与磁头偏离到左和右手臂和腿的plegic位置的担架。 </li></ol> 6.理论课<ol><li>坐在一群人围着一张桌子4-10名工作人员和医学生。邀请大家做自我介绍，描述他们的专业背景，并分享他们在卒中治疗的经验以及对培训的期望。 </li><li>中风队教练1:给受说明幻灯片支持的口头介绍，它涵盖了最常见的中风症状，被FAST 8分他们的检测，脑卒中病理生理学的基本原理和目前的治疗方式（IV溶栓治疗和血管内血栓），以及作为医院的卒中小组算法。 </li><li>教如何做一个简洁的NIHSS考试，让对方组的做法。 注:在这大约需要60分钟，并在其中的参与者应该明白"时间因素"和高效的团队合作的意义的重要的理论部分结束，进入ED。 </li></ol><ol><li>中风病研究小组的教练2:分配参与者的角色在theStroke团队算法，并建议他们把假人，好像它是一个真正的病人。 </li><li>告诉中风患者等待参与者。留给他们足够的时间来澄清一些问题，并作为一个团队扎堆。 </li><li>把假人放入ED，作为一个辅助。 </li><li>报告认为，病人是一名72岁的女性在午餐谁倒塌，表现出言语的损耗和右侧偏瘫。状态症状发作的确切时间是未知的，但有病人的女儿的电话号码。显示阿斯匹林的容器，并在患者家中收集的β阻断剂。 </li><li>卒中小组:对假人进行卒中小组算法而中风队教练的注意事项1的程序时间和性能的正面和负面的因素。 </li><li>卒中单元驻地:就拿从护理人员的历史，并通过电话的女儿和检查NIHSS。询问症状出现，更多的血液稀释剂，预先存在的医疗条件，尤其是最近的行动，出血性事件和恶性疾病前的摄入时间。委派一些任务（ 例如，服用历史，从电话的女儿）的团队。 注:电话到达行程队教练1。 </li><li>中风队教练1:报告的症状开始突然一个小时前，她的母亲肯定没有采取额外的血液稀释剂（"......既不是华法林，也没有任何提议她的医生，因为她的丈夫脑出血时服用死换新华法林和她不会有。"），爬楼梯，但除了轻度高血压原本健康的，当最近一直气短。 </li><li> ED居民:建立静脉通路，采取血液样本，封顶为&#39;六TAL"，确保血液样本带到实验室才能在医院信息系统的成像。 </li><li>中风病研究小组的教练1:显示的210毫米汞柱的收缩压。 </li><li>行程的团队:决定是否以及如何对待这个血压，这是一个禁忌溶栓治疗，与护士沟通和管理合适的静脉注射毒品的正确的剂量。 </li><li>病人转移到CT扫描仪。 </li><li>放射技师:执行假人的头部CT。 </li><li>中风病研究小组的教练1:用对垒中风患者大脑的印刷CT扫描无颅内出血的神经放射，无本地船只和无早梗死征象。 </li><li>神经放射:分析扫描并明确传达结果给卒中单元和ED的居民。 </li><li>卒中小组:确定治疗溶栓病人和管理丸。 </li><li>行程团队培训师:从事与discussi反馈会议在仿真之后。 <ol><li>中风病研究小组的教练1:名称是通常是20-30分钟，并低于由参与者所期望的训练期间取得的门到针计时。 </li><li>中风病研究小组的教练2:进行两轮反馈给各个团队成员。开始第一个与问题"做了什么呢？你会亲自做在你的下一个行程团队操作以同样的方式？"接着是第二轮的问题:"什么没有工作这么好？你会亲自不同的下一次呢？"和反馈一轮完整的团队得出结论:"什么是成功中风团队运作的重要因素" </li></ol></li></ol>

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作者有没有利益冲突。

A结合卒中小组算法和基于常规模拟冲程队训练可导致的门到针时间长期减排为主要基准处理时间为急性卒中治疗。一组改善的急性中风的工作流程的措施，这也激发我们的算法的很好的例子，已经由赫尔辛基组14,15说明。另一种非常新颖的方法来缩短从症状出现到溶栓的时间间隔是移动卒中单元，如创业STEMO在德国柏林16,17或者从俄亥俄州克利夫兰美国18 PHAST项目。相比之下，这里介绍的系统开始在医院的门口，很容易转移到其他医院没有具体的基础设施的先决条件。它依赖于一个固定的算法，允许由每个成员的角色的绑定定义上的笔触牛逼组织最佳疗效所有团队成员的并行工作EAM和非技术技能教学。 CRM的原则航空作为干类似的急救药品4,5高保真工作区。它们的应用尚未在其神经重症监护和中风医学领域处于起步阶段，但其适用于临床医药在麻醉19和20的手术已积极进行测试。认识到错误年初，沟通和纠正他们对病人的安全产生巨大的影响。因此，重要的是要创造共同的责任和平面层次结构，允许开放的沟通感。尤其是年轻的工作人员和团队的非学术成员往往不敢针砭更有经验的同事。阐明每个团队成员为了共同的治疗目标和非技术技能实践的责任提升每一个团队成员的权力说话。最近BEH医学学生在手术态度avioral研究表明，学生，谁是受术者鼓励说话时，承认错误是更有可能比谁被告知手术后21到保存的问题学生这样做。 急诊经常被年轻的医生和护士谁的经验相当大的压力，同时收集他们的第一次工作经验的人员。若干研究表明，抑郁症在年轻居民的发病率大于在普通人群中22和ED护士的采访研究表明，报告了相当大的比例来体验关键事件的侵入记忆在急诊室23。韧性因素包括对治疗目标和个人修养24的感觉一致。这两个因素是由跨专业团队行程算法和培训，珍视每individu的贡献增强人的团队成员，并提高团队的沟通。 在建立中风病研究小组的过程中的关键因素是目前急性卒中工作流和延迟送货NE时间的因素进行全面分析。这应该最优地神经学家，中风护士和neurointerventionalists和中央跨学科ED的情况下，合作完成还应该涉及到ED的主要代表。它有利于以书面记录新设计的算法，并经各部门的董事签字。如与医务人员，并通过快速拨号集体呼吁电信应急通信技术的简化也可以加快处理时间。该算法应根据每个医院的条件，因为规则和做法可能不同的国家和医院之间。也许不是每个医院都可以提供7一搏算法团队成员。的算法，这是呈现这里，应该可以与关于本地机构情况被修改的例子。由医生在我们的算法执行的一些任务可以通过根据他们的教育和培训其他卫生保健专业人员进行同样执行。例如，IV导管及采血也可以通过医护人员对他们的方式向医院或ED的护士完成。 定期模拟训练是一个最佳的车辆传播新算法的知识和体验式学习的方式引进新的团队成员。我们了解到随着时间的推移，最好是保持简单的模拟，并提出一个标准的情况下，该算法的第一次用户创造一个理想的急性中风后处理的心理印迹。我们使用的是专为高级心脏生命支持培训没有任何神经系统功能的心脏节律模拟器。这种人体模型允许改变心脏速率和节奏远程控制，模拟需要监测病人在运行的算法。我们与头偏差假人定位到左侧和右侧面瘫和模仿的失语症患者弥补缺乏讲话。可替代地，可以使用一个成本更低，技术上复杂的虚设或患者的演员。 关于反馈会议上，我们发现最有效的一个积极通过命名这是在运行实现了门到门针计时开始。它通常位于明显低于30分钟，鼓励新手的队伍，鉴于他们的第一个独立的班次。在此之后，两轮的个别反馈随后的因素成功的团队操作的讨论参与者刚才一直沉浸在高强度的团队合作后，我们的设置工作过最好的。我们的新治疗策略的持久影响的一个关键因素是在TRAI最年轻的中风医师的全面培训和授权宁和创造对急性中风护理的积极态度新手中风的护士。我们认为，两位经验丰富的行程队教练的指导下，关注这个体验式学习是教急性卒中治疗非常有效的方法。 一些读者，七中风队似乎效率不高，或只是在人员需求方面并不可行。我们要强调的是，我们从一个教学医院那里的居民通常没有认证资格的报告。我们做的培训初级医生尽早，前6个月的神经学居住的范围内，成为中风团队的一员，因此，在每一个部门的护士和医生可以运行算法的一个点。这期间，值班时间，保证高标准的7天24小时的维护，以及。当训练其他医院较小的卒中单元，例如区域网络中风INVN莱茵 - 美在我们的合作伙伴，我们强调的是第一30分钟，其中中风病人在急诊花费是关键的时间间隔，以达到良好的结果和患者应照顾的集中地。从这些医院，以1表示主和全面的卒中中心:1的比例，我们收到了一些重组，甚至更小的部门可以掌握从被卷入一个团队对初级人员的说教效果相当类似的算法和效益反馈。 即使算法是不可转让于每一个细节一个单独的医院，有很多方法可以简化和完善它，我们认为，一些关键点，如急性中风护理及定义结合算法，指出了时间因子团队合作和非技术技能，以全体员工的重要性，以及进行常规行程队训练可以转移到任何医院有一点点努力，并会导致更好的急性中风护理和改善病人的OUtcomes。

用重组组织纤溶酶原激活物（rt-PA），用于急性缺血性中风溶栓的效力是高度依赖于时间的，甚至在4.5小时1的治疗时间窗随时间减少。同样已经显示出血管内治疗中风2。溶栓后的额外的机械再通已被证明是在改善的重症患者中风的结果高效由于大血管闭塞（LVO）3。由于血管内治疗需要neurointerventionalist，一名麻醉师或neurointensivist，在许多情况下甚至急性以后病人的专门中心的转诊这种新疗法增加了复杂性和急性卒中治疗的交叉学科。 因此，需要的概念，以尽量减少治疗时间不把病人安全处于危险之中。由于急性中风护理是跨学科的团队提供，标准化ALGORithm以及技术和非技术技能的基于模拟的训练似乎是一个简单的方法。在这种情况下，不仅是"时间就是大脑"，还要"球队大脑"，因为珍贵分钟和安全相关的信息可以通过低效率的沟通团队成员会丢失。在非医疗高保真情况下，如航空，一个称为机组资源管理（CRM）的概念已被证明是4高度有效的。 有很大一部分致命错误是不是由于缺乏知识或技能，而是在沟通，交流和决策赤字。 CRM强调的"非技术技能"的重要性，并将其定义为补充的技术技能的认知，社会和个人资源。六大重点领域包括明确的沟通，团队合作，态势感知，决策，领导和应激5的管理。 这个概念有alreaDY被专业心血管生命支持6顺利实施。一个绑定的算法，在CRM基础教育为所有卒中小组成员和定期基于模拟的培训为高保真中风病研究小组提供的方法来改善急性卒中治疗的所有新成员。 成立谁是集体通过电话快速拨号通知，并有精确的任务定义行程算法于7人员专用中风病研究小组的治疗时间窗内治疗病人。这些是召集到每个笔画报警7强制性团队成员: 1居民从卒中单元神经病（SU） 1驻留在从急诊神经科（ED） 从ED 1名护士 1实验室技术员 1驻地专业神经放射学 1放射技师 1专科神经内科（卒中单元的资深神经科医师） 星期四S，一个基于仿真的行程队训练的构想，这是每隔一个月对所有新的Stroke团队成员，并作为长期工作人员复习进行。基于模拟训练传输CRM的价值，并强调了非技术技能的跨学科团队multiprofessional的重要性。监测这一由急诊室（ER）算法和定期培训，送货针次，溶栓相关的并发症，员工的满意度和安全感的中风病研究小组干预的影响连续记录。

<table><tbody><tr><td>&lt;strong&gt;Drug&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Alteplase (rtPA)</td><td>Boehringer Ingelheim, Ingelheim am Rhein, Germany</td><td></td><td>A licensed drug, which has proven effectiveness for acute ischemic stroke</td></tr><tr><td>Urapidil 50 mg/10 ml</td><td>Takeda Pharma, Berlin, Germany</td><td></td><td>A licensed drug, antihypertensive</td></tr><tr><td>Granisetron 3 mg/ml</td><td>Hameln Pharma, Hameln, Germany</td><td></td><td>A licensed drug, antiemetic</td></tr><tr><td>Lorazepam 2 mg/ml</td><td>Pfizer, Berlin, Germany</td><td></td><td>A licensed drug, sedative</td></tr><tr><td>Iopromid 300 mg/ml</td><td>Bayer Vital GmbH, Leverkusen, Germany</td><td></td><td>A licensed drug, non-ionic contrast agent for Computed Tomography (CT)</td></tr><tr><td>&lt;strong&gt;Name&lt;/strong&gt;</td><td>&lt;strong&gt;Company&lt;/strong&gt;</td><td>&lt;strong&gt;Catalog Number&lt;/strong&gt;</td><td>&lt;strong&gt;Comments&lt;/strong&gt;</td></tr><tr><td>&lt;strong&gt;Device&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>S-Monovette citrate 3 ml</td><td>Sarstedt, N&amp;uuml;rnbrecht, Germany</td><td></td><td>For blood collection for coagulation assays</td></tr><tr><td>S-Monovette EDTA 1.6 ml</td><td>Sarstedt, N&amp;uuml;rnbrecht, Germany</td><td></td><td>For blood collection for hematology assays</td></tr><tr><td>S-Monovette lithium heparinate 7.5 ml</td><td>Sarstedt, N&amp;uuml;rnbrecht, Germany</td><td></td><td>For blood collection for clinical chemistry assays</td></tr><tr><td>ACL Top 500&amp;nbsp;</td><td>Instrumentation Laboratory, Kirchheim, Germany</td><td></td><td>Automated hemostasis analyzer</td></tr><tr><td>Sysmex XE 2100</td><td>Sysmex Corporation, Norderstedt, Germany</td><td></td><td>Automated hematology analyzser</td></tr><tr><td>Cobas 6000</td><td>Roche Diagnostics, Mannheim, Germany</td><td></td><td>Automated clinical chemistry analyzser</td></tr><tr><td>Resusci Anne Skillreporter</td><td>Laerdal, Stavanger, Norway</td><td></td><td>Remote-controlled manikin</td></tr><tr><td>Ingenuity 128</td><td>Philips, Hamburg, Germany</td><td></td><td>CT-scanner</td></tr><tr><td>MEDRAD Stellant</td><td>Bayer Radiology, Leverkusen Germany</td><td></td><td>Contrast agent delivery system</td></tr><tr><td>Universal 320 R</td><td>Hettich, Tuttlingen, Germany</td><td></td><td>Centrifuge</td></tr><tr><td>Perfusor fm</td><td>Braun, Melsungen, Germany</td><td></td><td>Infusion pump</td></tr><tr><td>Infinity Gamma</td><td>Dr&amp;auml;ger, Hamburg, Germany</td><td></td><td>Monitor</td></tr><tr><td>Ivena ehealth</td><td>mainis IT-Service GmbH, Offenbach, Germany</td><td></td><td>Online prenotification platform</td></tr><tr><td>Braun ThermoScan PRO 4000</td><td>Welch Allyn, Hechingen, Germany</td><td></td><td>Ear thermometer</td></tr></tbody></table>

setting up a stroke team algorithm and conducting simulation-based training in the emergency department - a practical guide

时间就是生命关怀急性中风病人时。最终的目标是要血流恢复到缺血性脑。这可以通过重组组织型纤溶酶原激活物（rt-PA），对当前的第一时间出现症状的无禁忌之内谁中风患者的标准治疗或者溶栓来实现，或者通过血管内的办法，如果近端脑血管阻塞检测。由于两种治疗的功效随时间下降，每分钟沿途会改善患者的结果保存。 这种严峻的形势，需要深入细致的工作，并与病人，家庭和同事们从不同的行业来获取所有相关信息，达到正确的决策，同时仔细地监控病人精确沟通。这是一个高保真的局面。在非医疗高保真环境S使得航空，机组资源管理（CRM），用于提高安全性和团队效率。 本指南说明了如何一台S troke牛逼 EAM算法，这是转移到其他医院设置，建立和如何进行常规基于仿真的培训。这需要决心和耐力，以保持超过时间的推移定期这些耗时模拟培训。然而，由此产生的团队合作精神和卓越的送货时间针改善将有利于患者，并在任何一家医院的工作环境。 谁是集体通过电话快速拨号通知24/7并运行一个具有约束力的算法，大约需要20分钟，7人的专门团队行程，正式成立。对参与这个大家算法，为所有新款S troke牛逼 EAM成员基于仿真的团队训练的设想，并每隔一个月进行。这导致了一个相关的和持续减少的平均门到针时间25分钟，特别是加强在初中的医生和护士准备中风的感觉。

门到针次，溶栓率的影响伴随着常规的基于仿真笔划团队训练在2012年中风队算法的执行导致与门到针时间低于30分钟和60分钟，并增加了我们的溶栓速率治疗的患者相关的增加。 <img alt="图1" src="/files/ftp_upload/55138/55138fig1.jpg" /> 图1:法兰克福大学医院的中风病研究小组算法。所有的工作人员，以卒中小组结合的任命已经通过神经和神经放射学的部门以及大学医院中心实验室的负责人的董事一致同意。报警是通过快速拨号集体呼叫分配。 <a href="https://ecsource-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/55138/55138fig1large.jpg" target="_blank">请点击这里查看</a>更大的版本这个数字。 <img alt="图2" src="/files/ftp_upload/55138/55138fig2.jpg" /> 图2:门到针时间地层之前和卒中小组的介绍之后 。引进2012年10月复合中风病研究小组的干预增加了门到针的时间比30分钟短距离21.2％的年治疗的患者2010 - 2012年的份额为77％，在2013-2015年和共享与一门到针时间超过60分钟，从短到65.1 96.5％的患者。 （数据未显示）溶栓率也增加了约30％。基于从Tahtali 等人的数据。 13 该课程理念的评级由参与者该课程系统地发放调查问卷，以评估一个LL从参加2015年6月，以2016年1月（N = 45; 16医生，11名护士ED，放射技师和18名医学生）。参加卒中小组培训显著提高了参与者的信心，能够安全地治疗急性卒中患者。 <img alt="图3" src="/files/ftp_upload/55138/55138fig3.jpg" /> 图3:感知能力提供急性卒中治疗病人的安全。前和训练后，调查表2015年6月的基于仿真的行程团队培训的各个参与者的评估，以2016年1月（16医生，11名护士ED，放射技师和18个医学生N = 45）。答案在此期间的所有参与者给出％。 在一般基于仿真的行程团队培训学习形式被评为高度肯定，受到广大学员（中位数10从1-10分，N = 45）。另外，相关性日常实践（中位数10）和输送CRM的内容（平均9）被评为非常积极的。尤其是在神经内科（工作经验&lt;2岁）年轻的居民说，当然增加了病人的安全观念和恐惧减少治疗犯的错误。

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Setting Up a Stroke Team Algorithm and Conducting Simulation-based Training in the Emergency Department - A Practical Guide

每分钟在急性中风护理计数。本指南介绍了如何建立一个中风病研究小组算法并加强其与普通模拟训练的表现。 机组资源管理（CRM）的原则，有利于直的工作流程，减少送货针时间，提高员工的满意度。

建立中风病研究小组算法并进行急诊科基于仿真的培训 - 实用指南

Time is of the essence when caring for an acute stroke patient. The ultimate goal is to restore blood flow to the ischemic brain. This can ...

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视频: Setting Up a Stroke Team Algorithm and Conducting Simulation-based Training in the Emergency Department - A Practical Guide

Prehospital Thrombolysis: A Manual from Berlin

In acute ischemic stroke, time from symptom onset to intervention is a decisive prognostic factor. In order to reduce this time, prehospital thrombolysis at the emergency site would be preferable. However, apart from neurological expertise and laboratory investigations a computed tomography (CT) scan is necessary to exclude hemorrhagic stroke prior to thrombolysis. Therefore, a specialized ambulance equipped with a CT scanner and point-of-care laboratory was designed and constructed. Further, a new stroke identifying interview algorithm was developed and implemented in the Berlin emergency medical services. Since February 2011 the identification of suspected stroke in the dispatch center of the Berlin Fire Brigade prompts the deployment of this ambulance, a stroke emergency mobile (STEMO). On arrival, a neurologist, experienced in stroke care and with additional training in emergency medicine, takes a neurological examination. If stroke is suspected a CT scan excludes intracranial hemorrhage. The CT-scans are telemetrically transmitted to the neuroradiologist on-call. If coagulation status of the patient is normal and patient&#39;s medical history reveals no contraindication, prehospital thrombolysis is applied according to current guidelines (intravenous recombinant tissue plasminogen activator, iv rtPA, alteplase, Actilyse).
Thereafter patients are transported to the nearest hospital with a certified stroke unit for further treatment and assessment of strokeaetiology. After a pilot-phase, weeks were randomized into blocks either with or without STEMO care. Primary end-point of this study is time from alarm to the initiation of thrombolysis. We hypothesized that alarm-to-treatment time can be reduced by at least 20 min compared to regular care.

Identification of suspected stroke in the dispatch center of the Berlin Fire Brigade prompts the deployment of a CT-equipped ambulance. If ischemic stroke is confirmed and contraindications are excluded prehospital thrombolysis is applied.

院前溶栓治疗：从柏林手册

In acute ischemic stroke, time from symptom onset to intervention is a decisive prognostic factor. In order to reduce this time, prehospital thrombolysis ...

科研

医学

Optimized Management of Endovascular Treatment for Acute Ischemic Stroke

This manuscript describes a streamlined protocol for the management of patients with acute ischemic stroke, which aims at the minimization of time from hospital admission to reperfusion. Rapid restoration of cerebral blood flow is essential for the outcomes of patients with acute ischemic stroke. Endovascular treatment (EVT) has become the standard of care to accomplish this in patients with acute stroke due to large vessel occlusion (LVO). To achieve reperfusion of ischemic brain regions as fast as possible, all in-hospital time delays have to be carefully avoided. Therefore, management of patients with acute ischemic stroke was optimized with an interdisciplinary standard operating procedure (SOP). Stroke neurologists, diagnostic as well as interventional neuroradiologists, and anesthesiologists streamlined all necessary processes from patient admission and diagnosis to EVT of eligible patients. Target times for every step were established. Actually achieved times were prospectively recorded along with clinical data and imaging scores for all endovascularly treated stroke patients. These data were regularly analyzed and discussed in interdisciplinary team meetings. Potential issues were evaluated and all staff involved was trained to adhere to the SOP. This streamlined patient management approach and enhanced interdisciplinary collaboration reduced time from patient admission to reperfusion significantly and was accompanied by a beneficial effect on clinical outcomes.

The outcome of patients with acute ischemic stroke depends on swift restoration of cerebral blood flow. This protocol aims at optimizing the management of such patients by minimizing peri-procedural timings and rendering the time from hospital admission to reperfusion as short as possible.

急性缺血性中风血管内治疗的优化管理

This manuscript describes a streamlined protocol for the management of patients with acute ischemic stroke, which aims at the minimization of time from ...

神经科学

Establishing a Multidisciplinary Cavernous Carotid Injury Simulation to Train Neurosurgical, Otolaryngology, and Anesthesia Residents

Carotid artery injuries are serious complications of endoscopic endonasal surgery. As these occur rarely, simulation training offers an avenue for technique and algorithm development in resident learners. This study develops a realistic cadaveric model for the training of crisis resource management in the setting of cavernous carotid artery injury. An expanded endonasal approach and right cavernous carotid injury is performed on a cadaveric head. The cadaver&#39;s right common carotid artery is cannulated and connected to a perfusion pump delivering pressurized simulated blood. A simulation mannequin is incorporated into the model to allow for vital sign feedback. Surgical and anesthesia resident learners are tasked with obtaining vascular control with a muscle patch technique and medical management over the course of 3 clinical scenarios with increasing complexity. Crisis management instructions for an endoscopic endonasal approach to the cavernous carotid artery and blood pressure control were provided to the learners prior to beginning the simulation. An independent reviewer evaluated the learners on communication skills, crisis management algorithms, and implementation of appropriate skill sets. After each scenario, residents were debriefed on how to improve technique based on evaluation scores in areas of situational awareness, decision-making, communications and teamwork, and leadership. After the simulation, learners provided feedback on the simulation and this data was used to improve future simulations. The benefit of this cadaveric model is ease of set-up, cost-effectiveness, and reproducibility.

This protocol establishes a multidisciplinary model to train learners on management of cavernous carotid artery injury. Cadaveric heads undergo expanded endonasal approach and injury to the cavernous carotid artery, and perfusion pump simulates blood flow to the injury point. Learners are tasked with medical and surgical management over 3 scenarios.

Carotid artery injuries are serious complications of endoscopic endonasal surgery. As these occur rarely, simulation training offers an avenue for ...

Development of a Cadaveric Multiport Model of Posterior Circulation Aneurysm Clipping for Neurosurgery and Otolaryngology Residents

Posterior circulation aneurysms are difficult to treat with the current methods of coiling and clipping. To address limitations in training, we developed a cadaveric model to train learners on endoscopic clipping of posterior circulation aneurysms. An endoscopic transclival approach (ETA) and a transorbital precaruncular approach (TOPA) to successfully access and clip aneurysms of the posterior circulation are described. The model has flexibility in that a colored silicone compound can be injected into the cadaveric vessels for the purpose of training learners on vascular anatomy. The other option is that the model could be connected to a vascular perfusion pump allowing real-time appreciation of a pulsatile or ruptured aneurysm. This cadaveric model is the first of its kind for training of endoscopic clipping of posterior circulation aneurysms. Learners will develop proficiency in endoscopic skills, appropriate dissection, and appreciation for relative anatomy while developing an algorithm that can be employed in a real operative arena. Going forward, various clinical scenarios can be developed to enhance the realism, allow learners from different specialties to work together, and emphasize the importance of teamwork and effective communication.

A model protocol to train neurosurgery and otolaryngology resident learners on endoscopic transclival clipping of posterior circulation aneurysms is described. Two endoscopic approaches to access the silicone-injected or perfused posterior circulation of cadaveric heads are established for training. Learners are tasked with clipping of posterior circulation based on clinical scenarios.

Posterior circulation aneurysms are difficult to treat with the current methods of coiling and clipping. To address limitations in training, we developed ...

Emergency Undocking in Robotic Surgery: A Simulation Curriculum

The following is a training platform to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of a robotic system. In traditional robotic training for surgeons, a brief web based overview of performing an emergency undocking is provided during initial introductory training to the robotics system. During such a process, there is no training in delineation of interdisciplinary roles for operating room (OR) personnel. The training presented here uses formative simulation and debriefing followed by a lecture. For the simulation, a modified gynecologic simulator is draped in a steep trendelenburg position consistent with most gynecologic laparoscopic surgery. The training torso is modified using tubing hooked to pressure bags of red food colored IV fluid used to simulate a catastrophic vessel injury on demand. Positioned throughout the operating room setting is an interprofessional team consisting of embedded standardized persons (ESPs) to fulfill the roles of a circulating nurse, scrub nurse, anesthesiologist, and bedside assist surgeon. Robotic surgeons are presented a case scenario necessitating emergency undocking, and given control of the robotic instruments. The scenario is terminated following either successful completion of an emergency undock, or at five minutes due to the emergent nature of the case. A debriefing session with hands on training of the steps to emergency undocking, necessary equipment, troubleshooting techniques, and operating room personnel roles follows the simulation. The learners are presented with a short lecture reemphasizing the material presented in the debriefing for their own self-study. This training results in improved time accessing the patient, improved knowledge, confidence, and completion of critical actions, and can be replicated in most institutions. All robotic surgeons should be able to demonstrate competence in this crucial intervention. A limitation of the curriculum is ability to access the in-situ environment for training purposes.

This training platform is designed to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of the robotic system. Training includes the utilization of the technology and equipment to perform an emergency undocking, as well as delineation of roles for such a scenario.

机器人手术中的紧急脱位: 一个模拟课程

The following is a training platform to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of ...

Simulator Training for Endovascular Neurosurgery

Simulation-based training has become common practice across medical specialties, especially for learning complex skills performed in high-risk environments. In the field of endovascular neurosurgery, the demand for consequence- and risk-free learning environments led to the development of simulation devices valuable for medical trainees. The goal of this protocol is to provide instructive guidelines for the use of an endovascular neurosurgery simulator in an academic setting. The simulator provides trainees with the opportunity to receive realistic feedback on their knowledge of anatomy, as well as haptic feedback indicative of their success in handling the catheter-based systems without negative consequences. The utility of this specific protocol in relation to other neuroendovascular training modalities is also discussed.

Simulation of complex, high-risk procedures is critical to the education of medical trainees. A protocol for simulator-based endovascular neurosurgery training in a controlled academic environment is described. The protocol includes stepwise guidelines for trainees of varying levels, with a discussion of the advantages and limitations of this model.

血管内神经外科模拟器培训

Simulation-based training has become common practice across medical specialties, especially for learning complex skills performed in high-risk ...

Setup and Execution Of the Blindfolded Code Training Exercise

Miscommunication is the most common cause of preventable patient harm in medicine. Currently, there is limited knowledge of innovative techniques to improve resident physician communication and leadership strategies in high-acuity situations. The blindfolded code training exercise removes visual stimuli from the team leader, forcing the team leader to effectively utilize closed-loop communication. The simple act of blindfolding the team leader creates a learning environment where the leader must utilize a conceptual framework and critical thinking strategies to organize the team and manage the resuscitation. An advantage to this teaching technique is that it does not require any special simulation equipment, making it a low-cost approach. The blindfolded code training exercise can be applied to the management of any critically ill patient where the primary objective is to focus on developing communication skills in acute resuscitations. The purpose of the description of the blindfolded code training exercise is to provide guidance on how to perform this innovative teaching technique to force effective closed-loop communication.

The blindfolded code training exercise, which blindfolds the team leader in a code resuscitation simulation, is an advanced teaching technique to improve closed-loop communication, organizational skills, and critical thinking.&#160;

盲民代码训练练习的设置和执行

Miscommunication is the most common cause of preventable patient harm in medicine. Currently, there is limited knowledge of innovative techniques to ...

Setup and Execution of the Rapid Cycle Deliberate Practice Death Notification Curriculum

Death notification is an important and challenging aspect of Emergency Medicine. An Emergency Medicine physician must deliver bad news, often sudden and unexpected, to patients and family members without any previous relationship. Unskilled death notification after unexpected events can lead to the development of pathologic grief and posttraumatic stress disorder. It is paramount for Emergency Medicine physicians to be trained in and practice death notification techniques. The GRIEV_ING curriculum provides a conceptual framework for death notification. The curriculum has demonstrated improvement in learners&#8217; confidence and competence when delivering bad news. Rapid Cycle Deliberate Practice is a simulation-based medical education technique that uses within the scenario debriefing. This technique uses the concepts of mastery learning and deliberate practice. It allows educators to pause a scenario, provide directed feedback, and then let learners continue the simulation scenario the &#8220;right way.&#8221; The purpose of this scholarly work is to describe how to apply the Rapid Cycle Deliberate Practice debriefing technique to the GRIEV_ING death notification curriculum to more effectively train learners in the delivery of bad news.

The goal is to demonstrate how to apply the rapid cycle deliberate practice debriefing technique to the GRIEV_ING death notification curriculum.

快速循环故意练习死亡通知课程的设置和执行

Death notification is an important and challenging aspect of Emergency Medicine. An Emergency Medicine physician must deliver bad news, often sudden and ...

Creation of a High-Fidelity, Low-Cost, Intraosseous Line Placement Task Trainer via 3D Printing

The description of procedural task trainers includes their use as a training tool to hone technical skills through repetition and rehearsal of procedures in a safe environment before ultimately performing the procedure on a patient. Many procedural task trainers available to date suffer from several drawbacks, including unrealistic anatomy and the tendency to develop user-created &#39;landmarks&#39; after the trainer tissue undergoes repeated manipulations, potentially leading to inappropriate psychomotor skill development. To ameliorate these drawbacks, a process was created to produce a high-fidelity procedural task trainer, created from anatomy obtained from computed tomography (CT) scans, that utilize ubiquitous three-dimensional (3D) printing technology and off-the-shelf commodity supplies.
This method includes creating a 3D printed tissue mold capturing the tissue structure surrounding the skeletal element of interest to encase the bony skeletal structure suspended within the tissue, which is also 3D printed. A tissue medium mixture, which approximates tissue in both high-fidelity geometry and tissue density, is then poured into a mold and allowed to set. After a task trainer has been used to practice a procedure, such as intraosseous line placement, the tissue media, molds, and bones are reclaimable and may be reused to create a fresh task trainer, free of puncture sites and manipulation defects, for use in subsequent training sessions.

We describe a procedure to process computed tomography (CT) scans into high-fidelity, reclaimable, and low-cost procedural task trainers. The CT scan identification processes, export, segmentation, modeling, and 3D printing are all described, along with the issues and lessons learned in the process.

通过 3D 打印创建高保真、低成本、骨内线放置任务训练器

The description of procedural task trainers includes their use as a training tool to hone technical skills through repetition and rehearsal of procedures ...

使用仿真模型培训 POCUS 血管插管的新手

Using Simulation Models to Train Clinicians in the Use of Point-of-Care Ultrasound

The use of point-of-care ultrasound (POCUS) has shown to be a beneficial non-invasive vascular access assessment method by clinicians, which can provide critical elements of visual and measurable information that proves to be useful in the context of vascular access cannulation, in combination with the practical skill of the clinician performing the cannulation. However, the use of POCUS in this context is to practically train and enable individuals who are novices in using this technique to become proficient in performing this task subsequently on patients in a careful and successful way. The simulation of these vascular conditions may be useful to help healthcare professionals learn, understand, apply, and establish such practical skills for vascular cannulation safely to achieve the desired outcomes. This project intended, through the attendance of a half-day workshop, to establish skills to use POCUS in connection with simulation models and perform specific tasks to enable clinicians to use this method in their clinical practice for vascular access cannulation in patients. A mixed-methods longitudinal study design was used to evaluate the effect of a point-of-care ultrasound workshop for peripheral intravenous cannula insertion, including specific tasks for the participants to be performed on simulation models. A total of 81 individuals participated in 11 half-day workshops through 2021 and 2022. Offering a workshop that uses simulation models in combination with various POCUS devices is useful in establishing this newly learned skill in clinicians, such as measurements of depth, caliper, and direction of a vein with POCUS prior to cannulation providing essential anatomical facts to the operator, which increases the likelihood of first-time success in cannulation.

作者聚焦：通过模拟培训评估临床医生对超声引导下血管插管的采用情况

The present protocol describes an ideal solution to train novices in the use of point-of-care ultrasound devices for the practical clinical skill of visually assessing distinct individual anatomical vascular conditions prior to and during an intended venous vascular cannulation using point-of-care ultrasound in a patient.

使用仿真模型培训临床医生使用床旁超声 

The use of point-of-care ultrasound (POCUS) has shown to be a beneficial non-invasive vascular access assessment method by clinicians, which can provide ...