STAND AND DELIVER: STANDARDIZATION OF TELEMEDICINE TRAINING FOR ACUTE STROKE CARE
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1 STAND AND DELIVER: STANDARDIZATION OF TELEMEDICINE TRAINING FOR ACUTE STROKE CARE LEE S CHUNG, MD PETER M HANNON, MD JALEEN SMITH, BS JENNIFER J MAJERSIK, MD, MS DEPT OF NEUROLOGY, UNIVERSITY OF UTAH VA MEDICAL CENTER, SALT LAKE CITY
2 No Disclosures or Conflicts of Interest
3 OVERVIEW History of Telestroke Telestroke Codes Approaches to Learning Simulations Telestroke Curriculum Summary
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6 NON-LINEAR INCREASE IN TELESTROKE CONSULTS Number of Sites v. Number of Consults Number of Consults Number of Sites
7 WORKLOAD: 210 TELESTROKE CONSULTS THROUGH Q Q1 Q2 Q Augusta, ME Clarksburg, WV Fort Meade, SD Las Vegas, NV Marion, IL Martinsburg, WV Mather, CA Muskogee, OK Orlando, FL San Juan, PR Shreveport, LA Washington, DC Total
8 Social Work Pharmacy CT Neuro ED Res/Att Patient Arrives Back to Trauma Bay Nursing Brain Attack - ED Expedited CT Protocol CN: Assign RN HUC: - Activate Page; - Print labels & armband; - CT Ready? RN: Grab trauma pack & Brain Attack med kit RN: Place Arm Band EMT/Tech: Check IV Patency RN/EMT/ Tech: Weigh Patient RN/EMT/ Tech: Initiate Transfer back to Bay EMT/Tech: 2 nd IV, Labs, Glucose, EKG istat RN: Page ED Res/Att CN: Request Bed in NCCU RN: Start tpa drip EMT/Tech: Move scale to left of CT. Sling on CT table Order noncon CT Arrive in < 5 min of page Brief ABC Start exam (not full NIHSS) Go to CT? Time Out #2 (ED MD, Neuro MD, RN) All verbally agree. See Checklist on Back EMS Report out (to ED Neuro, RN, Tech) Look up patient real name. tpa or no tpa? (Res/Att/ Neuro decision) IR or no IR? NIHSS, confirm onset Order advanced imaging (if necessary) Time Out #3 (Neuro MD, ED MD, RN, Pharmacist) See Checklist on Back Give tpa Bolus Hold CT Call neuro rads and Perform CT ID Patient Med History Pre-arrival Plan (Time Out #1) Led by Neuro MD : Review Roles Introductions/Verbal acknowledgement See Checklist on Back Orders tpa (if not on shift Neuro orders) tpa arrives Timeout #1 Timeout #2 Talking w/family Getting contact information Timeout #3 Owner: UUHC Stroke Center January 29, 2016, V. 1.0
9 TELESTROKE: CHALLENGES People Factors Many stakeholders Competing priorities Inexperience Communication Patient & Family Consent process Systems Factors Time sensitive disease Complex disease Variation in resources Technology Disposition
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14 STROKE EXAM COMPONENTS Observational Mental Status Language Extraocular movements Facial Symmetry Dysarthria Motor Drift Coordination Gait* Interactional Visual Fields Strength Sensation Neglect Reflexes*
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16 Social Work Pharmacy CT Neuro ED Res/Att Patient Arrives Back to Trauma Bay Nursing Brain Attack - ED Expedited CT Protocol CN: Assign RN HUC: - Activate Page; - Print labels & armband; - CT Ready? RN: Grab trauma pack & Brain Attack med kit RN: Place Arm Band EMT/Tech: Check IV Patency RN/EMT/ Tech: Weigh Patient RN/EMT/ Tech: Initiate Transfer back to Bay EMT/Tech: 2 nd IV, Labs, Glucose, EKG istat RN: Page ED Res/Att CN: Request Bed in NCCU RN: Start tpa drip EMT/Tech: Move scale to left of CT. Sling on CT table Order noncon CT Arrive in < 5 min of page Brief ABC Start exam (not full NIHSS) Go to CT? Time Out #2 (ED MD, Neuro MD, RN) All verbally agree. See Checklist on Back EMS Report out (to ED Neuro, RN, Tech) Look up patient real name. tpa or no tpa? (Res/Att/ Neuro decision) IR or no IR? NIHSS, confirm onset Order advanced imaging (if necessary) Time Out #3 (Neuro MD, ED MD, RN, Pharmacist) See Checklist on Back Give tpa Bolus Hold CT Call neuro rads and Perform CT ID Patient Med History Pre-arrival Plan (Time Out #1) Led by Neuro MD : Review Roles Introductions/Verbal acknowledgement See Checklist on Back Orders tpa (if not on shift Neuro orders) tpa arrives Timeout #1 Timeout #2 Talking w/family Getting contact information Timeout #3 Owner: UUHC Stroke Center January 29, 2016, V. 1.0
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19 Simulations
20 VA SIMLEARN CENTER (ORLANDO)
21 DEBRIEFING Feedback Discussion Reflection
22 ADULT LEARNING THEORY Debriefing Should occur immediately 2-3 times the length of scenario Start with 5 minutes of initial reactions/feelings End with 5 minutes of summary/generalization
23 ADULT LEARNING THEORY Facilitator: Guides, clarifies, gives constructive feedback, actively listens Trustworthy, respectful, non-threatening Not the expert but rather a co-learner
24 ADULT LEARNING THEORY Plus-Delta (Decker, 2009, Jeffries, 2010) What went well What would like to change How to change
25 ADULT LEARNING THEORY Advocacy-Inquiry (Decker, 2009, Jeffries, 2010) Statement of observation followed by probing question of inquiry/why
26 Telestroke Curriculum
27 Technology Licensure, medicolegal, ethics Attitudes, professionalism Informed consent, privacy Skills History, exam, documentation Teleneurology limitations
28 Extension of Learning
29 PROJECT ECHO Extensions for Community Heathcare Outcomes Collaborative: medical knowledge-sharing and collaborative practice Longitudinal: regular teleecho clinics with community & rural providers Conserves resources: community providers present cases, get expert treatment plans Fosters mentorship: Specialist mentors and community provider mentees Maintains community relationships: Patients receive high-quality care in their communities from providers they trust.
30 Project ECHO vs. Telestroke Stroke ECHO Team Community-based Care Teams Patients reached with subspecialty knowledge Stroke Specialist Patient
31 WHAT DOES ECHO LOOK LIKE?
32 Dates STROKE PROJECT ECHO ECHO Topics 6/16/2016 The Need for Speed: The Importance of Timing in Endovascular Treatment Windows 9/16/2017 Living on the Edge: New Guidelines for tpa in Stroke 1/26/2017 Northwest Regional Telehealth Resource Center: Stroke ECHO: Keeping Expert Stroke Care in the Community 2/2/2017 From Dusk till Dawn: Current Management and Future Directions of Wake-Up Strokes 6/16/2017 Project ECHO Pregnancy Care: Stroke and Pregnancy 6/22/2017 Look Who s Talking: Stroke and Stroke Prevention in Pregnancy 9/28/2017 There will be Blood: Evaluation and Management of Hemorrhagic Stroke 2/22/2018 Short Circuit: Best Practices for Telestroke Consultation 5/3/2018 A Wrinkle in Time: Extended Windows for Endovascular Stroke Treatment 8/30/2018 Breaking Bad Blood: Hemorrhagic Complications of Alteplase Treatment
33 SUMMARY Telestroke training Start small Multi-modal Incorporate simulations effectively Formal telemedicine curriculum Project ECHO & Force Multipliers
34 THANK YOU!
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