stroke resuscitation

The stroke resuscitation simulation program: the teams we train, the courses we run, and the framework underneath them.

Project Description

A code stroke is a resuscitation. It is time-critical, cognitively loaded, and delivered by a team that has often never worked together before. Yet unlike cardiac arrest or trauma, it has historically not been taught or rehearsed as a resuscitation. Our project closes that gap. We introduced the concept of neurovascular resuscitation, applying the principles of medical and trauma resuscitation to hyperacute stroke care, thereby reinstating the “code” in code stroke, and we built a simulation program to teach it.

The framework rests on Crisis Resource Management (CRM): situational awareness, triage and prioritization, mitigation of cognitive load, explicit team role clarity, closed-loop communication, and structured debriefing. Our lab published the first reframing of CRM for stroke care, and developed the Protected Code Stroke during the COVID-19 pandemic, a protocol integrated into national and international guidelines and downloaded 47,945 times from the American Heart Association and Stroke journal’s website, with 171 citations (publisher metrics, August 2026).

The simulation program

What began in 2019 as in situ code stroke simulation with our Emergency Department colleagues has grown into a multi-stream, interprofessional program:

Emergency Department simulation (from 2019): the origin of the program, run in situ with ED physicians and nurses, focused on the first minutes of the code stroke.
Code Stroke RN (CSRN) simulation: interprofessional simulation with the code stroke nursing group, who are the connective tissue of every activation, from the EMS phone call onward.
Stroke Boot Camp: code stroke simulation for incoming PGY1 residents (2020–2025). An annual July day at Sunnybrook for incoming neurology residents across the city-wide University of Toronto Division of Neurology, centred on stroke emergencies and the role of CRM in resuscitation. Dr. Khosravani started this orientation and pioneered running it before residency begins rather than after. Over six years it grew from a simulation in a conference room into full sessions at the Sunnybrook Canadian Simulation Centre. As the orientation broadened to take in general neurology, he continued to lead its stroke resuscitation work (case selection and the development of case scenarios), booking the simulation lab and running it alongside colleagues at the simulation centre, with our code stroke nurses joining when able.
SRC-TO: the Stroke Resuscitation Course, Toronto (April 2024), Canada’s first local Stroke Resuscitation Course.
SRC-FU: the follow-up course (January 2025), with an innovative curriculum for neurology residents covering point-of-care ultrasound (POCUS) in hyperacute stroke assessment, a simulation centre phase, and EVT complications and considerations.
SRC-Ottawa, the national course (June 2025): Canada’s first Stroke Resuscitation Course, run as a course at the Canadian Neurological Sciences Federation Annual Meeting with Dr. Khosravani as Course Director. This was both the first extension of the course beyond Toronto and its first national delivery. Alongside it, Endovascular Escapades, a hands-on neurointervention course for trainees, co-chaired on CNSF Stroke Day.
B4 Neurovascular Unit skills days: nursing professional development days bringing resuscitation skills onto the inpatient neurovascular unit, with 91% participation and measured gains in staff knowledge and confidence in high-acuity cases.
EVT sedation simulation (Sunnybrook): a distinct, anesthesia-facing stream run in house with our anesthesia and endovascular colleagues, rehearsing sedation and airway decisions during thrombectomy, alongside quarterly code stroke EVT/anesthesia review. This was the first joint physician–nursing simulation for endovascular stroke treatment in Canada.
Door-to-CT (DT-CT): a quality improvement stream now led by the code stroke nurses, translating what the simulations surface into measured process change.

What it has changed

Simulation here is not an end in itself; it is a quality improvement instrument. Each stream is designed to move real metrics and to make team performance, not individual heroics, the unit of improvement. Alongside PDSA-cycle process redesign, median door-to-needle time at Sunnybrook fell 25%, from 38.5 to 29 minutes: below the national average, durable over eleven months, and holding near 30 minutes today, across a service managing more than 1,000 code strokes a year. Sunnybrook ranks in the top two in Ontario for low 30-day stroke mortality and readmission. That improvement was evaluated by comparing code strokes run with CRM against those run without (an analysis by Catherine C., then of the QI team), which is what attributes the gain to CRM rather than to a general trend over the same period.

The teaching infrastructure underneath it is codestroke.net, running since 2017, which now records over 25,000 page-user instances across more than 9,100 unique users and is used by trainees and stroke clinicians locally, provincially, internationally, and by Ontario EMS.

Teaching and spread

The program was presented at Provincial Stroke Rounds in May 2026 by Dr. Khosravani and Dr. Christine Hawkes, as Stroke Resuscitation Simulation: Building High-Performing Teams Through Crisis Resource Management, and the materials were subsequently requested for provincial distribution. Regional and inter-hospital collaborations, including transfer and EMS simulation with partner sites, are in active development.

The slides and audio from that session are below, presented by Dr. Houman Khosravani and Dr. Christine Hawkes.

Presentation slides (44 pages). Open or download the PDF if the viewer above does not display on your device.

Audio of the talk (58 minutes). Follow along with the slides above.

The program is run with the Sunnybrook Canadian Simulation Centre. In 2023, Dr. Khosravani and Dr. Hawkes formed the Neurovascular Innovations CollaborativE (NICE), and began collaborating to expand the simulation work to include neurovascular EVT simulation, now a component of SRC-TO, SRC-FU, and SRC-Ottawa. That collaboration is highlighted throughout the Provincial Stroke Rounds presentation above.

With thanks

Dr. Khosravani pioneered code stroke resuscitation, bringing the philosophy of the code blue to the code stroke and outlining crisis resource management for it. The work began in 2019, out of the serendipitous intersection of critical care, neurocritical care and stroke care, the same intersection as his own training journey. But no one operates on an island: a great team and stellar collaborations grew this from grass-roots beginnings in 2019 into what it is now. In the Emergency Department, for collaboration from the very first in situ sessions: Dr. Nicole K.-G., Lowyl N., Miranda L., and Leah K., and former QI team member Catherine C. At the Sunnybrook Canadian Simulation Centre, who make the sessions possible: Victoria M. and Susan D. Our PCMs Krishna A. and former PCM Lan M., and former Educator/APN KC L., whose Nursing Leadership Network work is behind the neurovascular unit skills-day results above. And all of the Code Stroke Nurses at Sunnybrook, who are in every stream on this page.

It has also been a sincere privilege to work with several residents through their training, mentoring them on the principles of code stroke resuscitation, and to see them now, as staff at various sites, building programs of their own: carrying the torch of CRM and putting simulation into practice in their local settings.

SRC-TO, SRC-FU and SRC-Ottawa were all funded through the Slamen-Fast New Initiatives in Neurology program at the University of Toronto Division of Neurology. Our thanks to the program and to its donors, whose support made the courses possible.

Project Objectives

Teach the code stroke as a resuscitation. Build and sustain high-performing interprofessional teams across neurology, emergency medicine, nursing, anesthesia, and prehospital care. Use simulation to expose latent safety threats and process gaps before they reach patients. Measure the effect on acute stroke metrics, provider comfort, and interprofessional collaboration. Share the curriculum and lessons learned so other centres can adopt and adapt them.

Background and Purpose- Hyperacute assessment and management of patients with stroke, termed code stroke, is a time-sensitive and high-stakes clinical scenario. In the context of the current coronavirus disease 2019 (COVID-19) pandemic caused by the SARS-CoV-2 virus, the ability to deliver timely and efficacious care must be balanced with the risk of infectious exposure to the clinical team. Furthermore, rapid and effective stroke care remains paramount to achieve maximal functional recovery for those needing admission and to triage care appropriately for those who may be presenting with neurological symptoms but have an alternative diagnosis. Methods- Available resources, COVID-19-specific infection prevention and control recommendations, and expert consensus were used to identify clinical screening criteria for patients and provide the required nuanced considerations for the healthcare team, thereby modifying the conventional code stroke processes to achieve a protected designation. Results- A protected code stroke algorithm was developed. Features specific to prenotification and clinical status of the patient were used to define precode screening. These include primary infectious symptoms, clinical, and examination features. A focused framework was then developed with regard to a protected code stroke. We outline the specifics of personal protective equipment use and considerations thereof including aspects of crisis resource management impacting team role designation and human performance factors during a protected code stroke. Conclusions- We introduce the concept of a protected code stroke during a pandemic, as in the case of COVID-19, and provide a framework for key considerations including screening, personal protective equipment, and crisis resource management. These considerations and suggested algorithms can be utilized and adapted for local practice.

Management of stroke patients in the acute setting is a high-stakes task with several challenges including the need for rapid assessment and treatment, maintenance of high-performing team dynamics, management of cognitive load affecting providers, and factors impacting team communication. Crisis resource management (CRM) provides a framework to tackle these challenges and is well established in other resuscitative disciplines. The current Coronavirus Disease 2019 (COVID-19) pandemic has exposed a potential quality gap in emergency preparedness and the ability to adapt to emergency scenarios in real time. Available resources in the literature in other disciplines and expert consensus were used to identify key elements of CRM as they apply to acute stroke management. We outline essential ingredients of CRM as a means to mitigate nontechnical challenges providers face during acute stroke care. These strategies include situational awareness, triage and prioritization, mitigation of cognitive load, team member role clarity, communication, and debriefing. Incorporation of CRM along with simulation is an established tool in other resuscitative disciplines and can be incorporated into acute stroke care. As stroke care processes evolve during these trying times, the importance of consistent, safe, and efficacious care facilitated by CRM principles offers a unique avenue to alleviate human factors and support high-performing teams.

References

2024

2020