Stroke Resuscitation Course (SRC, “Source”) Ottawa 2025
Canada’s national Stroke Resuscitation Course at the Canadian Neurological Sciences Federation (CNSF) 2025 meeting. The course handout below covers Crisis Resource Management and high-performing teams in hyperacute stroke care.
Crisis Resource Management and high-performing teams in hyperacute stroke care
Assessment of patients with stroke for hyperacute treatments such as thrombolysis and thrombectomy must be timely, precise, and effective to achieve the best clinical outcomes. Stroke care has advanced significantly with the emergence of new hyperacute therapies, including late-window thrombectomy, advanced imaging, and the creation of systems of care. Current challenges, including the COVID-19 pandemic, have stressed existing stroke pathways, exposing potential quality gaps in emergency preparedness — especially during the hyperacute phase, as providers form ad hoc teams to evaluate and resuscitate patients.
Elements at play include patient factors, health-care resources, team dynamics, and the well-being of providers. These span the chain of survival in stroke from hyperacute assessment to admission and discharge. Specific to hyperacute assessment, the concept of a protected code stroke (PCS) emerged, highlighting the importance of screening, adherence to infection prevention and control measures, and coordinated team responses.
The foundation of CRM in stroke care
Knowledge and mastery of technical skills are key to the successful execution of a code stroke. However, a myriad of nontechnical skills are equally critical. CRM provides a framework for these skills, including situational awareness, triage and prioritization, cognitive load reduction, role clarity, communication, and debriefing.
These principles were originally described as “crew resource management” in aviation, where human error can similarly have disastrous consequences. CRM has taken root in emergency medicine, critical care medicine, and anesthesia. These specialties share a common thread with hyperacute stroke care — resuscitation that bridges stroke with neurocritical care.
Providers in code strokes face a high-acuity scenario and effectively function as “brain resuscitationists.” Implementing CRM principles ensures that when additional health-system pressures arise, stroke teams remain equipped to deliver effective resuscitation.
Core CRM principles for stroke teams
The zero point survey framework
CRM combines essential elements spanning the team, the environment, and the individual provider. In the resuscitation setting, these nontechnical components should be considered before hands-on patient assessment as a “zero point survey” — prior to the primary survey and resuscitation (see the zero point survey):
Self check
- Mental readiness assessment
- Physical readiness evaluation
- Stress and fatigue awareness
Team
- Determine the code stroke leader
- Establish role clarity
- Pre-brief with team members
Environment
- Space assessment and crowd control
- Noise management and lighting
- Equipment verification
Patient
- Primary survey: ABCDE
- Clinical history
- NIHSS assessment preparation
Update
- Share the mental model of patient status
- Ensure team alignment on assessment
Priorities
- Identify team goals
- Set mission trajectory
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1 · Situational awareness
Full awareness of self, team, and environment: recognizing pertinent cues, comprehending the environment, and projecting future status, then synthesizing these into focused differentials and patient trajectory. In stroke care this is critical when:
- A patient’s hemodynamic and/or airway status is tenuous
- Providers must perceive all available clues and predict impending decompensation
- Teams need to start resuscitative measures before deterioration en route to the scanner or neuroangiography suite
For protected code stroke: ensure team safety and minimize environmental contamination, designate a safety leader and follow PPE protocols, and stay aware of mask placement on patients.
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2 · Triage and prioritization
Tasks can be overwhelming and not congruent with immediately available resources. Prioritize medical tasks (neurologic exam, blood pressure control) and nontechnical tasks (communication with neuroangiography, imaging, critical care) while triaging their effectiveness.
- Use knowledge from previous code stroke debriefings
- Implement lessons learned from simulation
- Rapidly triage simultaneous code strokes
- Leverage help from other teams in dynamic scenarios
- Complete zero point surveys before patient arrival
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3 · Cognitive load management
Decision-making in stroke resuscitation is cognitively taxing; working memory is limited. Two models apply: System I — fast, intuitive, experience-based judgments; System II — slower, analytical reasoning needed for complex situations.
- Delegate tasks to appropriate team members
- Use memory aids and tools
- Remove unnecessary steps to reduce clutter
- Use “buddy systems” for safety leads
- Keep clear communication between the resuscitation leader and external team members
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4 · Role clarity
Clear roles and responsibilities optimize team dynamics, minimize duplication, and prevent errors of omission.
- Pre-arrival briefings for team introductions
- Team members know each other by name
- Familiarity with each member’s skills, capability and experience
- Spatial allocation of team members (pit crew approach)
- Role-designation stickers during protected code strokes
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5 · Communication
Communication breakdown is a leading cause of medical error and patient harm.
- Closed loops: information vocalized, repeated back by the receiving clinician, and reported back
- Brevity and precision: key information stated calmly
- Clear handovers: precise transfers to other units, centres, or operative settings
- Patient/family communication: an assigned team member, especially for informed consent
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6 · Debriefing
After the initial resuscitation, debrief with all team members — ideally a “hot debrief” shortly after the event, especially with suboptimal outcomes or safety issues.
- Initiate — announce a quick debrief; encourage participation
- Safe space — psychological safety, flat hierarchy
- Review — chronological progression; team perspectives
- Participate — equal opportunity to speak
- Follow-up — track concerns; allow private discussion
Simulation, implementation & conclusion
Simulation and training
Translating nontechnical skills into clinical practice requires deliberate, repeated exercise. Simulation provides repeated exposure to variations of clinical scenarios in a safe environment. With repeated exposure to simulated high-stakes situations, clinicians undergo stress inoculation and become more likely to recognize immediate threats and respond appropriately.
- Effective transfer of CRM skills to clinical settings
- Improvement in patient outcomes and mortality
- Enhanced communication behaviours and teamwork
- Addresses challenges encountered with ad hoc teams
Implementation during crisis
The current environment offers a unique opportunity to introduce CRM within stroke care. Day-to-day use of CRM principles can enhance team cohesion and satisfaction, improving team performance — potentially translating to a stronger culture of safety, reduced post-resuscitation length of stay, improved patient satisfaction, and better survival.
Conclusion
Crisis Resource Management principles are uniquely positioned to address current needs and future emergency preparedness in stroke care. The therapeutic tools available in stroke care are only as effective as the teams working together to deliver them to patients. As stroke care processes continue to evolve, consistent, safe, and efficacious care facilitated by CRM principles offers a unique avenue to alleviate human factors and support high-performing teams.
Both hyperacute stroke care and follow-up care on stroke units rely heavily on multidisciplinary teams. Systems and pathways must be able to adapt rapidly to acute and emergent stressors. To be prepared for future adversity with high-performing teams, routine implementation of CRM principles will be of significant value to stroke care delivery.
Course slides & video
Zero point survey, debrief & paper
The course also uses the zero point survey, the hot debrief card, and the CRM-in-stroke paper:
Zero point survey
STEP-UP: self, team, environment, then patient, update, priorities — the steps before the primary survey.
Hot debrief
Initiate, safe space, review, participate, follow-up — the post-resuscitation debrief card.
CRM applied to stroke
Rajendram et al., Neurocritical Care 2020 — the abstract and full-text PDF.