Emergency Department simulation
The origin of the program, run in situ with ED physicians and nurses and focused on the first minutes of a code stroke.
Stroke resuscitation & simulation
A code stroke is a resuscitation: time-critical, cognitively loaded, and delivered by a team that may never have worked together before. SiLab introduced neurovascular resuscitation — applying medical and trauma resuscitation principles to hyperacute stroke — and built an interprofessional simulation program to teach it.
−25%median door-to-needle time: 38.5 → 29 minutes
47,945Protected Code Stroke downloads · 171 citations
91%B4 Neurovascular Unit nursing participation in skills days
01 / Framework
Putting the “code” back in code stroke
Unlike cardiac arrest or trauma, code stroke has historically not been taught or rehearsed as a resuscitation. This project closes that gap. Neurovascular resuscitation applies the principles of medical and trauma resuscitation to hyperacute stroke care, with team performance — not individual heroics — as the unit of improvement.
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. SiLab published the first reframing of CRM for stroke care.
During COVID-19, the lab also developed Protected Code Stroke, integrating infection-control and human-factors considerations into hyperacute care. It was incorporated into national and international guidelines and has been downloaded 47,945 times, with 171 citations (publisher metrics, August 2026).
02 / Program
The simulation program
What began in 2019 as in situ simulation with Emergency Department colleagues has grown into a multi-stream, interprofessional program spanning the ED, nursing, residency, the neurovascular unit, anesthesia, EVT, and prehospital partners.
Code Stroke RN simulation
Interprofessional simulation with the code stroke nursing group — the connective tissue of every activation, from the EMS phone call onward.
Stroke Boot Camp
An annual July day at Sunnybrook for incoming PGY1 neurology residents across the city-wide University of Toronto Division of Neurology. Dr. Khosravani pioneered running the orientation before residency begins. Over six years, it grew from a conference-room simulation to full sessions at the Sunnybrook Canadian Simulation Centre, with code stroke nurses joining when able.
SRC-TO
The Stroke Resuscitation Course, Toronto (April 2024) — Canada’s first local Stroke Resuscitation Course, including neurovascular EVT simulation through NICE.
SRC-FU
The follow-up course (January 2025), with an innovative resident curriculum covering point-of-care ultrasound (POCUS) in hyperacute stroke assessment, a simulation-centre phase, and EVT complications and considerations.
SRC-Ottawa: the national course
Canada’s first national Stroke Resuscitation Course, delivered at the Canadian Neurological Sciences Federation Annual Meeting in June 2025 with Dr. Khosravani as Course Director — its first extension beyond Toronto. Alongside it, Endovascular Escapades, a hands-on neurointervention course for trainees, was 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
An anesthesia-facing stream run in house with anesthesia and endovascular colleagues, rehearsing sedation and airway decisions during thrombectomy alongside quarterly code stroke EVT/anesthesia review — the first joint physician–nursing simulation for endovascular stroke treatment in Canada.
Door-to-CT quality improvement
A CSRN-pioneered QI stream, championed by Anna L. and Myla (Mylene) I., translating what simulations surface into measured process change.
03 / Impact
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 expose latent safety threats before they reach patients.
Alongside PDSA-cycle process redesign, Sunnybrook’s median door-to-needle time 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 Ontario’s top two for low 30-day stroke mortality and readmission.
The 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 is a stroke educational website running since 2017, now recording more than 25,000 page-user instances across more than 9,100 unique users, used locally, provincially, internationally, and by Ontario EMS.
04 / Spread
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. Materials were subsequently requested for provincial distribution.
Regional and inter-hospital collaborations — including transfer and EMS simulation with partner sites — are in active development. SRC-TO FU2 is in planning.
Slides and audio are hosted on strokeinnovationlab.ca and open from those direct links; no media is embedded here.
The program runs with the Sunnybrook Canadian Simulation Centre. In 2023, Drs. Khosravani and Hawkes co-founded the Neurovascular Innovations CollaborativE (NICE), expanding simulation to include neurovascular EVT work now embedded in SRC-TO, SRC-FU, and SRC-Ottawa.
05 / Objectives
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 effects on acute-stroke metrics, provider comfort, and interprofessional collaboration.
- Share the curriculum and lessons learned so other centres can adopt and adapt them.
06 / Thanks
With thanks
No one operates on an island. The program grew from grass-roots beginnings in 2019 through stellar collaborations: in the Emergency Department, Dr. Nicole K.-G., Lowyl N., Miranda L., Leah K., and former QI team member Catherine C.; at the Sunnybrook Canadian Simulation Centre, Victoria M. and Susan D.; PCMs Krishna A. and former PCM Lan M., and former Educator/APN KC L.; and Sunnybrook’s Code Stroke Nurses — Anna, Myla, Steven, Abelle, Mumtaz, Ann, and Hans.
It has also been a privilege to mentor residents in code stroke resuscitation and to see them, now as staff at various sites, building programs of their own.
SRC-TO, SRC-FU, and SRC-Ottawa were funded through the Slamen-Fast New Initiatives in Neurology program at the University of Toronto Division of Neurology.
07 / References
Key references
- The In-Hospital Code Stroke: A Look Back and the Road Ahead — A.M. Kuczynski, W.D. Freeman, L.H. Mooney, J.F. Huang, A.M. Demchuk, and H. Khosravani, Neurohospitalist — 2024
- Protected Code Stroke: Hyperacute Stroke Management During the Coronavirus Disease 2019 (COVID-19) Pandemic — Houman Khosravani, Phavalan Rajendram, Lowyl Notario, Martin G. Chapman, and Bijoy K. Menon, Stroke — 2020
Abstract in brief
A protected code stroke algorithm balancing timely, efficacious hyperacute care with infectious-exposure risk: precode screening, focused personal-protective-equipment considerations, and CRM factors affecting team roles and human performance.
- Crisis Resource Management and High-Performing Teams in Hyperacute Stroke Care — Phavalan Rajendram, Lowyl Notario, Cliff Reid, Charles R. Wira, Jose I. Suarez, Scott D. Weingart, and Houman Khosravani, Neurocritical Care — 2020
Abstract in brief
CRM as a framework for the nontechnical challenges of acute stroke: situational awareness, triage and prioritization, cognitive-load mitigation, role clarity, communication, and debriefing — paired with simulation as in other resuscitative disciplines.