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Background: University Hospitals Comprehensive Stroke Center (UH CSC) is an academic medical center with a dedicated 19 bed Neuroscience Intensive Care unit (NSU). As the only comprehensive stroke center in a 22 hospital system, the majority of ischemic stroke patients requiring a mechanical thrombectomy procedure are transferred to the UH CSC. A post thrombectomy patient requires intensive monitoring to assess for complications and is best cared for by highly trained neuro nurses in an intensive care environment. Lack of available NSU beds often resulted in these patients returning to the high volume emergency department with less than ideal staffing. The request for a NSU bed was not initiated until the thrombectomy procedure began delaying the chain of events that lead to an available NSU bed. Hypothesis: A proactive process that would initiate obtaining a NSU bed sooner would avoid these patients from boarding in the emergency department. Methods: Key stake holders from the stroke program, neurocritical care, emergency medicine, neuro interventional and the transfer center met in early 2019 to review data and quality concerns. An algorithm was developed and shared with all staff. Once the stroke faculty accepts a transfer of a potential thrombectomy patient, the new process includes notifying the NSU fellow and charge nurse to initiate making an open bed before the patient arrives to UH CSC. Results: In 2018, 48% of patients that underwent a mechanical thrombectomy returned to the emergency department. After the implementation of the new process the percentage of patients returning to the emergency department declined to 28% in 2019. In 2020 only 8% returned to the emergency department. The number of quality concerns significantly decreased. Conclusion: The bed ahead process initiated before a thrombectomy patient arrives at the comprehensive stroke center has been successful in avoiding returns to the emergency department and meeting our goal to achieve high quality patient outcomes and improve care efficiency.

Individualized interactive instruction provides an opportunity for significant innovation and advances in curriculum design. We describe the development and implementation of virtual small group exercises into the curriculum of an emergency medicine residency training program using a free social media and communication platform (Slack). Two virtual small group exercises, one case‐based and one open‐ended, were trialed during the 2016 to 2017 academic year. We found that the exercises were feasible to implement in a learner group where 66% (41/62) had little or no prior experience with Slack. There was a trend toward a more favorable rating of the quality of the dialogue and of the task‐technology fit for the case‐based format as opposed to the open‐ended educational activity.