Curriculum Innovation: A Multicenter Feasibility Study of a Consensus-Based Brain Death Simulation Curriculum

Competency in brain death/death by neurologic criteria (BD/DNC) determination is an Accreditation Council for Graduate Medical Education (ACGME) milestone in neurology residency and neurocritical care fellowship; however, trainees have limited clinical exposure and receive inconsistent training across institutions. Simulation offers a standardized, safe environment to teach and assess BD/DNC, but multi-institutional implementation remains unstudied. The aim of this study was to evaluate the feasibility of implementing a consensus-based BD/DNC curriculum and to assess its impact on trainee confidence.

By the end of the curriculum, trainees will be confident in assessing BD/DNC prerequisites, performing a complete neurologic examination, safely conducting and interpreting apnea testing, and accurately declaring BD/DNC.

Through an iterative consensus process, 3 simulation cases addressing BD/DNC confounders were developed and implemented across high-fidelity and low-fidelity settings. Neurology residents and neurocritical care fellows were recruited by email from 6 academic centers in the United States. Participants each completed one case and received debriefing. Learning objectives were assessed using a 17-item, 5-point Likert pre/postsurvey assessing confidence across 4 BD/DNC domains: "Setup and Family Counseling," "Prerequisites," "Neurologic Examination," and "Apnea Test and Declaration of BD/DNC." Composite domain medians were compared using the Wilcoxon signed-rank test, and change scores (post-pre) were compared between fidelity groups using the Mann-Whitney U test.

Nineteen participants (9 female [47%]; predominantly PGY-4 trainees) were enrolled. Median [IQR] pre-post composite confidence scores improved significantly across all domains: "Setup and Family Counseling," 4 [3.5-4] to 4.5 [4-5]; "Prerequisites," 4 [4-5] to 4.5 [4-5]; "Neurologic Examination," 4 [4-4] to 4.5 [4-5]; and "Apnea Test and Declaration of BD/DNC," 3 [3-4] to 5 [4-5]. The effect sizes (Wilcoxon r) ranged from 0.79 to 0.88 across domains. There were no significant differences in the magnitude of improvement between high-fidelity and low-fidelity groups. After curriculum implementation, 13 of 19 participants (68%) self-assessed their ACGME BD/DNC milestone competency to be level 4 or 5.

This multi-institutional pilot demonstrated that a consensus-based BD/DNC simulation curriculum is feasible and improves trainee confidence despite limited previous clinical exposure. Key lessons include the feasibility of multicenter collaboration, standardizing core practices while accommodating local variability, and designing adaptable curricula that achieve similar outcomes across resource-diverse settings.