Simulation for Resuscitation

2015 - 3 June – Targeted Temperature Management
Diana Kelm, MD; Cassie C. Kennedy, MD
Two experts discuss simulation education in relation to CPR training.



Successful resuscitation is the most important determinant of survival after a cardiopulmonary arrest. This resuscitation requires complex, often rarely utilized knowledge and skills, as well as effective teamwork and communication among multidisciplinary personnel. The average survival rate for an in-hospital cardiac arrest is approximately 10%.(1) Factors influencing survival include time to resuscitation and adequate provider knowledge and technique. For example, the American Heart Association guidelines recommend that chest compressions be started within one minute and defibrillation within three minutes (if indicated) of a cardiac arrest. Every minute of delay in the initiation of these actions increases the risk of death.(2,3)

Like resuscitation itself, training healthcare providers in the performance of resuscitation requires an emphasis on timing, technique and teamwork. The classic medical teaching model of “see one, do one, teach one” is not sufficient when training in resuscitation, given the rarity and unpredictable timing of events. Furthermore, in the modern culture of patient safety, it is undesirable for trainees to practice high-stakes skills they have not yet mastered when viable alternatives exist.(4) Typical didactic teaching methods do not incorporate situational awareness, timing, teamwork and communication, and coordination of simultaneous skilled tasks.

Simulation provides an experiential learning opportunity in which a “real-life” environment or clinical scenario is mimicked. Cardiopulmonary arrest simulation closely resembles a real cardiopulmonary event. This simulation can involve a script and simulated environment, a multidisciplinary team, a patient (actor, virtual/computer-based or mannequin), and/or a task-trainer.  Scripted scenarios can be specific to one task (such as airway assessment and intubation in a patient with a pulse) or integrate multiple tasks (such as management of a ventricular fibrillation arrest). Mock code scenarios increase providers’ comfort level and skill and improve team collaboration.(5-11) They also increase equipment familiarity, clarify team roles and provide an opportunity for individual and team assessment to ensure staff readiness.(12)
 
Evidenced-based medical education supports the use of simulation in healthcare professional training. Two large meta-analyses demonstrated that in general simulation education for healthcare professionals was superior to no educational intervention or to an alternative intervention (such as didactic lectures, small-group sessions, computer-based tutorials, standardized patients, or educational videos) in improving learners’ knowledge, skills, behaviors, and patient-related outcomes.(12,13)  Simulation education is effective specifically in resuscitation training. A focused meta-analysis of resuscitation training demonstrated that simulation was superior to no intervention, in terms of the learners’ knowledge and skills and for patient-related outcomes, such as adherence to advanced cardiac life support algorithms, compression depth and rate, and pediatric survival after cardiopulmonary resuscitation.  This was true regardless of the learners’ level of training or study design.(14)  In addition, simulation compared to other instructional modalities improved learners’ satisfaction, knowledge, and skills and improved patient-related outcomes.(14)
 
The true cost of simulation education remains unknown. One meta-analysis found that only 6.1% of studies reported cost elements and only 1.6% provided costs compared to another educational modality.(15) Thus, further studies are needed to determine the cost-effectiveness of simulation.
Data supporting one specific simulation education design over another are less robust. A meta-analysis by Mundell et al supported group (versus individual) training, inclusion of external stressors/noise during training, and use of computer or real-time video feedback.(14) Sophisticated equipment is available for resuscitation training. High-fidelity mannequins can produce computer-generated vital signs that can be adjusted by an instructor. However, although high-fidelity mannequins showed increased learner satisfaction over low-fidelity mannequins, no other objective differences in learner outcomes were appreciated.(14)
 
Studies have shown that procedural or crisis management skills decline with time; ongoing simulation training leads to maintenance or decreased decline of learned skills.(16-19)  A refresher course for resuscitation training is also beneficial.(14) An emerging approach to refresher courses is the so-called in situ simulation. These occur in the learners’ environment with the typical team members and can be planned or unannounced. This approach has been studied in neonatal resuscitation and was found to effectively improve technical skills and teamwork.(20)
 
Emerging evidence in simulation for cardiopulmonary resuscitation skills supports the inclusion of leadership instruction. One study demonstrated that students who received leadership training exhibited improved skills and team performance.(21)

In conclusion, simulation education can safely address the complex integration of timing, skills and teamwork needed to achieve competence in cardiopulmonary resuscitation, without relying on the occurrence of rare events or subjecting patients to risk. The current literature supports simulation education in general, and in resuscitation training specifically, in improving knowledge, skills, behaviors, and patient-related outcomes. When building a simulation curriculum for resuscitation training, real-time feedback, group training, external stressors, and refresher courses should be considered.

References:

1. Dichtwald S, Matot I, Einav S. Improving the outcome of in-hospital cardiac arrest: the importance of being EARNEST. Semin Cardiothorac Vasc Anesth. 2009;13(1):19-30.
2. Ali B, Zafari AM. Narrative review: cardiopulmonary resuscitation and emergency cardiovascular care: review of the current guidelines. Ann Intern Med. 2007;147(3):171-179.
3. Zed PJ, Abu-Laban RB, Shuster M, Green RS, Slavik RS, Travers AH. Update on cardiopulmonary resuscitation and emergency cardiovascular care guidelines. Am J Health Syst Pharm. 2008;65(24):2337-2346.
4. Kohn CJ, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine; 2000..
5. Messmer PR. Enhancing nurse-physician collaboration using pediatric simulation. J Contin Educ  Nurs. 2008;39(7):319-327.
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9. Tofil NM, Lee White M, Manzella B, McGill D, Zinkan L. Initiation of a pediatric mock code program at a children's hospital. Med Teach. 2009;31(6):e241-e-247.
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11. Carroll L, Pignataro S. Use of portable simulation manikins to increase the frequency of mock code training on four inpatient surgical units. J Contin Educ Nurs. 2009;40(6):250-251.
12. Brown J, Lattimer-Heeter M, Marinelli A, Rex E, Reynolds L. The first 3 minutes: code preparation for the staff nurse. Orthop Nurs. 1995;14(3):35-40.
13. Cook DA, Brydges R, Hamstra SJ, et al. Comparative effectiveness of technology-enhanced simulation versus other instructional methods: a systematic review and meta-analysis. Simul  Healthc. 2012;7(5):308-320.
14. Mundell WC, Kennedy CC, Szostek JH, Cook DA. Simulation technology for resuscitation training: a systematic review and meta-analysis. Resuscitation. 2013;84(9):1174-1183.
15. Zendejas B, Wang AT, Brydges R, Hamstra SJ, Cook DA. Cost: the missing outcome in simulation-based medical education research: a systematic review. Surgery. 2013;153(2):160-176.
16. Carter YM, Marshall MB. Open lobectomy simulator is an effective tool for teaching thoracic surgical skills. Ann Thorac Surg. 2009;87(5):1546-1550; discussion 1551.
17. Oermann MH, Kardong-Edgren SE, Odom-Maryon T. Effects of monthly practice on nursing students' CPR psychomotor skill performance. Resuscitation. 2011;82(4):447-453.
18. Stefanidis D, Korndorffer JR, Markley S, Sierra R, Scott DJ. Proficiency maintenance: impact of ongoing simulator training on laparoscopic skill retention. J Am Coll Surg. 2006;202(4):599-603.
19. Kovacs G., Bullock G, Ackroyd-Stolarz S, Cain E, Petrie D. A randomized controlled trial on the effect of educational interventions in promoting airway management skill maintenance. Ann Emerg Med. 2000;36(4):301-309.
20. Rubio-Gurung S, Putet G, Touzet S, et al. In situ simulation training for neonatal resuscitation: an RCT. Pediatrics. 2014;134(3):e790-e797.
21. Hunziker S, Buhlmann C, Tschan F, et al. Brief leadership instructions improve cardiopulmonary resuscitation in a high-fidelity simulation: a randomized controlled trial. Crit Care Med. 2010;38(4):1086-1091.