Comparison of sudden cardiac arrest resuscitation performance data obtained from in-hospital incident chart review and in situ high-fidelity medical simulation

doi:10.1016/j.resuscitation.2010.01.003

Resuscitation

Volume 81, Issue 4, April 2010, Pages 463-471

https://doi.org/10.1016/j.resuscitation.2010.01.003 Get rights and content

Abstract

Introduction

High-fidelity medical simulation of sudden cardiac arrest (SCA) presents an opportunity for systematic probing of in-hospital resuscitation systems. Investigators developed and implemented the SimCode program to evaluate simulation's ability to generate meaningful data for system safety analysis and determine concordance of observed results with institutional quality data.

Methods

Resuscitation response performance data were collected during in situ SCA simulations on hospital medical floors. SimCode dataset was compared with chart review-based dataset of actual (live) in-hospital resuscitation system performance for SCA events of similar acuity and complexity.

Results

135 hospital personnel participated in nine SimCode resuscitations between 2006 and 2008. Resuscitation teams arrived at 2.5 ± 1.3 min (mean ± SD) after resuscitation initiation, started bag-valve-mask ventilation by 2.8 ± 0.5 min, and completed endotracheal intubations at 11.3 ± 4.0 min. CPR was performed within 3.1 ± 2.3 min; arrhythmia recognition occurred by 4.9 ± 2.1 min, defibrillation at 6.8 ± 2.4 min. Chart review data for 168 live in-hospital SCA events during a contemporaneous period were extracted from institutional database. CPR and defibrillation occurred later during SimCodes than reported by chart review, i.e., live: 0.9 ± 2.3 min (p < 0.01) and 2.1 ± 4.1 min (p < 0.01), respectively. Chart review noted fewer problems with CPR performance (simulated: 43% proper CPR vs. live: 98%, p < 0.01). Potential causes of discrepancies between resuscitation response datasets included sample size and data limitations, simulation fidelity, unmatched SCA scenario pools, and dissimilar determination of SCA response performance by complementary reviewing methodologies.

Conclusion

On-site simulations successfully generated SCA response measurements for comparison with live resuscitation chart review data. Continued research may refine simulation's role in quality initiatives, clarify methodologic discrepancies and improve SCA response.

Introduction

Sudden cardiac arrest (SCA) is a leading cause of death in the United States, accounting for an estimated 325,000 deaths per year.1, 2 A significant proportion of these patients experience ventricular fibrillation (VF) or pulseless ventricular tachycardia, arrhythmias that may be reversible if cardiopulmonary supportive interventions and defibrillation are immediately available.3, 4 The proven association of early intervention and rapid defibrillation with survival-to-discharge,5, 6, 7 however, has not resulted in hospital resuscitation performance that consistently meets nationally established recommendations.⁸

In-hospital SCA presents an opportunity for definable improvements in patient outcomes,9, 10 even though specifics of its current incidence are limited¹¹ and its very nature poses several challenges. A fundamental problem is exposed in published reviews of unanticipated in-hospital medical resuscitation (“code” or “emergency”) management, which repeatedly report problems with documentation of events.12, 13 Especially for patients admitted to non-telemetry units, accurate resuscitation records following Utstein¹⁴ and National Registry of Cardiopulmonary Resuscitation (NRCPR)¹⁵ guidelines, e.g., documentation of intervals between time of cardiac arrest until time to cardiopulmonary resuscitation (CPR) initiation or time to first defibrillation, may not be available. Events preceding the arrest may never be fully clarified even in monitored high-acuity settings, and temporal measurements of critical actions during the resuscitation may be incomplete and imprecise.¹² Medicolegal concerns may discourage disclosure¹⁶ and clear discussion of peri-arrest details, effectively impeding quality management efforts. Limitations in data collection can generate misleading, if not hazardous or ineffective,¹⁷ interpretations of in-hospital SCA response performance.

An alternative approach to examining in-hospital SCA exists in the form of advanced medical simulation (SIM), the advent of which is changing education and assessment across the spectrum of healthcare systems.¹⁸ In situ simulations employing interactive full-body manikins and carried out within actual clinical environments are especially pertinent for systems probing and context-dependent performance assessment¹⁹; examples include pediatric medical and trauma patient care scenarios in an Emergency Department resuscitation bay²⁰ and teamwork and communications sessions held inside an actual obstetric suite.21, 22

Investigators applied in situ medical simulation to conduct in-hospital medical cardiopulmonary arrest scenarios [SimCodes] to (1) assess the local feasibility of in-hospital high-fidelity medical resuscitation simulations; (2) evaluate the simulation methodology's ability to generate objective, reproducible resuscitation data for system safety analysis; and (3) determine the concordance of common and accessible data elements between SimCode observation results and institutional quality management data compiled from chart review of actual (live) resuscitations. This manuscript presents SimCode program development and the investigative acquisition, characterization, and comparison of resuscitation performance datasets from traditional and simulated methods.

Section snippets

Setting and sample

The SimCode program is ongoing at an academic 719-bed regional referral hospital and Level 1 trauma center. Personnel from the institution's simulation center and departments of Emergency Medicine, Medicine, Nursing Education, Quality Management and Risk Management developed and implemented the program.

The SimCode team developed several on-site SIM scenarios with a modified SimMan manikin (Laerdal, Wappingers Falls, NY) for interdisciplinary resuscitation team immersion. Scenarios featured

Results

During a 27-month period between May 2006 and July 2008, a convenience sample of nine multi-disciplinary resuscitation teams involving a total of 135 hospital personnel participated in nine on-site SimCode resuscitations. Data from completed simulation sessions (excluding one set of time data lost with video record) revealed resuscitation teams arriving 2.5 ± 1.3 min (mean ± SD; range 0.5–4.4 min [n_team(SIM) = 8 available data points out of 9 possible]) after SimCode initiation, proper bag-valve-mask

Discussion

Simulation is described as “a technique to replace or amplify [real-life] experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive fashion.”²³ Even as studies are ongoing to establish its efficacy and validity, medical simulation is generally believed to contribute to the safety of patients. Notably, several recent reports demonstrate the utility of simulation training for knowledge and skills acquisition with retention in medical,

Conclusions

Scientific investigation of system performance in situ during simulated in-hospital SCA events may reveal overt as well as latent issues that jeopardize patient safety. SIM may prove valuable in accurate assessment of the care of patients requiring unanticipated cardiopulmonary resuscitation.

Conflicts of interest statement

No conflicts of interest for authors have arisen during the study or manuscript preparation.

Funding

This material is based upon work supported by the institution's Departments of Emergency Medicine and Risk Management. The opinions, findings, conclusions and recommendations expressed in the manuscript are those of the authors and do not necessarily reflect the views of the supporting departments.

Acknowledgements

The authors would like to acknowledge Anna C. Cousins for her insight and assistance in manuscript preparation and Jason Machan for his assistance with statistical analysis.

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Citation Excerpt :
To our knowledge no studies support or refute the conjecture that ‘sex matters’. Typically, CPR training and research tend to use one type of simulator, either torso mannequins (Laerdal's Little Anne®)9 or full body mannequins (SimMan®).10,11 Although medical simulators are considered “realistic models of real patients”12 and educationally useful,13 they have been described as having “perceived low levels of realism”.14
While males and females are equally at risk of sudden cardiac arrest (SCA), females are less likely to be resuscitated. Cardiopulmonary Resuscitation (CPR) may be inhibited by socio-cultural norms about exposing female victims’ chests. Empirically confirming this hypothesis is limited by lack of patient simulators modeling realistic female physiques. A commercially-available patient simulator was transformed to evaluate how physical attributes of a patient's sex might influence lay participants who were asked to resuscitate a female versus a male during simulated cardiac arrest.
Sixty-nine participants consented to be in the study. Participants were randomly assigned to provide CPR and defibrillation as instructed by a commercially-available automated external defibrillator on a patient simulator presented as either a male or female experiencing cardiac arrest.
Rescuers removed significantly more clothing from the male than the female, with men removing less clothing from the female. More rescuers’ initial hand placements for CPR were centered between the female's breasts compared to the male, on which placement was distributed across the chest towards the nipples.
While rescuers had better hand placement for CPR on the female, both men and women rescuers were reluctant to remove the female's clothing, with men significantly more hesitant. Reticence to remove clothing was often articulated relative to social norms during structured interviews. We suggest that using only male simulators will not allow trainees to experience social differences associated with the care of a female simulated patient. Realistic female patient simulators are needed.
In situ and mobile simulation: Lessons learned . . . authentic and resource intensive
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In situ simulation refers to a learning activity that takes place in the location or environment where the participants may actually provide patient care. Even as more and more simulation labs, schools, and centers emerge, the need for a mobile simulation plan often arises, including the ability to deliver simulation-based training at a clinical site other than one's home simulation site. This article is not only a review of the current literature, but it also incorporates practical solutions that are based on experiences from hundreds of in situ sessions provided at 11 New York City public hospital locations. This article also provides a list of some benefits and considerations when considering in situ or mobile simulation and some useful learning theories behind in situ training in addition to a checklist based on numerous in situ sessions that facilitators may find useful.
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Facts and fiction - Training in centres or in situ
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Citation Excerpt :
The identified problems included active errors by individuals and teams as well as systemic or latent errors in the environment. Performance data from simulated cardiac arrest scenarios have been compared with chart review data.22 Interestingly, chart review identified fewer problems with cardio pulmonary performance than the simulations.
Simulation based training is now widely used in health professions education to train both individuals and teams. Initially, most of these training initiatives were conducted in simulation centres, but over time concepts such as in situ and mobile simulation were developed. The idea is to train locally using the normal equipment. In this topical review, we will identify and elaborate on the major factors of importance for learning in the different settings. Facts and fiction of how to conduct cost effective training in the simulation centre, in situ and using mobile simulation will be discussed. Examples of how simulation can be used as a research tool will be presented. Last, this topical review will focus on suggestions for how to optimize training conditions in the different types of settings.
A search of publications was carried out in January 2012.
Simulation based training in situ/mobile and in centres both have advantages and disadvantages. It is recommended to carefully consider the purpose of training and consider the opportunities (financial, technical and human resources) and based on this to create the training cost effectively. In situ simulation can be used as a diagnostic tool to identify technological, organisational and human challenges.
Novelities in resuscitation training methods
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La importancia de la parada cardiaca como problema sanitario hace que la formación en las técnicas de resucitación constituya un tema de gran interés. Es necesario potenciar la formación en resucitación de todos los ciudadanos y que ésta se inicie en las escuelas y en los institutos, siendo dianas de la formación para convertirse en futuros instructores los maestros y los enfermeros. Parece demostrado que el modelo de cursos cortos con videoinstrucción y utilización de maniquíes es de gran utilidad para la difusión de las técnicas de resucitación. Parece conveniente la liberalización de la utilización de los desfibriladores externos automáticos (DEA) y la reducción de las exigencias formativas en soporte vital básico y DEA para aquellos profesionales no sanitarios que puedan utilizarlos. La formación a nivel sanitario debe mejorarse en las escuelas de medicina y enfermería a nivel de pregrado. Los profesionales sanitarios deberán recibir una formación acorde a sus necesidades y deberá destacarse el desarrollo de habilidades no técnicas, como el liderazgo y el trabajo en equipo. El modelo formativo con la utilización de instructores y maniquíes de baja fidelidad sigue siendo un elemento básico y fundamental en la formación. La formación mediante la evaluación del desempeño es una técnica que debe implantarse en todas aquellas áreas donde se presenten casos de parada cardiaca y el equipo de profesionales sanitarios haya intervenido. La simulación parece orientarse como la técnica actual y futura para la formación en distintos ámbitos sanitarios y, cómo no, dentro de este importante campo como es el de la resucitación. Finalmente, la investigación en formación en resucitación debe ser considerada como un claro ejemplo de ciencia translacional, en la que estudios rigurosos de adquisición de habilidades con medida de resultados, trasladen las mismas al entorno clínico, para el análisis de su repercusión sobre la atención de los pacientes.
The importance of cardiac arrest as a health problem makes training in resuscitation a topic of great interest. It is necessary to enhance resuscitation training for all citizens, starting in schools and institutes, targeting teachers and nurses for training, to in turn become future trainers. The model of short courses with video-instruction and the use of mannequins is useful for the dissemination of resuscitation techniques. Liberalization of the use of automated external defibrillators (AED) and reduction of the training requirements in basic life support and AED for those non-health professionals who can use them, seems appropriate. Training must be improved in schools of medicine and nursing schools at undergraduate level. Health professionals should be trained according to their needs, with emphasis on non-technical skills such as leadership and teamwork. The model based on the use of trainers and low-fidelity mannequins remains a basic and fundamental element in training. Training through performance evaluation is a technique that should be implemented in all areas where cases of cardiac arrest are seen and the healthcare team has intervened. Simulation appears to be defined as the current and future modality for training in various medical areas, including of course the important field of resuscitation. Lastly, research in resuscitation training should be considered an example of translational science, where rigorous studies of skill acquisition with outcome measures serve to transfer the results to the clinical environment for analysis of their impact upon patient care.
Crisis checklists for the operating room: Development and pilot testing
2011, Journal of the American College of Surgeons
Because operating room crises are rare events, failure to adhere to critical management steps is common. We sought to develop and pilot a tool to improve adherence to lifesaving measures during operating room crises.
We identified 12 of the most frequently occurring operating room crises and corresponding evidence-based metrics of essential care for each (46 total process measures). We developed checklists for each crisis based on a previously defined method, which included literature review, multidisciplinary expert consultation, and simulation. After development, 2 operating room teams (11 participants) were each exposed to 8 simulations with random assignment to checklist use or working from memory alone. Each team managed 4 simulations with a checklist available and 4 without. One of the primary outcomes measured through video review was failure to adhere to essential processes of care. Participants were surveyed for perceptions of checklist use and realism of the scenarios.
Checklist use resulted in a 6-fold reduction in failure of adherence to critical steps in management for 8 scenarios with 2 pilot teams. These results held in multivariate analysis accounting for clustering within teams and adjusting for learning or fatigue effects (11 of 46 failures without the checklist vs 2 of 46 failures with the checklist; adjusted relative risk = 0.15, 95% CI, 0.04–0.60; p = 0.007). All participants rated the overall quality of the checklists and scenarios to be higher than average or excellent.
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^☆: A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2010.01.003.

^☆☆: Aspects of portable and mobile simulation sessions discussed within the article were presented as abstracts at the April 2008 BMJ International Forum on Patient Safety in Healthcare, Paris, France, the October 2008 Research Forum of the American College of Emergency Physicians Scientific Assembly in Chicago, IL, the November 2008 Lifespan Research Celebration, Providence, RI, and the January 2009 International Meeting on Simulation in Healthcare in Orlando, FL.

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Simulation and educationComparison of sudden cardiac arrest resuscitation performance data obtained from in-hospital incident chart review and in situ high-fidelity medical simulation☆,☆☆

Abstract

Introduction

Methods

Results

Conclusion

Introduction

Section snippets

Setting and sample

Results

Discussion

Conclusions

Conflicts of interest statement

Funding

Acknowledgements

Am J Prev Med

Resuscitation

Mayo Clin Proc

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Jt Comm J Qual Patient Saf

Nurse Educ Today

Chest

J Am Coll Surg

J Am Coll Surg

Surgery

Ann Emerg Med

Resuscitation

Deaths: leading causes for 2002

Natl Vital Stat Rep

Long-term outcomes of out-of-hospital cardiac arrest after successful early defibrillation

N Engl J Med

Advanced cardiac life support in out-of-hospital cardiac arrest

N Engl J Med

Delayed time to defibrillation after in-hospital cardiac arrest

N Engl J Med

Improving in-hospital cardiac arrest process and outcomes with performance debriefing

Arch Intern Med

Survival from in-hospital cardiac arrest during nights and weekends

JAMA

Simulation and education
Comparison of sudden cardiac arrest resuscitation performance data obtained from in-hospital incident chart review and in situ high-fidelity medical simulation☆,☆☆