Advanced Training for Providers: Simulation in ACLS and PALS Presented by: David L. Rodgers, EdD, EMT-P, NRP, FAHA Manager, Clinical Simulation Center and Resuscitation Sciences Training Center Penn State Hershey Medical Center Hershey, PA Strive to Survive: Improving Cardiac Resuscitation Nov. 4, 2016

Presenter Disclosure Information David Rodgers Advanced Training for Providers: Simulation in ACLS and PALS FINANCIAL DISCLOSURE: No relevant financial relationships exist UNLABELED/UNAPPROVED USES DISCLOSURE: None

What we are NOT going to cover…

What we are going to cover… What is “Fidelity” Instructor preparation Student preparation Administrative preparation Research into practice

Simulation and Life Support Training: A Good Match? “As sites gain access to an advanced patient simulator, the training and testing phases of ACLS are becoming more realistic. There are several advantages to the use of this technology, particularly with regard to a course such as ACLS (p. 399).” Franklin GA. (2004). Simulation in life support protocols, Practical Health Care Simulations. Edited by Loyd GE, Lake CL, and Greenburg RB, Philadelphia, PA, Elsevier/Mosby, p. 393-404.

Simulation is not new It’s always been there Asmund Laerdal and Bjorn Lind demonstrate CPR on the original Resusci Anne

Pre- “Simulation” ACLS

Post- “Simulation” ACLS

Hi-Tech Simulation is … More than just a manikin upgrade

Hi-Tech Simulation is an Upgrade to … Manikin Environment Instructor Learner

Fidelity “Fidelity is the extent to which the appearance and behaviour of the simulator/simulation match the appearance and behaviour of the simulated system (p. 23).” Maran, N. J., & Glavin, R. J. (2003). Low- to high-fidelity simulation - A continuum of medical education? Medical Education, 37 22-28.

Fidelity Low-fidelity simulators are focused on single skills and permit learners to practice in isolation. Medium-fidelity simulators provide a more realistic representation but lack sufficient cues for the learner to be fully immersed in the situation. High-fidelity simulators provide adequate cues to allow for full immersion and respond to treatment interventions. Yaeger, K. A., Halamek, L. P., Coyle, M., Murphy, A., Anderson, J., Boyle, K., et al. (2004). High-fidelity simulation-based training in neonatal nursing. Advances in Neonatal Care, 4, 326-331.

Fidelity a “system that presents a fully interactive patient and an appropriate clinical work environment (p. i5).” Gaba, D. (2004). The future vision of simulation in health care. Quality and Safety in Health Care, 13, i2-i10.

Fidelity Equipment

Fidelity Equipment Task

Fidelity Equipment Task Environmental

Fidelity Equipment Task Environmental Psychological

Fidelity Which is more important for most learning events …? 12% A high-fidelity simulator 88% A high-fidelity environment Dieckmann, P. (2008). How much realism is needed in medical simulation? Presentation at the International Meeting on Simulation in Healthcare, San Diego, Ca.

Fidelity

Instructor Perspective The simulator is just a tool for the instructor to use to accomplish learning objectives more effectively. The instructor is still the most critical resource in the room.

Instructor Perspective Teaching Style Objective Driven Technology Debriefing Skills Workload Realistic Scenario

Debriefing

Debriefing

Expectations for performance Student Perspective Orientation Expectations for performance Intimidated by technology Quickly accepted

Administrative Perspective Cost (Capital and Operating) Scheduling (Push-back from other users) Return on Investment

Outcomes Wayne DB, et al.: Mastery learning of Advanced Cardiac Life Support skills by Internal Medicine residents using simulation technology and deliberate practice. Journal of General Internal Medicine 2006; 21: p. 251. Wayne DB, et al.: Simulation-based training of internal medicine residents in Advanced Cardiac Life Support protocols: A randomized trial. Teaching and Learning in Medicine 2005; 17: p. 202-208. Wayne DB, et al.: Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: A case-control study. Chest 2008; 133: p. 56-61. BACKGROUND: Simulation technology is widely used in medical education. Linking educational outcomes achieved in a controlled environment to patient care improvement is a constant challenge. METHODS: This was a retrospective case-control study of cardiac arrest team responses from January to June 2004 at a university-affiliated internal medicine residency program. Medical records of advanced cardiac life support (ACLS) events were reviewed to assess adherence to ACLS response quality indicators based on American Heart Association (AHA) guidelines. All residents received traditional ACLS education. Second-year residents (simulator-trained group) also attended an educational program featuring the deliberate practice of ACLS scenarios using a human patient simulator. Third-year residents (traditionally trained group) were not trained on the simulator. During the study period, both simulator-trained and traditionally trained residents responded to ACLS events. We evaluated the effects of simulation training on the quality of the ACLS care provided. RESULTS: Simulator-trained residents showed significantly higher adherence to AHA standards (mean correct responses, 68%; SD, 20%) vs traditionally trained residents (mean correct responses, 44%; SD, 20%; p = 0.001). The odds ratio for an adherent ACLS response was 7.1 (95% confidence interval, 1.8 to 28.6) for simulator-trained residents compared to traditionally trained residents after controlling for patient age, ventilator, and telemetry status. CONCLUSIONS: A simulation-based educational program significantly improved the quality of care provided by residents during actual ACLS events. There is a growing body of evidence indicating that simulation can be a useful adjunct to traditional methods of procedural training. Chest 2008; 133: p. 56-61

Outcomes Rodgers, D. L., Securro, S., & Pauley, R. D. (2009). The effect of high-fidelity simulation on educational outcomes in an Advanced Cardiovascular Life Support course. Simulation in Healthcare, Vol. 4 (4) 200-206.

Outcomes Senior nursing students with little to no experience in ACLS First group – ACLS with low-fidelity manikins Second group – ACLS with high-fidelity manikins Both low- and high-fidelity did equally well at basic skills and activities in the first minutes of a simulated cardiac arrest Students in the high-fidelity group did better as the case grew longer and became more complex.

Outcomes Conlon, LW; Rodgers, DL; Shofer, FS; & Lipschik, GY. (2014). Impact of levels of simulation fidelity on training in ACLS. Hospital Practice. 42(4): 135-141 AIM: Identifying the modality and fidelity of simulation that offers the greatest benefit to the learner is critical to Advanced Cardiac Life Support (ACLS) training. Our hypothesis is that participants who receive ACLS training on high-fidelity mannequins will perform better than those trained on low-fidelity mannequins. METHODS: The study was performed in the context of an ACLS Initial Provider course for new postgraduate year 1 residents and involved 3 training arms: (1) low-fidelity, (2) mid-fidelity, and (3) high-fidelity. Educational outcomes were evaluated by written scores, student evaluations of the course, and expert rater reviews of megacode performance. RESULTS: A convenience sample of 54 subjects was randomized to 1 of the 3 training arms. All 3 groups significantly improved based on written posttest scores (P < 0.0001); however, pretest to posttest improvement among the 3 training arms was not significantly different: low-fidelity = 42.3 (95% CI, 35.7-48.9); mid-fidelity = 41.3 (95% CI, 34.7-47.9); high-fidelity = 40.8 (95% CI, 34.3-47.5; P = 0.95). All participants felt the simulator environment was realistic regardless of level of fidelity. Participants in the high-fidelity group were less likely to feel comfortable in the simulator environment (P = 0.0045). Clinical performance as assessed by expert raters' megacode scores was better for high-fidelity (66.3) than mid-fidelity (60.1) (P = 0.04). CONCLUSION: Overall, there was no difference among the 3 groups in test scores or perceived instructor or course quality; however, subjects trained on high-fidelity mannequins performed better than those trained on mid-fidelity with respect to megacode performance.

Outcomes BACKGROUND: Simulation is an effective tool for teaching medical students in cardiac arrest management. PURPOSE: The purpose of this article is to compare the efficacy of a traditional Advanced Cardiovascular Life Support (ACLS) course versus a modified longitudinal ACLS course using high-fidelity simulation in medical students. METHODS: One group enrolled in a 2-day traditional ACLS course while another group participated in independent learning over 2 weeks and 2 simulation sessions using Laerdal Sim-Man. The modified curriculum also included environmental fidelity with simulation, access to materials electronically, smaller class sizes, and integration of real experiences in the Emergency Department into their learning. Student performance was measured with a scripted, videotaped mega code, followed by a survey. RESULTS: We enrolled 21 students in a traditional ACLS program and 29 students in the simulation-based program (15 and 26 videos available for analysis). There was no difference in Time to Initiate CPR or Time to Shock between the groups, but the modified curriculum group demonstrated higher performance scores. They also felt better prepared to run the code during a simulation and in a hospital setting compared to students in the traditional ACLS curriculum. CONCLUSIONS: Students in a modified longitudinal simulation-based ACLS curriculum demonstrated better proficiency in learning ACLS compared to a traditional curriculum.

Outcomes Abstract OBJECTIVE: We performed a single-blinded, randomized controlled trial to evaluate the retention of advanced cardiac life support (ACLS) knowledge between high-fidelity simulation training (HFST) and traditional training (TT) in medical students. METHODS: Medical students were randomized to HFST or TT for their ACLS training. Students were then tested on 2 different mega-code scenarios immediately after their training and then 1-year later. A survey was performed asking their satisfaction of ACLS training and confidence of ACLS knowledge with a 10-point rating scale. RESULTS: 93 students were randomized with 86 completing the study (HFST=45, TT=41). The HFST group scored a higher percentage correct on initial testing than the TT group (83% vs. 70%, P<0.0001). However at 1-year follow up, both groups performed the same (66% vs. 66%, P=0.84). Satisfaction with training was higher with the HFST compared to the TT group (9.0 vs. 7.8, P<0.0001). Confidence in ACLS knowledge between HFST and TT groups were similar at baseline (6.9 vs. 6.5, P=0.18) and at 1-year (4.8 vs. 4.5, P=0.46). CONCLUSION: Students demonstrated greater ACLS knowledge initially with HFST than with TT. However, after 1-year, both groups performed the same. Satisfaction with training was higher with HFST compared to TT. Confidence in ACLS knowledge was the same initially and decreased similarly over a 1-year time period regardless of the type of ACLS training. Further studies will need to determine optimal strategies to retain ACLS knowledge.

Outcomes The use of high-fidelity manikins for ALS training can be beneficial for improving skills performance at course conclusion (Class IIa, LOE B-R). The usefulness of high-fidelity manikins for improving knowledge at course conclusion and skills performance beyond course conclusion is uncertain. Given the increased cost associated with high-fidelity training, the use of high-fidelity manikins is particularly appropriate in programs where existing resources (ie, human and financial resources) are already in place. More than just the simulation, debriefing must also be accomplished. Bhanji F, Donoghue AJ, Wolff MS, Flores GE, Halamek LP, Berman, JM, Sinz EH, Cheng A. Part 14: education: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015; 132(suppl 2):S561–S573.

Outcomes Objective: To describe the history of the Pediatric Advanced Life Support course and outline the new developments in instructor training that will impact the way debriefing is conducted during Pediatric Advanced Life Support courses. Outline: The Pediatric Advanced Life Support course, first released by the American Heart Association in 1988, has seen substantial growth and change over the past few decades. Over that time, Pediatric Advanced Life Support has become the standard for resuscitation training for pediatric healthcare providers in North America. The incorporation of high-fidelity simulation-based learning into the most recent version of Pediatric Advanced Life Support has helped to enhance the realism of scenarios and cases, but has also placed more emphasis on the importance of post scenario debriefing. We developed two new resources: an online debriefing module designed to introduce a new model of debriefing and a debriefing tool for real-time use during Pediatric Advanced Life Support courses, to enhance and standardize the quality of debriefing by Pediatric Advanced Life Support instructors. In this article, we review the history of Pediatric Advanced Life Support and Pediatric Advanced Life Support instructor training and discuss the development and implementation of the new debriefing module and debriefing tool for Pediatric Advanced Life Support instructors. Conclusion: The incorporation of the debriefing module and debriefing tool into the 2011 Pediatric Advanced Life Support instructor materials will help both new and existing Pediatric Advanced Life Support instructors develop and enhance their debriefing skills with the intention of improving the acquisition of knowledge and skills for Pediatric Advanced Life Support students. (Pediatr Crit Care Med 2012; 13:000–000) Cheng A, Rodgers D, van der Jagt E, Eppich W O'Donnell J. Evolution of the Pediatric Advanced Life Support course: Enhanced learning with a new debriefing tool and Web-based module for Pediatric Advanced Life Support instructors. Pediatr Crit Care Med 2012:.13(5), 589-595

Summary The use of high-fidelity simulation leans towards being efficacious in advanced life support courses such as ACLS and PALS. A high-fidelity simulation includes manikin, environment, and a realistic scenario. Both instructors and students need to be adequately prepared for teaching/learning in a high-fidelity simulation. Not everything needs to be taught in a high-fidelity simulation. Some objectives are better suited to task trainers while others benefit from a higher fidelity simulation.

Questions David L. Rodgers, EdD, EMT-P, NRP, FAHA Manager, Clinical Simulation Center and Resuscitation Sciences Training Center Penn State Hershey Medical Center 717-531-3947 drodgers1@hmc.psu.edu Acknowledgements: Roberta L. Hales, MHA, RRT-NPS, RN Barbara R. McKee, RN, MS