Simulation-Based ACLS Going Beyond the Card… Mark Meyer MD Department of Emergency Medicine Kaiser Permanente San Diego Medical Center Southern California Regional Simulation Physician Coordinator Core Faculty, Kaiser Permanente Emergency Medicine Residency Program Clinical Faculty, UCSD School of Medicine

Background American Heart Association Emergency Cardiovascular Courses (ECC) are part of our daily operations – ACLS, PALS, etc. Current courses have changed in an attempt to become more effective and to include other concepts (teamwork/communication) essential for successful resuscitation Extensive resources are utilized to insure medical staff carry ACLS cards, yet research demonstrates that skill acquisition and retention is lacking

Objective: Create a more effective ACLS model that is largely simulation- based and can be delivered over a large scale with a variety of target audiences 1. Maintained focus on clinical knowledge, but also skills needed to effectively EXECUTE ACLS skills in a realistic setting 2. Create more engaging experience for participants AND instructors 3. Demonstrate improved performance behaviors and adherence to ACLS guidelines

Objective: Create a more effective ACLS model that is largely simulation- based and can be delivered over a large scale with a variety of target audiences 4. Demonstrate link between improved teamwork/communication skills and faster interventions 5. Evaluate tools that will provide more accurate and useful code data for documentation To demonstrate value of simulation To evaluate course effectiveness Clinical – QI and medical record

First Steps…

First Steps: Course Structure All participants will participate in a minimum of two scenarios as active participant All participants will participate in a minimum of two scenarios as active observer All simulation scenarios will include a cardiac arrest rhythm of pulseless VT/VF. Scenarios will include management of unstable tachycardia and bradycardia as well as ROSC.

First Steps: Course Structure Course will be taught by instructors with both ACLS instructor experience and high fidelity simulation instruction expertise Video-assisted debriefing If participating in ACLS re-certification, all participants must complete pre-test with passing score of 80% or greater. If participating in initial ACLS certification, all participants must complete HeartCode ACLS program

First Steps: Course Structure – Changes to Traditional ACLS Format High fidelity simulation scenarios are primary teaching modality: Replace traditional mega code stations and require ability to execute ACLS knowledge in a realistic environment Replace traditional skills stations and require ability to execute ACLS skills in a realistic environment Teach human factors/teamwork/communication skills during video- assisted debriefing

First Steps: Course Structure – Changes to Traditional ACLS Format Remediation as needed near the end of the session using traditional skills stations for those who did not perform skills satisfactorily during simulation. Participants perform roles they would play in a real code situation i.e. no leadership requirement unless appropriate No written post-course test

First Steps: Course Structure Instructor Requirements

Research Considerations- General Outcomes in cardiac arrest are universally poor. Even with improved performance behaviors, any change in patient outcomes after simulation based ACLS will require further study. The goal is to demonstrate improved performance behaviors and adherence to ACLS protocols Hypothesize that improved teamwork/communication skills will correlate with improved objective measures of medical management

Research Considerations Teamwork/Communication Skills Taught/reinforced in simulation debriefing using the Harvard Debriefing Model Selected elements of SBAR, as a tool for establishing a shared mental model Assessment Recommendation Role clarity/ Task assignment

Research Considerations Teamwork/Communication Skills

Research Considerations Medical Management All cardiac arrest scenarios will include VF or pulseless VT and will measure the following: Time to initiate compressions Time to initiate assisted ventilation Time to identify VF or pulseless VT and decide to shock Time to prepare defibrillator and deliver shock. Total time from Vfib to first defibrillation

Research Considerations Medical Management 4 Scenarios: 1. CHEST PAIN, STEMI,VF-ROSC 2. Family calls for unresponsive patient - pulseless VT-1 shock-VF-2 nd shock, vasopressor 3. AFIB – MED- UNSTABLE AFIB- SHOCK-VF-SHOCK – PEA-EPI- ROSC 4. Unstable Bradycardia-pace-capture x 30 sec- VF- 3 shocks, epi, amiodarone-ROSC

Research Considerations Medical Management

All cardiac arrest scenarios will include VF or pulseless VT and will measure the following: Time to initiate compressions Time to initiate assisted ventilation Time to identify VF or pulseless VT and decide to shock Time to prepare defibrillator and deliver shock. Total time from Vfib to first defibrillation

Research Considerations Limitations Inability to insure teams return in 6-12 months for repeat assessment Inability to insure teams from same clinical area train together Inability to insure mix of physician and nursing participation i.e. all nurses, all physicians No baseline performance measures available

Research Considerations Data Collection

Where next? – BLS RQI (Resuscitation Quality Initiative)

Where To Next? Resource utilization requirements have resulted in increasing pressure to provide ACLS certifications with less resources i.e. larger class size and less time for each session These limitations make a robust simulation ACLS course untenable given the number of current staff that require ACLS While code documentation is lacking, we know that there are delays in initiating BLS skills before code team arrives. Even ACLS certified staff are not providing BLS interventions. There is a significant number of staff that are required to carry ACLS certification that rarely if ever use their ACLS skills. These would be better served with more robust BLS training.

Where To Next? By shifting a portion of those staff currently required to have ACLS certification to more robust BLS/AED training, we can decrease the total number of staff that are required to have ACLS. This would result in: A decrease in the total resources required for ACLS – this would allow a portion of these savings to be applied to more effective ACLS training for the staff that really need it Increase the quality of our code responses since those responding would be most qualified and best trained Improvement of initiating BLS skills before code team arrives (chest compressions and defib have biggest impact on survival) An overall savings in the amount of resources dedicated to ECC courses (BLS+ACLS)

We Just Have to Be Willing to Make the Jump…