Data Collection Forms SS



Advanced Cardiac Life Support Checklists for Simulation-based Education

Background:

The following checklists are used at Northwestern University as assessment tools for internal medicine residents in Advanced Cardiac Life Support (ACLS). This is an update from our prior published checklists which used an earlier version of American Heart Association (AHA) ACLS guidelines. The current guidelines emphasize prompt defibrillation for appropriate rhythms and minimizing disruption of chest compressions. The checklists are part of a mastery learning program in ACLS for second-year internal medicine residents. Each resident has already completed a traditional AHA ACLS course at the beginning of the first training year, but is also required to complete the simulation-based training program as a second-year resident to serve as an ACLS team leader.

Mastery learning is a strict form of competency based education in which the learner must meet or exceed a minimum passing standard in order to progress in the curriculum. Features include pre and post-testing, deliberate practice and feedback, standard setting and remediation if the minimum standard is not met.

The checklists assess resident performance in 6 common ACLS events. These are: ventricular fibrillation, pulseless electrical activity, supraventricular tachycardia, symptomatic bradycardia, asystole and ventricular tachycardia. Checklists were developed for each procedure using the AHA ACLS 2010 guidelines1 and rigorous step-by-step procedures.2

The checklists have been used in our program to assess the competencies of medical knowledge and patient care. They could also be used to teach and assess teamwork and communication/leadership.

The checklists were designed to be used with a full-body human patient simulator. These models allow realistic responses to medications and are compatible with defibrillator and pacemaker equipment. Additionally, practice time for chest compressions and airway management skills are important components of the curriculum.

Timeline and Content of Simulation Program

In our program, 38 internal medicine residents participate in 3-two hour sessions in the simulator center in the fall of the PGY2 year. Residents attend sessions in groups of 4-6. The first session includes a pretest in which the resident is asked to lead a clinical response to 6 simulated ACLS scenarios. Each scenario contains a brief clinical history and has a defined endpoint. The resident’s performance is assessed by the examiner on the skills checklist for each scenario. Examinees are not allowed to refer to the checklists or other written materials during pre or posttest assessments. The remainder of the first session and the second session involve deliberate practice of the 6 ACLS scenarios.

Activities in each session are focused, standardized, and accompanied by specific feedback from the instructor.3

Checklists are available for review during teaching sessions. In addition to specific ACLS procedures and skills, intubation, airway management and chest compressions are important components of the curriculum. Effective closed-loop communication with patients, families, nursing and other team members is also emphasized. During team based ACLS care practice sessions, residents rotate through 4 roles. These are: team leader, chest compressor, airway manager, and nurse. Residents rotate so that each participant has the opportunity to practice the set of skills associated with each role. The nurse is responsible for medication administration. The team leader directs other team members, determines medication use and dosage and is responsible for equipment handling including the defibrillator/pacemaker.

The third session includes posttesting. Residents must meet or exceed a minimum passing score (MPS) for each ACLS scenario. If a resident does not meet the MPS for 1 or more scenarios, they are referred back to the simulator center for more deliberate practice.

Sample Schedule:

July-August – pretesting of residents during first simulator session

Sept-October – teaching sessions for residents

November-December – posttesting of residents

Details regarding development and effectiveness of the ACLS curriculum are available in prior published reports.4-9 These include a randomized trial of simulation training4, standard setting and development of the MPS5, use of simulation training for mastery learning of ACLS procedures,6 documentation of skill retention 14 months after training 7 and a dramatic and sustained improvement in actual ACLS patient care after simulator-based training.8,9

Highly reliable data is obtained when using the checklists. When using experienced raters, interrater reliabilities were 0.8 or higher for each of the six scenarios.6 High data reliability allows for valid inferences or judgments about each subject’s skills, i.e. achievement of the MPS and continuing on to provide actual ACLS patient care. Skill retention7 and improved clinical performance in actual patient care8,9 after completion of the curriculum provide additional validity evidence for the effectiveness of the intervention.

Equipment needed:

-Human Patient Simulator

-Cardiac Monitor

-Defibrillator/AED

-Pacemaker

-Prefilled syringes to administer medications named in ACLS algorithms

-Intubation equipment

-Airway management supplies (oxygen tank, nasal cannula, mask)

Participants in the educational program:

|Session |Content |Participants |

|1 | |4-6 Residents |

| |Pretest and Teaching |1 Simulator center staff* |

| | |1 Faculty+ |

| | |1 Examiner‡ |

|2 |Teaching: |4 Residents |

| |Pulseless arrhythmias, tachycardias, bradycardia |1 Simulator center staff* |

| | |1 Faculty+ |

|3 | |1 Resident |

| |Review and Posttest |1 Simulator center staff* |

| | |1 Faculty+ |

| | |1 Examiner‡ |

*Simulator staff operate the simulator and provide a voice for the simulated patient. Staff are located behind a one-way mirror at our facility and can see the scenario and simulator but are not visible to the learners.

+Faculty facilitate testing sessions by carrying out tasks as assigned by the examinee. Faculty provide direction and feedback during teaching sessions.

‡Examiner scores each resident on the checklists.

Abbreviations used in the Checklists:

1) 5H/5T is an abbreviation for reversible causes or contributing factors to pulseless arrythmias.1 The five “H’s” are: hypovolemia, hypoxia, hydrogen ion (acidosis), hypo/hyperkalemia, and hypothermia. The five “T’s” are: toxins, tamponade (cardiac), tension pneumothorax, thrombosis (coronary) and thrombosis (pulmonary).

2) Monitored/Non Monitored. At the beginning of the case scenario, the patient is on a cardiac monitor (monitored) or is not on a monitor (non-monitored). Timing of telemetry monitoring is important for the assessment of each clinical scenario.

3) Confirm Code Status is a new step inserted into each scenario. This reflects the need to ensure that patients do not receive care (such as defibrillation) they do not desire.

A recent publication by a group at Medical College of Georgia used our checklists and a low fidelity simulator. The investigators showed that the low-fidelity model also led to significant skill acquisition and retention.10

References

1. Neumar RW, Otto CW, Link MS.et al. Adult Advanced Cardiovascular Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S729-S767.

2. Stufflebeam DL. The Checklists Development Checklist. Western Michigan

University Evaluation Center, July 2000. Available at . Accessed 12/15/2005.

3. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2004;79:S70-S81.

4. Wayne DB, Butter J, Siddall VJ, Fudala M, Lindquist L, Feinglass J, Wade

LD, McGaghie WC. Simulation-based training of internal medicine residents

in advanced cardiac life support protocols: a randomized trial. Teach Learn Med. 2005;17:202-208.

5. Wayne DB, Fudala MJ, Butter J, Siddall VJ, Feinglass J, Wade LD, McGaghie

WC. Comparison of two standard-setting methods for advanced cardiac life

support training. Acad Med. 2005;80(10 Suppl):S63-S66.

6. Wayne DB, Butter J, Siddall VJ, Fudala MJ, Wade LD, Feinglass J, McGaghie

WC. Mastery learning of advanced cardiac life support skills by internal medicine using simulation technology and deliberate practice. J Gen Intern Med. 2006;21:251-6.

7. Wayne DB, Siddall VJ, Butter J, Fudala MJ, Wade LD, Feinglass J, McGaghie

WC. A longitudinal study of internal medicine residents’ retention of advanced

cardiac support life skills. Acad Med. 2006;81(10 Suppl):S9-S12

8. Wayne DB, Didwania A, Fudala M, Barsuk JH, Feinglass J, McGaghie WC.

Simulation-based education improves quality of care during advanced cardiac

life support events: a case control study. Chest. 2008;133:56-61.

9. Didwania A, McGaghie WC, Cohen ER, Butter J, Barsuk JH, Wade LD, Chester

R, Wayne DB. Progress toward improving the quality of cardiac arrest medical

team responses at an academic teaching hospital. J Grad Med Educ. 2011;3:211-

216.

10. Colquitt JD, Parish DC, Trammell AR, McCullough J, Swadener-Culpepper L, et

al. Mastery learning of ACLS among internal medicine residents. Analg

Resusc: Curr Res S1. 2013

Data Collection Forms Advanced Cardiac Life Support Simulation Program

Study # ____________________

Date ______________ Evaluator ________________________________

Ventricular Fibrillation/Pulseless : Persistent / Refractory

Skill Key: A = Done Correctly B = Done Incorrectly C = Not Done

|Check responsiveness |A |B |C |

|Confirm patient code status |A |B |C |

|Get Help/Assign roles |A |B |C |

|Call for defibrillator |A |B |C |

|Check for a pulse 100/min, > 2in deep |A |B |C |

|Open airway, give 2 rescue breaths |A |B |C |

|Continue respirations at ratio compressions:respirations of 30:2. |A |B |C |

|Give oxygen. |A |B |C |

|Attach monitor/defibrillator |A |B |C |

|Check/Identify rhythm on monitor ................
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