Simulcast Journal Club October 2018


Introduction :  

Simulcast Journal Club is a monthly series that aims to encourage simulation educators to explore and learn from publications on Healthcare Simulation Education.  Inspired by the ALiEM MEdIC Series, each month we publish a case and link a paper with associated questions for discussion.  We moderate and summarise the discussion at the end of the month in pdf and podcast format, including opinions of experts from the field. 

For the journal club to thrive we need your comments!  Some participants report feeling nervous about their initial posts, but we work hard at ensuring this is a safe online space where your thoughts are valued and appreciated.  To ensure this, all posts are reviewed prior to posting.  We look forward to learning from you. 

Journal Club (1)

Title :  “Homeostasis 

Brad panted as he raced up the last of the hospital stairs and into the hallway.  Nitin had gone to help with the arrest 15 minutes earlier but when he’d called for backup his voice had been laced with fear.  

As Brad walked into the patients’ room he kept quiet and surveyed the lay of the land.  With resignation he realised he’d seen this scene too many times in his career.   A messy resuscitation, stressed out staff, poor quality chest compressions, noise. 

He supressed the urge to voice frustration.  Contain the emotion.  They’re doing their best. 

But that wasn’t true, he thought, this wasn’t their best.  These were smart, capable people who cared about their patients.  And they sucked at resuscitation.  Annual competencies just couldn’t keep ward staff skilled enough at CPR when a child might arrest on them once in a career. 

He placed a supportive hand on Nitin’s shoulder and smiled grimly. 

“What do we need?” he asked. 

The Article : 

Cheng, A., Nadkarni, V., Mancini, M., Hunt, E., Sinz, E., Merchant, R., Donoghue, A., Duff, J., Eppich, W., Auerbach, M., Bigham, B., Blewer, A., Chan, P. and Bhanji, F. (2018). Resuscitation Education Science: Educational Strategies to Improve Outcomes From Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation, 138(6). 

 

Discussion :  

This month we’re moving journal club from debriefing to look more at curriculum development.  In August 2018, Cheng et al published this extensive, open access document providing a detailed look at current evidence about what works in Resuscitation Education. 

For our journal clubbers, please share your perspectives on the paper, and if you don’t have any specific thoughts :  

  • How does this paper reflect or diverge from the reality of your resuscitation training? 
  • Do the principles outlined in this article ring true? 
  • What would be barriers towards implementing these strategies? 

 

References : 

Cheng, A., Nadkarni, V., Mancini, M., Hunt, E., Sinz, E., Merchant, R., Donoghue, A., Duff, J., Eppich, W., Auerbach, M., Bigham, B., Blewer, A., Chan, P. and Bhanji, F. (2018). Resuscitation Education Science: Educational Strategies to Improve Outcomes From Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation, 138(6). 

 


About Ben Symon

Ben is a Paediatric Emergency Physician at The Prince Charles Hospital in Brisbane and a Simulation Educator at Lady Cilento Children's Hospital. He currently teaches on a variety of paediatric simulation based courses on paediatric resuscitation, trauma and CRM principles. Ben has a growing interest in encouraging clinical educators to be more familiar with simulation research.


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36 thoughts on “Simulcast Journal Club October 2018

  • Eve Purdy

    Hey Ben,

    Thanks for bringing up such an important paper. We covered it in this week’s “Educators Get Educated” meeting as well on the Gold Coast! It certainly is…comprehensive and I appreciated the alternate summary and infographic publications with the option to dive deep into a few topics that I was particularly interested in. Thanks to the authors for this massive effort.

    To be honest though, I am a bit disappointed that we didn’t get a more juicy chapter in the Nimali and Nitin saga…

    Fortunately, my resuscitation training in an Emergency Medicine residency has consisted of many of the evidence-based suggestions that these authors put forward including:

    -mastery learning: from PGY1-PGY5 we engage in simulation rounds every week. We develop graded responsibility and eventually become the teachers.
    -spaced practice: when learning central lines as PGY2s we have 5 x 2hr sessions over the course of the summer building on everything from setup to needle control to the full procedure.
    -feedback and debriefing: a strength of our program is our daily feedback sessions at the end of each shift and informal debriefing of resus cases that we have led
    -assessment: this is something that is being developed and becoming more and more part of our reality with CBME

    We don’t:
    -do as much contextual training (i.e. practicing with the teams that we work with on a regular basis)
    -innovative learning methods unless sought out on your own

    I would expect that the level of education for specialists in resuscitation should be touching on many of these high quality indicators. I am glad that they didn’t feel entirely foreign. Although we should continue to make efforts to improve emergency medicine resident education, the bigger question becomes how can we raise the bar as teams in our hospital in the ED and beyond. In my experience ACLS and BLS has been the effort to at least make a bar that must be met by hospital administrators. This training modality does not use many (any?) of these evidence-based best practices. So the debate about where we go from here is where things get very interesting….In my mind this paper basically shows that ACLS/BLS – as delivered in my experience – must undergo significant changes if they are going to remain relevant. So if it doesn’t actually teach resuscitation skills effectively, what does mandatory training do?

    -signals to employees that we think it’s important that they know how to do CPR, even if it doesn’t give them the skills
    -exerts control over employees which is part of a bigger institutional effort to standardize behaviour and maintain power (beyond resuscitation)
    -makes big bodies money and more powerful/recognized (they have an ongoing vested interest in this rather than supporting contextualized grassroots training)
    -allows people who teach the courses (and who are most likely to be in resuscitation scenarios) to engage in some of the best practices (mastery learning, spaced repetition)

    Will mandatory BLS/ACLS remain in place even if it doesn’t start to incorporate more of these best practices? Probably…at least for quite some time because:

    -as the article points out, unlearning is hard and probably even more challenging for institutions than for individual learners.
    -the best practices are expensive and necessitate tireless champions and interested learners
    -it is easily measured in a tick box
    -institutions hire individuals and it is easier to incentivize them

    Bigger questions we need to be considering are a bit more philosophical and probably shouldn’t be coming from a resuscitationist…what is the value add of training for everyone? There are potentially more important things that we should be spending money on from an training perspective outside of high risk areas (ED, periop, ICU). Some of these interventions have the ability to reduce costs compared to current training (which I think should be the goal for most places in the hospital) but some of the interventions might significantly increase the price tag. We need to be mindful of the fact that there is an opportunity cost to everything and we must carefully consider if we will be taking away from other more high yield topics in non-resuscuation areas of the hospital. The “contextualization” aspects brought up in this paper MUST be at the forefront of our minds as we work with hospitals and our colleagues to improve training to a level that is appropriate for the roles that people are in.

    • Ben Symon Post author

      Hi Eve, thanks so much for starting the conversation.
      It was great to hear from someone who can identify so many of these innovations having been already incorporated in your practice, I wish I could say the same.
      I was particularly intrigued by your points at the end : 1) Unlearning is harder for institutions than learners, 2) Best practices are expensive and need champions 3) Current practices involve tick boxes 4) Mandatory competencies allow incentivisation.

      Interesting thoughts, as well as your question about training everyone. It’s an interesting thought, particularly relevant in paeds where a cardiac arrest is exceptionally rare. I still think good quality CPR in particularly is a valid expectation of every hospital staff member, but I agree there is an opportunity cost in prioritising that as an annual review over other things. Hmm…. much to think about!

      • Eve Purdy

        Thanks for prompting me to clarify a few thoughts.

        1) Unlearning is hard for everyone (institutions and individuals) but likely harder for for institutions because of the inertia and bureaucracy associated with large organizations. So even if we all agree that we should be doing things differently, actually affecting that change at the institutional level will be slow to happen.
        2) Best practices aren’t *necessarily* more expensive than the way that we are already doing things but certainly many of the interventions they suggest might be. We have to be mindful of the cost-benefit ratio with any new and existing intervention. Champions are necessary for any variety of change!
        3) Certainly many places that I work in Canada to be hired I have to have ACLS, ATLS, PALS, US training etc. These are tick boxes to satisfy employment but this article shows us that those checks do not guarantee any type of long term learning, ability to apply skills within a new group, or ongoing competence.
        4) Mandatory tick boxes (see 3) are easy for organizations to measure. I.e. you don’t get hired or you don’t get paid unless you have done this mandatory training. It certainly isn’t a high level of intrinsic motivation but is enough that we all do it, and continue to do it, despite knowing that it is potentially a waste of time. In my mind though these extrinsic measures really target the wrong kind of motivation. What would be really neat would be to incentivize individual units to sort out what is the best way to train their employees for what is needed.

        Yes, CPR is a universal skill that we should all know about and many should be able to perform. Should everyone be able to bag-valve mask, probably not. I think just important however, is identifying people who should not be performing CPR (and not penalizing them for it but identifying what other important roles they can play). We have all seen older, or smaller, or less physically capable colleagues that are not the people that make the most sense to task with this job.

        • Christina Choung

          Hi Eve & Ben,
          Really great comments, and definitely on the pulse! The healthcare organization I work for is actually looking into the very issue of maintaining competency in resuscitation versus “ticking off the box,” as Eve has mentioned. Those of us in the sim department were quite excited when this paper was published, as it was “evidence” for what we have been preaching.
          Currently, I would say that our resuscitation education does not look like this across the board. It varies widely, depending on the department. We don’t have one centralized education department, therefore each department sort of does its own thing. On a more positive note, I have been seeing more departments move towards this model – its in its infancy, but more and more people have been asking for the sim department’s assistance to provide 4-6 of the 8 suggested key elements in this paper.
          That being said, widespread implementation does become a question of cost and resources – as the authors of the paper mention several times under the “implementation issues” headings. The specific costs and resources which stand in the way, IMHO, are competing priorities, and having the right people for certain tasks. As mentioned:
          1) Where does resuscitation sit in the hierarchy of ever-competing priorities in any healthcare department? Surely in the ED and for those on the code team, it’s a no-brainer. But how about for those on general wards? In clinics? In residential care? Do we do an assessment of areas with the highest rates of cardiac/respiratory arrest, and focus on those? Typically those are the areas with the highest acuity and complexity, with the greatest amount of educational need.
          2) Who does the actual implementation of these suggestions? We have two ideas, none of which is perfect… I’m hoping others have other ideas. The first is that this work falls within the realm of the distributed network of educators throughout the institution, as they know each department’s culture and needs best – they know the context and can tailor education to it. However, many do not possess the educational skills required, or have the confidence in their abilities, to implement these suggestions. Faculty development is great, but educator turnover is high and we can never keep on top of it, and they too, have their own competing needs. The second option is to have a position specifically for sim/resuscitation practice. I think this is the ideal, however this person wouldn’t know the local contexts as well – especially in larger institutions. I think this person could work with the local educator to fill that gap, and I think this option is best. But that requires adding a new FTE/position – and is expensive. Which leads to…
          3) I hate to say this, but it’s often the elephant in the room… in many instances, saving people is more costly than not. Ugh, I feel gross even saying it. But, IRL when it comes to administrators, it can often boil down to dollars and cents. Funding positions which ultimately cost the institutions more can be very challenging, uphill battles.

          On a more positive note, I do think this paper is brilliant. Although explicitly cautioned in the opening paragraphs to not generalize, I’ve been calling it “a primer for adult education and maintenance of competency”. I especially like the first figure, on the second page of the article. And, as Eve also mentioned, the accompanying infographics have been very helpful – in my conversations with others, I typically use the infographic with the 8 key elements as a jumping-off point.

          • Farrukh Jafri

            Hi All

            I built a simulation lab 3 years prior at a busy community hospital in New York. I had a meeting with our finance committee after sustaining funding, and came prepared with a presentation about safety, education and benefits of simulation… but was blown away by the focus on finances. It really comes down to monetary value at the executive level. Since that period of time, I’ve been to many more of these meetings and am less shell shocked. I think the bringing up of finances is so important and relevant to the survival of such programs.

            I also find this distributed network of educators. I’m the only one doing simulation where I am, but I attend quarterly meetings at my tertiary hub and see such amazing programs that are being run, but, in silos. A benefit of an overall full time head is to be able to involve integration. I’m fortunate to have this and am now working on a multiple hospital collaborative with an ENT regarding critical airway interventions and was able to get the Emergency Department involved. But yes, how about cost! One thing I feel that also needs to be evaluated is the return on investment to continue to have these programs develop. I feel that the success of changing simulation education from tertiary care centers to be able to also move to community practice relies on this return of investment. For pediatrics alone, 90% of children are seen in community settings and data on variability of care or even pediatric readiness is scary (this is ED literature)! I now have the kirkpatrick phillips model for learning education as my screensaver. The cost aspect is something I am acutely aware of as I am teaching in an non-academic environment and realize that I need to demonstrate this return or my program can be scrapped. My focus is on CRM and I do this through simulations of multi-disciplinary teams. There is data among medical students, that teaching teamwork was superior to teaching technical performance regarding CPR. The teams with leadership training had more leadership utterances and better overall cardiopulmonary resuscitation performance (PMID: 20124886). Can we translate this further? I feel resuscitation education in so many environments is important (ED, ICU) but if we also focus on day to day interactions of teamwork and team behaviors (CRM) that this may also improve the quality of resuscitative care. I hope over the next few years to focus on moving my research out of the simulation lab and see its effect on “flash mob resuscitations” i.e. rapid responses and pediatric codes. CRM has been shown to decrease medical errors, I feel, like they did with central lines, by putting a price tag on it, we can easily justify so many of these positions and programs.

  • Susan Eller

    Hello Ben,

    Like Eve – I was also disapointed that you left us hanging with Nimali and Nitin saga… 😉

    I laughed when Adam said on Twitter that he would give a gold star to anyone who got through all 41 pages. Then I had to laugh at myself when I realized it was 30 pages of content, with over 400 references. Such a stellar group of researchers, authors and educators who contributed to this… comprehensive review of resuscitation education. I really liked the flow of each topic: background, definitions, summary of evidence, suggestions for improvement, and implementation issues.

    Some of the topics were familiar to me, Mastery learning, feedback and debriefing, contextual learning, and assessment. I probably took a deeper dive into some of the topics that challenge our institution: spaced practice and innovative educational strategies. I think that the logistical challenges of spaced practice are one of our greatest hurdles for some learning groups. It is one thing to have a group of learners who have simulation scheduled once a month to schedule resuscitation practice in at regular intervals – this is the case with our residents, and perhaps medical students. However, the nurses, pharmacists, or respiratory therapists usually only are scheduled for CPR or ACLS once every two years. Implementation of spaced practice not only requires learning management systems, but in some cases contract negotiations with certain learner populations. In terms of the gamification – I concur that it can be used to enhance knowledge or decision-making skills, but does not adequately address the issue of hands-on practice of the high quality CPR or other skills such as defibrillation.

    Like Eve, Christina and yourself, I am not a big fan of this education existing as tick- box, or something that needs to be done in order to make the regulatory agency happy. Which is sadly what happens sometimes to those groups who don’t use it on a regular basis and so don’t live with the daily value. One of the great things about the ECC conference is the time devoted to hearing the survivor stories. It is great for those of us who teach resuscitation skills, but we are probably not the ones who benefit most from those stories.

    I do have to confess that at times I was experiencing a little cognitive overload. Like Eve and Christina, I appreciated the graphic at the beginning, so that I could have a visual frame of reference, or framework, to re-orient myself to the various articles. I might have wished that it was broken down into 8 smaller articles for each of the key elements, but that probably is an individual preference. It made me sorry that I had missed the educational summit in 2017, as I would have loved a chance to hear the topic group experts and have a chance for questions.

    • Ben Symon Post author

      OK I think I need to offer a formal apology for no romance this month. I couldn’t find a way to combine CPR Education and Romance without sounding vaguely disrespectful :p I will solemnly work harder on it next month.

  • Shannon McNamara

    Thanks for starting a great discussion! In reading Eve, Christina, and Susan’s comments, I identify with many of the same challenges of being stuck in an economically driven tick-box system. From the structure of the JC questions presented:

    How does this paper reflect or diverge from the reality of your resuscitation training?

    -Though I do my best to teach a lot of awesome resuscitation sim courses, my ACLS experience has been that I need to supply my employer with a card, and I need to get one quickly and cheaply in my free time. There are many businesses that will do that for me, as quickly as possible. I am guilty of buying really terrible sim courses for ACLS. I would be ashamed to run one like that, but I’ll take whatever I can get as a learner.

    Do the principles outlined in this article ring true?

    -As an educator, I absolutely agree with the educational principles outlined for high quality education and outcomes. As a somewhat frenzied ER doc, I would like the fast food of resus education – quick and cheap. I would prefer that the time that ACLS (etc) takes is factored into my employment, and not an extra thing that I’m required to do on my off time.

    What would be barriers towards implementing these strategies?

    -ACLS (etc) is BIG business. Doing it well is not incentivized – quick and cheap is. Though I am 100% on board with the educational modalities listed, I don’t know how to incentivize the unlearning and huge mindset and financial investment shift that would need to happen.

    -In an ideal world: I would do an in situ ACLS (etc) case every day or every week at the beginning of the shift with my team. This would be factored into my work day and I would be paid for it. This would be tracked. We would get rigorous performance based feedback. Then I would get all my merit badges.

    Another point not mentioned here is the role of human factors (or perhaps it was and I missed it – there’s a whole sim fellowship in this paper, y’all!). We can’t just educate ourselves into great resuscitation. We need to innovate in our clinical spaces to make it easier. I appreciate Betsy Hunt’s recent updates on using a CPR coach, an innovative role to improve performance, and the Hicks / Petrosniak team on their trauma human factors work. Education is essential, but it only goes so far. We need human centered systems designed to fill in the inevitable gaps.

    • Ben Symon Post author

      Hi Shannon, great to hear from you! It’s an interesting conflict, this tension between economic efficiency, bureaucratic data requirements and achieving tangible proficiency in a technical skill. In some ways it makes sense, in other ways, it seems like the whole wheel needs to be rethought. Surely there would be a way to address all of these things in a way that becomes more patient focused? I notice that both yourself and Christine allude to slight undercurrents that economic efficiency might not be the same thing as saving lives.
      Sad though, if our institutions have become such behemoths that their drive for checkboxes outrides their drive for quality care.
      I wonder what kind of incentives might bring hospitals to the table to this sort of agenda? I guess the AHA Statement itself is a start.

      • Shannon McNamara

        “I wonder what kind of incentives might bring hospitals to the table to this sort of agenda? I guess the AHA Statement itself is a start.”

        Helpful framing, Ben! Overall, I think institutions aren’t opposed to quality care, I think the boat is just very very very large and difficult to steer in a new direction. My big challenge with this paper is that it’s basically saying that the entire ACLS industry (in the US at least) is doing it wrong, but doesn’t have the teeth attached to change it. I have a feeling there’s a grand plan to add teeth in the long game and that this statement is only a start. At what point and how to we acknowledge that the current ACLS training industry is likely broken and start over? Unfortunately the drive for online only courses is not promising in that direction.

        • Ben Symon Post author

          It’s tricky hey, the sheer enormity of the implications of this paper.
          I see it as a mission statement and a call to action, and I hope that the next step in this conversation is to break those changes down into incremental small steps.
          I agree this can seem insurmounatable, but I’ll bet in 10 years we’ll look back and find that Resuscitation Education has changed.

        • Christina Choung

          Great question! I honestly think if the shift from mere tick boxes to competency – as is happening with the Royal College here in Canada, I believe – comes to fruition, we’ll see more cries for practice opportunities and spaced learning. I’m not sure what it’s like in other countries, but over here accreditation through Accreditation Canada often has the ability to change practice. I would LOVE to see education modalities and offerings included in part of the accreditation process!

  • Jesse Spurr

    Hello JC team.
    I am going to be super brief, as I have little to add to the reflections thus far. So:
    1) I think this is one of those ‘gateway drug’ type articles that will hopefully serve as a conduit to some great educational theory and learning science for a whole lot of clinical educational enthusiasts and hopefully even some hospital administrators. I liken this to ‘The Human Factor’ paper by Hicks and Petrosoniak featured on JC a few months back in that it provides a one stop shop to refer people interested in going down and educational rabbit hole.
    2) In fitting with contextual learning, spaced practice and other instructional design features outlined by Adam and colleagues, this is a really interesting complimentary paper from Resuscitation Sep 2018 “Hospitals with more-active participation in conducting standardized in-situ mock codes have improved survival after in-hospital cardiopulmonary arrest”. https://www.clinicalkey.com.au/#!/content/playContent/1-s2.0-S0300957218309080?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS0300957218309080%3Fshowall%3Dtrue&referrer=https:%2F%2Fwww.jwatch.org%2Fna47661%2F2018%2F10%2F05%2Fmock-codes-save-lives%3Fijkey%3DZOXytCPuV Well worth the read if not just to confirm our own biases! Thanks to James French @Grade1View (https://twitter.com/grade1view) for pushing this paper in front of me.

  • NEMAT ALSABA

    Thanks Ben for choosing such a masterpiece of an article!

    Thanks to the authors for a well written and designed article. Nice flow and complemented with a great summary and infographic. I agree with previous comments that it can easily be published as multiple articles. It will be great as a chapter in one of the books!

    A lot of great points and discussion has been covered in the above conversations and post but these are the highlights for me :
    • This article encourages cultural changes in our ACLS/BLS training and delivery through customizing the program and training to fit the department and staff needs rather than just ticking a box on a piece of paper.
    This might include the duration of the course, the intervals between 2 courses or the place where the course is taking place (insitu Vs in sim labs or both).
    There is nothing wrong with identifying staff who can’t deliver effective Chest compression in resuscitation due to physical issues but on the other hand, they can be more effective in another task in resuscitation. So know your learners ( staff ) and design the training that meets their need and accommodates their abilities.
    • The assessment section had an interesting discussion. Shifting the measurement from WHAT? to SO WHAT? and measuring what is truly important for the patient outcome.
    Assessment should not only be limited to individual tasks but should also include collective ability and teamwork. I also liked the article suggestion to make the assessment longitudinal.
    • An excellent point was brought up in the contextual learning. Stressing and challenging your learner (to an extent!) will maximize the learners engagement. We had a great journal club article review about psychological safety so I don’t need to say more 😊
    And last your question Ben: What would be barriers towards implementing these strategies?
    It has to be fear of change! this includes learners + trainers and employee + employer.
    I am looking forward to see the changes in our ACLS / PALS training programs that the article has discussed.

  • Ben Symon Post author

    I just want to include the CanadiEM Infographics that have been developed to cover this paper as well, for the ADHD cohort among us who are currently cursing my name for including a 40 page document in Journal Club!
    The infographics are posted here :

    https://canadiem.org/aha-scientific-statement-on-resuscitation-education/

    Created by Simon Huang and Alvin Chin, they provide a great snapshot of the principles outlined in the paper.
    Thanks guys!

    • Victoria Brazil

      Yes thanks Ben
      Truly landmark paper with thorough review of the literature.

      We have been (relatively ) successfully implementing the Laerdal RQI cart (NB Nil disclosures) in our institution which incorporates many of these elements for the pure, individual core skills of BVM and compressions
      – short, low volume, high frequency sessions ( 5 min every 3 months)
      – mastery learning with clear, machine assessed performance criteria, and unlimited attempts to pass
      – real time feedback – visual and auditory – on CPR and BVM performance
      – plus the carts are located in the workplace
      (and it actually costs less than having nurse educators do BLS, allowing them to do more work that actually requires their skills)

      Obviously the teamwork stuff is harder, as it the myriad of knowledge and skill sets that fall into the ‘deteriorating patient’, as opposed to actual cardiac arrest. The paper gives guidance on that too (although i am biased and would suggest in situ/ translational sim could have been more strongly recommended)

      The only ‘omission’ for me was not incorporating pro-active end of life planning in resuscitation education. Our skills in NOT resuscitating patients that won’t benefit from it are arguably as important as resuscitating the ones that will benefit ?

      thanks again

      • Benjamin Symon

        Hi Vic,
        Interesting points about the benefits of automated tech freeing up nurse educators to actually be educators!
        I’m intrigued by your thoughts about end of life planning in resuscitation education. From my perspective that seemed like a can of worms that was outside the scope of an already epic 40 page monster of a paper. Is there a bit of feature creep here?

  • Adam Cheng

    Hello Friends,

    Thanks for the excellent discussion and thoughts on this paper. Your comments are bang-on!

    While on one hand, the paper serves as a review of the resuscitation education literature … the more pressing role it serves is as a call to arms for the resuscitation education community. Why are we trapped in our usual ways of doing things, and what can we do to change?

    There are lots of suggestions described in the paper, and some of them may not be feasible for certain organizations to implement. That’s ok….. baby steps … or in Vic’s words … what is your 1%? Let’s make small gains by implementing changes in a stepwise manner, measuring impact, celebrating successes, repeat.

    Locally, we have tried, over the past 3-4 years, to make gains by (1) implementing just in time CPR training; (2) rolling out in situ, inter professional, contextualized resuscitation team training; (3) integrating CPR feedback defibrillators (into clinical and simulation-based environments; (4) clinical (HOT) debriefing a-la INFO style (see Stuart Rose); and (5) data-informed debriefing using outputs from the CPR defibrillator. Next up – CPR Coaches in the ER. While providers are still required to do PALS courses (some evidence suggests this type of training still helps – https://www.cercp.org/images/stories/recursos/articulos_mes/agosto_2018_articulo.pdf ), they are support by other educational strategies in their work environment that can help to enhance performance.

    I believe this Scientific Statement represents the first step in an effort by the AHA to rethink how resuscitation education should be delivered to the masses. While courses such as PALS and ACLS may never completely go away, I anticipate change coming. The AHA will be hosting a series of online “town halls” in the coming months to discuss the principles highlighted in this paper, to answer questions, and to brainstorm with folks on how to implement these strategies locally. I will share the date/time of these on twitter once they are announced. Your ideas, input, and concerns will help to inform future changes to educational offerings … please join in on these town halls if you are able.

    Thanks again to Ben, Vic and Jesse for helping to share this work!

    Cheers
    Adam

    • Benjamin Symon

      Adam thankyou so much for coming along, it’s such a delight to have you join us and I’m very appreciative of your time and the paper itself.
      I look forward to your town halls and learning more from you guys with regard to this important ‘call to arms’.

      Just for fun though, can I be devil’s advocate with you for a second? PEM physician to PEM physician? The sheer intensity and volume of work that’s been put into CPR training in your hospital sounds incredible. But I’ve been in a small, community hospital the last 2 years and in that time we have had a single paediatric cardiac arrest. That arrest was in an infant with coronary artery aneuryms from kawasaki’s, who didn’t even arrest in our hospital, but enroute to a tertiary ICU.

      When I think of how much time is needed to optimise CPR training, and hearing everything you’ve achieved in Calgary. For paediatrics, is this really where the bang for buck is? A little niggling Jiminy Cricket on my shoulder keeps asking if this is where we should be spending our scarce public hospital education budget, when there’s stuff that we do badly that we see on a much higher frequency basis. It’s a challenge to get my junior staff consistently investigating paediatric limp appropriately, let alone getting them to zen mastery in paediatric CPR training.

      Should I just invest in a good CPR coach?

      • Farrukh Jafri

        If I can jump in, I’m currently teaching pediatric code training (really I’m teaching CRM through peds codes). My hospital sees 10,000 peds patients a year, and 8-9 pediatric codes a year. The cases revolve around PALS… our teams wanted the peds focus, mostly because of their discomfort with managing pediatrics. However, a lot of this teaching is translatable. I find it’s not only about BPM and depth and the 15:2… that is part of it… but it’s also about “action-linked phrases,” teaching team dynamics, transparent thinking so that these are not skills that they will use only once. I ask my colleagues to translate this into their regular practice. When I think of CPR training, I think of contextual training.

        Having a pediatric CPR coach would be great… can you have that in every resuscitation, easily available at 2am on a saturday night? I wish I had that extra resource. My staff is a resource and I am very resource limited. If I can teach that contextual interprofessional teamwork, that would be great for the adult cardiac arrest, pediatric arrest or even the conscious sedation with ketamine.

      • Adam Cheng

        Great points Ben! A few quick thoughts on this…..

        1. Yes, institutions definitely need to prioritize to determine where they want to allocate resources (especially if they are scant)…. that being said…..
        2. Sometimes there is a misconception that implementing change is associated with the need for MORE resources, when in fact this is not always true. Example – Spaced/distributed workplace-based CPR training is more cost-effective than annual BLS certification (paper coming soon!). Example #2 – using a CPR coach doesn’t require an additional team member (in most institutions), but rather a re-organization of existing human resources.
        3. Many of the lessons we learn from cardiac arrest specific educational efforts (eg. just in time ER simulations) can be extrapolated to other contexts …. with lessons positively impacting departmental culture, attitudes etc!

        Let’s keep this great discussion going….

        Adam

  • Sarah McNamee

    Thanks for picking a great paper! This is my first few weeks listening to Simulcast and certainly my first time taking a jump into commenting rather than existing as a lurker (thanks to Vic Brazil’s gentle, but firm, nudgings).

    We reviewed this paper in our weekly education catchup meeting at Gold Coast Hospital. There were probably three points that were my “take home thoughts” after reading and discussing this article.

    1. How good are infographics!
    I’ve not had a whole lot of contact with academic reading and writing (I intending on changing that over the next 12 months). A huge barrier to me is the “wall-of-words” that I often see when I first engage with a text. Having a simple summary with lots pretty colours definitely helps me to contextualise and digest the article when I read it.

    2. Delivering effective resuscitation training to rotational residents is challenging
    Interestingly, I have not had the experience Eve describes as an emergency registrar in Canada. Most of my medical school and hospital based resuscitation education implements approximately none of the educational strategies described. I think a lot of this stems from the challenges of providing education to rotational junior residents who a) change their workplace/teams every 5-10 weeks and b) frequently work in areas where resuscitation codes are a rare occurrence (mental health, palliative care, rehab). Most of my resuscitation training has come from one off courses I’ve chosen to sign up for outside my hospital training (eg APLS, EMST) where I think we often see strategies such as mastery learning, contextual learning, debriefing/feedback and assessment utilised really well. The limitation of these courses however is that there’s rarely the opportunity for spaced practice.
    After reading the article, I realised that the RQI carts for BLS performance demonstrate a lot of the practical strategies discussed. The carts give the chance to practice CPR/BVM skills until you “master” them, immediate feedback on compression depth and breath volume, short sessions, and 3 month interval spacing before you’re required to “refresh”. I can definitely appreciate why we have implemented them in our hospital now.

    3. Unlearning is hard. Changing how we learn and teach is also hard.
    I was reflecting back to some courses I participated in which included skills like a venous cutdown, but no ultrasound access teaching. I remember thinking at the time “why are they still teaching this!”. We are working and teaching in a rapidly developing technological era. We discover, learn and information share faster than ever before, but this means we also have to UNLEARN more quickly too. I can totally appreciate that that’s going to be hard for both institutions as well as more” traditional” learners and educators.
    This article suggests using “today’s blogs and podcasts over yesterdays textbooks”. I think this is a great suggestion – but probably because I’ve started working as a doctor at a time where engaging in these innovative, always evolving platforms is the norm (also I am a millennial, and textbooks are heavy). However, I feel this could be a really confronting challenge for traditional educators (I have my Mum who is a secondary school teacher in mind) who may have gone their whole careers using the same textbooks, and had minimal interaction with things like podcasts and blogs.

    • Benjamin Symon

      Hi Sarah, welcome to journal club! It’s great to have you here, and I appreciate the quiet power of Vic’s firm but gentle persistence :p
      As you can hopefully see, we don’t bite!
      I think you’ve provided a fresh perspective with regards to the honest experience of many junior staff rotating through busy hospitals. While we might romanticise giving CPR and saving lives on a daily basis as we watch ER over our study books in med school (showing my age I know), the reality is that we develop a whole bunch of other skillsets that on a frequency basis are much more useful. De-escalating stressed families, Doing paperwork efficiently, Following a chest pain algorithm…… Giving CPR in hospital is still a pretty rare event for many of us (especially in Paeds).

      You echo many others who report the benefits of incorporating automated tech into the workplace, but I’ve yet to see it enforced and utilised effectively in either of the hospitals I work in. Hopefully this article will kick start that conversation.

      I agree the infographics provided for this paper are fantastic, although after making several myself, I have some cynical thoughts about them too. Primarily I worry that many people don’t use them so much as a ‘taste test’ to contextualise principles, and instead hope to just receive fully digested, streamlined information in dot point format. My worry with a paper such as this, is that actually the meat isn’t in the infographic. It’s in the 40 page document. And that’s a more challenging, less sexy sell.

    • Kara Allen

      So many good points already raised and I agree with what Sarah has said here- have been thinking about the question of organisational unlearning. Is it cost (including staff time), or inertia? How much are organisations representative of the people who work there or the people who lead? These philosophical discussions aside there was lots to think about here including incorporating ‘teaching on the run’ or flipped classroom strategies for ACLS which I hadn’t really thought deeply about before.

      When thinking about that it’s important to consider what Cheng et al said about incorporating psychological fidelity into teaching and training, which is harder to do in the flipped classroom context!

      I’d be interested to know the answer to the questions raised about clinical debriefings in the performance gaps. Cognitive load is high after critical events-is it too high to discuss ways to improve critical skills such as the provision of good quality compressions etc?

      Great paper, thank you for sharing Ben!

      • Benjamin Symon

        Cheers Kara, thanks for coming again!
        I agree with you that ‘it’s too expensive’ can be a defence mechanism to protect the status quo, and I think Adam in his comments above also mention that as well, that some of these interventions aren’t necessarily expensive, just different. Food for thought!

  • Komal Bajaj

    I thoroughly enjoyed reading this manuscript and all these thought-provoking comments. This paper is a true jewel and I hope to revisit it regularly, especially with our sim fellows each cycle.

    On the topic of getting hospitals to the table, I’d like to throw out patient/family demand as a crucial catalyst. I agree, $$ unfortunately drives many decisions and, in some circumstances, patients directly or indirectly drive the $$.

    • Benjamin Symon

      Thanks Komal! I think that’s a great point that patient/family expectations can be a great motivator, and an appropriate one!

  • Matt Nettle

    Thanks Ben for another great paper. This really is a great launch pad article for those dipping their feet into simulation literature. So many great comments thus far that echo my thoughts as I was reading the paper. The fiscal utility of resuscitation education in the paediatric setting, where this is a rare occurrence is a valid point, however resuscitation education is often the nursery for many simulation programs. It may not now be a financial imperative to support a “all bells and whistles” program that addresses all the educational principles espoused in the article, but the development of such frames will allow the translation of these refinements to pass into more common patient presentations, that often require or can be effective with less resources. Improving patient care by 5-10 % in presentations seen 5 times a day, rather than once a year, will have a dramatic increase in patient safety and care. An inexpensive communication based simulation will have more of an impact in the eyes of patients in general than perhaps the efforts to avoid death from an arrest if the overall outcome is poor. That is not to say that efforts should not be made in the latter, but if improvements in management of general presentations is afforded by principles of educational design outlined in this paper, then greater expense on education on resuscitation may be justified in the eyes of the medical managers. It really is on the shoulders of education in resuscitation that many simulation programmes stand.

    I loved the phase used in the paper of “evidence rep”. It gives a sense of someone coming to give the clinician something, rather than the champion perceived as asking others to give back, all the while in both situations really aiming for all parties to contribute to the betterment of the patient’s care. Semantics, but evidence of how subtle aspects of a program could influence people’s decisions to change and we are all servants of our limbic system when asked to change (best to “start with why”).

    I found the concept of spaced learning finally being contextualised to the work environment directly as part of the mastery phase intriguing and would love to implement this final stage in our simulations. I surmise the limitations to implementation is that often massed learning is done in discrete locations away from the normal work place so continuity of education needs to be initiated within the hospital of practice and followed up in real practice. Also many would see this as just another tick box to proving competency in a beuricratic environment, rather than perhaps the conclusion of learning phase and the commencement of the ongoing maintainence phase. But it seems to be the necessary conclusion to the efforts placed in delivering an educational program. I suspect technology and shared community of practice in education may provide as solution to this in the near future.

    Wonderful paper and discussion. Thanks Ben and community.

    • Benjamin Symon

      Hi Matt,
      Was great to see you in Hobart this week, and thanks so much for your contribution! I look forward to seeing you implement some spaced learning at work :p

  • Kylie Moon

    I’m getting in at the last minute Ben! Have loved the discussion and this very important (long!) statement from the AHA.

    On my mind is the issue of what we do when we identify a mistake that has been made in a real resus or in simulation. Beyond a hot debrief, is there a review of each resus to identify learning needs/system faults/team dysfunction issues that can be targeted?
    For example do we know that we have we been slow to identify team leaders/roles? Poor at crowd control? Have there been accidental discharges of the defib (for non-shockable rhythms)? Poor quality CPR? And what happens with this important data on mistakes/learning gaps? This is where each departments’ ALS training has to be aligned to their learning needs.

    I think the question of assessment design here is key (and could be a journal article/chapter in itself!). I feel like it should have featured more strongly in the paper, and have been written in a more accessible way. I have been studying assessment design for 2 years now and still struggle with it! But I think assessment design really is playing a big part in the issues we are facing in resus education.

    I like the saying ‘we get the learners we deserve’ (not sure where it came from!) and how we assess and how often we assess is key to this. Assessment drives learning. If passing ALS requires memorisation of an algorithm THAT is what learners will learn. If passing requires memorisation of drug doseages THAT is what learners will learn. If you only need to pass once a year, and it is part of a group assessment (not individual), then that is what learners will study for – a once/year event. Will this result in meaningful learning? Will it be at the level of mastery? Will it be retained, be easily reproduced and able to be finessed?

    I like the longitudinal approach a lot and the 4 year simulation based mock code programme by Andreatta et al (2011) demonstrated good progression of skill by having a programmatic approach with more frequent and higher quality insitu sims (and were able to demonstrate an improved survival rate). They pulled the data on previous codes and identified mistakes/learning gaps, and then designed their sims with these issues in mind. I like the idea of staff having an ALS passport, where they document there participation in simulations over the year, their learning issues, reflections on codes they have participated in, mastery learning goals.

    Lastly, there is of course a discussion to be had on the resources to carry out these changes in resus education. Although, how much is this paper about getting smarter with ALS teaching? Mastery learning (not tick boxing), spaced learning, aligning ALS assessment/learning to your departments needs, use of debriefing/feedback with skilled facilitators, and better use of this feedback (growth mindset). These things are not necessarily much more resource intensive but are likely to be more effective!

    Thanks for this Ben!

    • Sara Chesney "Dr Distance"

      Good Afternoon all, just a few thoughts from an Education & Simulation Registrar (fairly new – please be gentle!).

      I could not agree more that this is an exceptional publication – extremely comprehensive and well written.
      In view of the incredible level of complexity of their research, it would have been interesting to have some form of official appraisal of the level of their evidence. This is already a limitation identified by the authors themselves. One must question how feasible it would be to design an adequate assessment tool to grade the evidence of 407 different papers. It is not a significant issue. This paper is an outstanding piece of work regardless.

      As an ALS instructor, I was particularly interested in the concept “practice makes perfect, but not all practice is equal. It is possible for a learner to practice multiple times with no observable improvement”. We are fortunate enough to have CPR manikins with direct machine assessed feedback in my current workplace. It allows us to give feedback directed to any issue i.e rate/depth of compression. These did not exist when I was a student. I remember being forced to do an OSCE station that consisted of 8 minutes of solo BLS – I highly doubt that this lead to any “mastery” in that specific skill. Perhaps I mastered looking tired and generally awful by the end of the 8 minutes. It is interesting, however, how poorly the official machine assessed performance score can be received by the current generation of learners. I thought the directed score would drive the learner to improve in that area, however, on occasion, they instead disengage from the whole education and improvement process.

      The paper mentions “rapid cycle deliberate practice” and whilst it may not be feasible to incorporate this into everyday practice whilst on shift due to time, staff and resource pressure, it may be however, be more feasible to incorporate a brief daily drill (5 minutes max) at the start of each shift. The drill could be a VF cardiac arrest for example. This could allow the team members to identify each other, allocate roles and highlight any issues that occurred i.e insufficient skill set in the team or defibrillation error for example. This kind of drill could be done on a low fidelity manikin and simply start with “the patient is in cardiac arrest”.

      We have incorporated “gamification” into our teaching sessions such as “CPR/BLS Wars”. Medical staff can be highly competitive even for a cheap shop bought toy trophy. The session usually incorporates a brief tutorial after the first competition round. The tutorial usually focusses on a key area of clinical need that has been identified such as safe debilitation for example. Whilst there is no current evidence to support gamification as a tool to improve CPR performance (as highlighted in the paper), I would estimate that most of our CPR teams show a significant performance in all aspects of their cardiac arrest scenario (team work, leadership, communication and machine assessed performance score). As mentioned above it has been noted that on occasion there can be a team who disengages with the whole competition and game process and receives a worse score on their subsequent attempts. I am never sure how to address this.

      Having initially trained in the UK, where it was compulsory to pass ALS Level 2 to complete foundation training, the current gaps in resuscitation performance remain striking. I have long since left the UK, however, these knowledge gaps have provided a significant stumbling block in my clinical debriefing – how to address these without threatening the self-esteem of the participants remains a persistent challenge. This has extended into real cardiac arrest patients where the code blue team was recently challenged for “precharging the machine”.

      My adventure into education and simulation continues…

      Thanks

      • Benjamin Symon

        Hi Sara, welcome to journal club! We will indeed be very gentle, in fact in the 2 years we’ve been doing journal club, nobody’s got nasty, ever! Turns out Simulationists tend to be nice people :p
        I agree some further appraisal of the literature would be handy, but I think for this particular paper personally it would have lead to a much too unwieldy paper given its length already.
        I was interested in your use of gamification at work, it sounds pretty fun! Why do you think the teams occasionally disengage?
        I think addressing knowledge gaps without threatening the self-esteem of participants is a long term challenge for many of us, but sounds like you’ve some important work ahead of you!

    • Benjamin Symon

      Hi Kylie, I’ve been noticing you on twitter with all of the retweets and likes etc, it’s so great to have you along in the discussion!
      I love the idea of an ALS passport to reinforce the longitudinal nature of our CPR journeys, I hadn’t heard of that before!!