Elsevier

Resuscitation

Volume 85, Issue 8, August 2014, Pages 1093-1098
Resuscitation

Simulation and education
Time matters – Realism in resuscitation training

https://doi.org/10.1016/j.resuscitation.2014.05.008Get rights and content

Abstract

Background

The advanced life support guidelines recommend 2 min of cardiopulmonary resuscitation (CPR) and minimal hands-off time to ensure sufficient cardiac and cerebral perfusion. We have observed doctors who shorten the CPR intervals during resuscitation attempts. During simulation-based resuscitation training, the recommended 2-min CPR cycles are often deliberately decreased in order to increase the number of scenarios. The aim of this study was to test if keeping 2-min CPR cycles during resuscitation training ensures better adherence to time during resuscitation in a simulated setting.

Methods

This study was designed as a randomised control trial. Fifty-four 4th-year medical students with no prior advanced resuscitation training participated in an extra-curricular one-day advanced life support course. Participants were either randomised to simulation-based training using real-time (120 s) or shortened CPR cycles (30–45 s instead of 120 s) in the scenarios. Adherence to time was measured using the European Resuscitation Council's Cardiac Arrest Simulation Test (CASTest) in retention tests conducted one and 12 weeks after the course.

Results

The real-time group adhered significantly better to the recommended 2-min CPR cycles (time-120 s) (mean 13; standard derivation (SD) 8) than the shortened CPR cycle group (mean 45; SD 19) when tested (p < 0.001.)

Conclusion

This study indicates that time is an important part of fidelity. Variables critical for performance, like adherence to time in resuscitation, should therefore be kept realistic during training to optimise outcome.

Introduction

Current guidelines of advanced life support (ALS) and basic life support with the use of automated external defibrillator recommend a standard of 2 min of cardiopulmonary resuscitation (CPR) with as few and short pauses as possible between rhythm controls.1, 2 A combination of continuous high quality of CPR and minimised hands-off time during rhythm controls/defibrillation ensures the highest possible quality of resuscitation.3, 4, 5, 6, 7 The recommended algorithm is critical as every interruption in chest compressions (CC) decreases the coronary and cerebral perfusion.3, 8, 9

We have anecdotally observed doctors who shorten the CPR cycles during resuscitation attempts in real-life in different departments at Danish hospitals as well as in training situations. This was done by using a stopwatch or counting the 30 compressions:2 ventilations cycles.10 In the clinical setting when shortened CPR cycles were observed they were corrected immediately. This shortening of CPR cycles increases the number of pauses used for rhythm controls/defibrillation, and such increased hands-off time impairs the quality of resuscitation3, 4, 5, 6, 7 as illustrated in Fig. 1.

Our own observations have been affirmed by informal interviews with instructors/educators from Denmark, the United States and Australia. The failure to adhere to the recommended 2 min CPR cycles may be attributed, among others, to the way the simulation-based training is conducted. The 2-min CPR cycles are often deliberately shortened during resuscitation training (fake-time training) to save time and thereby increase the number of scenarios. Fake-time training may unintentionally be transferred to real-life situations when ALS is provided. Training that unintentionally results in the acquisition of incorrect knowledge, skills or behaviour has been termed negative training.11 We speculated whether the shortened CPR cycles we have observed represent examples of such negative training. We therefore explored whether a shortening of the CPR cycles between rhythm controls/defibrillation during simulation-based resuscitation training was transferred to later resuscitation attempts.

The aim of this study was to test if keeping 2-min cycles of CPR during resuscitation training (real-time training) as opposed to fake-time training results in better adherence to recommendation of 2-min CPR cycles during resuscitation in a simulated setting.

Section snippets

Methods

We conducted a prospective, randomised, controlled, single-blinded intervention study embedded in a voluntary extra-curricular ALS course.

Eligible participants were 131 4th year (7th semester) medical students from the Faculty of Health Sciences, Aarhus University, Aarhus, Denmark. Participants were recruited among the 131 4th year medical students through email advertisements and through face-to-face invitations prior to lectures. Seventy-three students expressed their interest to participate

Results

The intervention group (real-time) showed statistically significant better adherence to the 2-min CPR than the control group (fake-time) with a deviation from the prescribed 120 s of (mean (SD)) 13 s (SD 8) for the intervention group (real-time) and 45 s (SD 19) for the control group (fake-time) (p < 0.001, Monte Carlo permutation test (n = 10,000)). The hands-off time for the control group (fake-time) was increased by 30% compared with that of the intervention group (real-time). No differences in the

Discussion

A statistically significantly better ability to stay adherent to time, that is to perform CPR for 2 min between pauses to control rhythm and defibrillate, was found in the intervention group (real-time) compared to the control group (fake-time) (p < 0.001). This is most likely directly related to the timing aspects of the simulation scenarios and not to the knowledge acquired through written material or didactic teaching, which were identical for the two groups. Accordingly, the post training

Conclusions

Participants trained in ALS using simulation retained the perception of time equivalent to how it was practiced during the simulation scenarios. Consequently, there was a statistically significant difference between the two groups (p < 0.001) in terms of their adherence to the 2-min CPR cycles. During post-tests, the time of CPR cycles were significantly shorter in the control group (fake-time) than in the intervention group (real-time).

Our study suggests that a shift to real-time simulations

Conflict of interest statement

The authors have no conflicts of interest related to topics or data discussed in this paper.

Acknowledgements

We thank the Tryg Fundation (TrygFonden) (grant number: 7-11-1189), The Laerdal Foundation for Acute Medicine (grant number: 30006), SkejSim (grant number: 1112231324601424372), and The Central Denmark Region Health Scientific Research Fund (grant number: 1-30-72-114-10) for their financial support.

We thank the ERC for granting us permission to use the previous validated CASTest. We wish to thank all the graduates for their participation in this study.

References (34)

  • D. Ostergaard et al.

    Simulation and CRM

    Best Pract Res Clin Anaesthesiol

    (2011)
  • D.M. Gaba

    Crisis resource management and teamwork training in anaesthesia

    Br J Anaesth

    (2010)
  • M. Rall et al.

    Education, teaching & training in patient safety

    Best Pract Res Clin Anaesthesiol

    (2011)
  • D. Cumin et al.

    Standards for simulation in anaesthesia: creating confidence in the tools

    Br J Anaesth

    (2010)
  • D. Lamb

    Could simulated emergency procedures practised in a static environment improve the clinical performance of a Critical Care Air Support Team (CCAST)? A literature review

    Intensive Crit Care Nurs

    (2007)
  • G.D. Perkins et al.

    Out-of-hospital cardiac arrest: recent advances in resuscitation and effects on outcome

    Heart

    (2012)
  • R.W. Neumar et al.

    Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

    Circulation

    (2010)
  • Cited by (17)

    • Basic life support skills can be improved among certified basic life support instructors

      2021, Resuscitation Plus
      Citation Excerpt :

      From a learning perspective, any mistake during a demonstration made by an instructor should be avoided because this may lead to negative learning. Negative learning occurs when learners acquire a skill incorrectly, which can be due to, e.g. technical factors (i.e. physical settings not as in the real world), instructional, or environmental factors (i.e. artificial time factors or tasks).32,33 An example of negative learning is the 2001 American Airlines Flight 587 crash.

    • Improving skills retention after advanced structured resuscitation training: A systematic review of randomized controlled trials

      2019, Resuscitation
      Citation Excerpt :

      Jensen et al.64 randomized first-year residents to ALS course immediately following graduation vs. six months after acquiring some clinical experience and found a significantly higher 6-month mean retention scores in those with prior clinical experience (82% vs. 78%, p = 0.002). Krogh et al.65 examined CPR taught in real-time training cycles (120 s) compared to shortened CPR training cycles (30–45 sec). When CPR training was delivered in real-time, trainees had statistically significant better adherence to 2-min CPR during retention testing delivered twelve weeks later (p < 0.001).

    • In a bed or on the floor? – The effect of realistic hospital resuscitation training: A randomised controlled trial

      2018, American Journal of Emergency Medicine
      Citation Excerpt :

      We can choose to focus limited resources on simple, but more frequent, training with the manikin on the floor, e.g., to a deeper target depth as supported by Oh et al. [16] Another direction is creating an even more realistic training environment to emphasise the importance of optimising working position when performing CPR. There are various benefits to both approaches and, to date, the literature regarding the level of realism in healthcare simulation is conflicting [7,30,31]. Further studies to investigate the optimal CPR training methods in hospitals are needed.

    View all citing articles on Scopus
    View full text