Simulation and educationTime matters – Realism in resuscitation training
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.
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