151CHAPTER 15
Advanced Cardiac Life Support
A. IMPLEMENTATION OF SIMULATION-BASED PEDAGOGY IN YOUR INDIVIDUALIZED TEACHING AREA
Changing trends in health care demand that nurses expand their roles to care for patients with increasingly complex health conditions. Such a challenge, along with a mandate to prepare students to become competent nurses working in the dynamic health care delivery system, leads nurse educators to look for effective training approaches and tools (Norman, 2012). Simulation-based learning, or virtual-reality learning, is an innovative teaching strategy used for nursing students to practice skills in a safe and controlled environment. It enables students to consolidate learning and develop competence through repeated and self-controlled practice, immediate debriefing from facilitators, and video recording (Cant & Cooper, 2010). It also can improve learners’ knowledge and performance in clinical skills, consequently bridging the gap between theory and practice (Chakravarthy et al., 2011; Nestel, Groom, Eikeland-Husebø, & O’Donnell, 2011; Thomas, Johns, Marsh, & Anderson, 2014; Tsai et al., 2008). In simulation education, a clinical crisis can be planned as an essential tool used to facilitate students in making the transition to the real clinical setting as smoothly as possible and reducing their reality shock of entering clinical practice. Those skills not appropriate for learning and practicing in the real clinical setting because of ethical concerns about protecting the safety and best interest of patients are most suitable to be practiced under a simulated environment.
In the context of Hong Kong, apart from undergraduate nursing education in tertiary institutions, simulation-based pedagogy has been adopted for decades in health care professional training. With patient safety as the centerpiece of health care service, simulation-based pedagogy in invasive skills training is particularly valued for its capacity to provide students with exposure to realistic, context-rich scenarios, thereby facilitating a balance between the learning needs of students and the safety as well as care needs of patients. Multidisciplinary simulation and skills centers have been established in the local public health care sector to facilitate skills training and knowledge updates. A series of advanced team-based training and specialty emergency management courses have been launched, including an advanced surgical trauma course, obstetrics emergency workshop, airway management simulation training, and acute wound care workshop (Queen Elizabeth Hospital, Hong Kong, 2014). These simulation-based training activities aim to develop health care professionals’ knowledge, skills, and attitudes while protecting patients from unnecessary risks, thus decreasing the possibility of litigation related to patient safety (Hicks, Coke, & Li, 2009; Hope, Garside, & Prescott, 2011; Lateef, 2010).
Cardiac arrest is an abrupt loss of cardiac functionality that accounts for more than 300,000 deaths worldwide annually (Kalus, 2012). For such a critical crisis, timely management with required knowledge and skills is essential as the survival rate declines 7% to 10% for every minute delayed in the initiation of resuscitation. The American Heart Association (AHA) advocated a “chain of survival” for patients with cardiac arrest, which emphasizes a series of 152treatment and interventions that should be performed immediately to identify the patients’ need for help and to activate the emergency response system. However, inexperienced nursing students and junior nurses may not have the opportunity to practice the skills or to get involved in managing a critical crisis in a real situation because of ethical considerations. Simulation-based learning is therefore adopted in our institution for advanced cardiac life support (ACLS) training to enable students to practice the skills and to obtain relevant experience.
B. EDUCATIONAL MATERIALS AVAILABLE IN YOUR TEACHING AREA RELATED TO YOUR SPECIALTY
The Nethersole School of Nursing at the Faculty of Medicine of The Chinese University of Hong Kong houses four simulation laboratories, each simulating a real clinical setting with sophisticated, high-tech specialized cardiopulmonary resuscitation (CPR) human patient simulators (HPSs; e.g., central and peripheral pulses, real cardiac and respiratory sounds, improved airway simulation) for student practice. Each simulation laboratory is equipped with two high-fidelity HPSs and one SimBaby®; hospital beds; a crash cart, including a defibrillator with a functioning electrocardiogram (ECG) and pacemaker; invasive and noninvasive airway supplies; fluid infusion devices; a fluid drainage system; an oxygen/suction headwall unit; a monitoring system; and an overhead table. A video-recording system with phones, video equipment, and microphones is available to record student performance, which can be used for debriefing and group discussion after the simulation scenario is completed. Outside the simulation laboratory there is a classroom-sized area where a projection screen has been set up.
The high-fidelity HPSs can respond to procedures and interventions in ACLS, and the simulation system also allows the educators to integrate the complexity of ACLS scenarios to meet the learning objectives. Therefore, great clinical variation in scenario designs can be captured and achieved without risking the safety of patients.
C. SPECIFIC OBJECTIVES FOR SIMULATION USAGE WITHIN A SPECIFIC COURSE AND THE OVERALL PROGRAM
In compliance with the extensive curriculum requirements stipulated by the Nursing Council of Hong Kong (The Nursing Council of Hong Kong, Hong Kong, 2016), a variety of scenarios have been designed through modification of the American Heart Association (AHA) guidelines according to the local health care situation and the learning needs of our students. The International Nursing Association for Clinical Simulation and Learning (INACSL) Standards of Best Practice: SimulationSM is also modified and used to guide the design and implementation of simulation scenarios to achieve the learning objectives within the local context and curriculum (INACSL, 2013/2016). The objective of integrating simulation-based training into the nursing curriculum is to enhance students’ critical thinking skills in the care of patients with complex health care needs. Simulation-based training provides opportunities for students to get involved in managing crisis situations with less stress and to work as a team with classmates. Specifically, simulation-based ACLS training is incorporated into a theoretical course for year-4 students in the 5-year baccalaureate nursing program.
Learning Objectives
Through scenario-based ACLS simulation learning, students will be able to:
1. Describe client manifestations in cases of ventricular fibrillation (VF), pulseless ventricular tachycardia, and asystole.
2. Perform immediate resuscitation management, including airway management, application of various components in the emergency trolley, and defibrillation.
3. Increase proficiency in performing critical care skills for the management of VF, pulseless ventricular tachycardia, and asystole according to ACLS algorithms.
4. Understand the importance of a team approach in resuscitation.
Student Learning Activities
Before starting the simulation-based ACLS training, students are required to attend a 2-hour lecture for ACLS content regarding interventions according to different EKG algorithms, medication, defibrillation, cardioversion, and intubation. To facilitate effective learning, a big class of more than 200 students will be divided into 12 groups, with 16 to 17 students in each group. To have hands-on practice, each student will have to attend a 4-hour laboratory session that allows each student to be involved as a team member for teamwork practice at least once. During practice, each group will be divided into three teams and each team will have at least five members. Each member has a role to play in the team: one as team leader who is taking the lead to manage the situation and is also responsible for defibrillation, one is responsible for cardiopulmonary resuscitation (CPR), one is responsible for ventilation and intubation, one is responsible for medication and laboratory work, and one is responsible for documentation. Each team has 15 minutes for practice, that is, the whole group has 45 minutes in the simulation laboratory. The whole process will be video-recorded and the recording will be used for debriefing.
During skill practice, each team will have chances to practice ACLS, and the main focus is to develop students’ ability to provide optimal artificial respiration and circulation. Students will also have numerous opportunities to provide chest compressions and artificial ventilation, prepare and administer medications, record the administration of medications, and give defibrillation.
D. INTRODUCTION OF SCENARIO
Setting the Scene
The scenario takes place in an Accident and Emergency Department (AED). The patient, a 73-year-old man, attends AED for decreased general condition and he complains of shortness of breath with poor oral intake in the past few days. Pertinent medical history includes an open-heart surgery undertaken 10 years ago but no history of dysrhythmia. The patient complains of chest pain at AED and a 12-lead EKG and cardiac markers have been performed. On admission, he is lethargic and not responding to verbal communication. During a reassessment, his condition suddenly changes and he becomes unresponsive.
Technology Used
A high-fidelity HPS, a crash cart equipped with a defibrillator and intubation devices, other medical equipment (e.g., pulse oximeter, blood pressure cuff, oxygen flow meter, intravenous infusion device, stethoscope, and medication tray), medical records, and a video recording system were used.
Objectives
1. Understand circulation, airway, and breathing principles.
2. Identify various dysrhythmias.
3. Perform immediate resuscitation management, including airway management, CPR, defibrillation, and administration of medications.
4. Assist in the intubation procedure.
5. Describe the principle and related care for defibrillation and automated external defibrillation.
6. Discuss how to manage VF, pulseless ventricular tachycardia, and asystole according to ACLS algorithms.
7. Document the assessment, intervention, and evaluation of findings.
8. Demonstrate a team approach to resuscitation.
154Description of Participants
Each group, comprising approximately 16 to 17 students, will attend a 45-minute laboratory session. The students will be divided into three teams with at least five students per team, and each team will take turns practicing for 15 minutes in the planned scenario. Each team has:
• A team leader
• A member for ventilation and intubation
• A member for cardiac compression
• A member for medication administration
• A member for documentation
E. RUNNING OF THE SCENARIO
Students are introduced to their assigned roles. They are provided with the medical record of the patient with information about his past medical history, chief complaints, and current condition. The team leader approaches the patient to perform assessment and the patient suddenly becomes unresponsive. The student is required to respond to this critical condition and to identify the cardiac rhythms during focused assessment, then intervene appropriately according to the ACLS algorithm.
It will take approximately 15 minutes for each team to complete the scenario. After all three teams have completed the scenario, there will be a 20-minute debriefing for discussion and evaluation of the whole group.
F. PRESENTATION OF COMPLETED TEMPLATE
Title
Advanced Cardiac Life Support
Scenario Level
Undergraduate nursing students
Focus Area
Critical care nursing, senior year
Scenario Description
This scenario takes place at 10 a.m. in the waiting area of the AED. A patient (73-year-old man) attends AED for decreased general condition and shortness of breath with poor oral intake. On arrival to the AED, he also complains of chest pain. Students will play the role of RNs working at the AED. During reassessment at 11 a.m., the patient’s condition suddenly changes and he becomes unresponsive. Students are expected to use critical thinking skills to identify what the problems are and intervene appropriately with reference to the following information provided to them beforehand:
Patient: Rene Tam (Mr.)
Age: 73 years
History: Open-heart surgery undertaken 10 years ago, with no history of dysrhythmia
Medication record: Lisinopril 20 mg PO QD (per os every day), Betaloc 50 mg PO BD (per os twice a day)
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