The 2008 Spacelabs Innovative Project Award, provided through the Canadian Association of Critical Care Nurses (CACCN), was awarded to a health care team from the Victoria General Hospital (VGH) in Winnipeg, MB, led by Dr. Wendy Fallis. The successful project was titled, "A megatonne of care" and consisted of a megacode simulation workshop and development of a training video called, "Code blue: Live and interactive". The simulation was held on May 11, 2007, at Victoria General Hospital in Winnipeg, MB, during which participants listened to didactic instruction in the latest techniques in resuscitation with an emphasis on the importance of each team member's role during a cardiac arrest situation. This was followed by a "surprise code blue" scenario (cardiac resuscitation) that occurred during the participants' nutrition break. This simulation was professionally filmed so that an educational DVD could be produced for the purpose of training critical care and non-critical care personnel in resuscitation and Advanced Cardiac Life Support (ACLS) guidelines 2005 (American Heart Association, 2005).
This event was planned and undertaken by an interdisciplinary advisory group with knowledge and expertise in critical care, and was sponsored by the Clinical Institute of Applied Research and Education (CIARE), VGH, and the Winnipeg Regional Health Authority (WRHA), Winnipeg, MB. The event was held following a day of education sessions during which participants learned from experts who presented lectures on topics from healthy lifestyle choices for the prevention of chronic diseases to best practice updates in areas of critical care.
The megacode simulation was open to any health care worker, including non-professional staff such as porters and health care assistants who often serve critical roles in resuscitation. The session was attended by a total of 48 participants and 12 trainers from across the province of Manitoba and from Northwestern Ontario (NWO). Participants ranged from multiple disciplines, including frontline workers, nurse managers, and students.
Until this event, there had been neither simulation training workshops of this nature for health care personnel within Manitoba and NWO, nor other educational videos produced following the release of the updated 2005 ACLS guidelines for handling of a cardiac arrest situation. Thus, this workshop was a unique method of providing resuscitation training and exposure to health care workers in Manitoba.
Purpose
The megacode simulation workshop afforded an opportunity for participants to experience a live running of a cardiac arrest code blue scenario through simulation, whereby they could apply knowledge of the ACLS guidelines in a non-threatening environment. This unique method aimed to produce more efficient responses and better outcomes of resuscitation by providing the opportunity to witness state of the art and best practices in cardiac and respiratory care. The project also endeavoured to expose health care workers to the roles and responsibilities of various team members in the event of a code blue, to raise awareness of the importance of rapid response by all team members, to improve participants' skills in resuscitation, and to generate interest in the field of critical care.
The educational video "Code blue: Live and interactive" resulting from the workshop could be used to train new staff, or as a continuing education support tool for the critical care environment. It includes video footage of megacode procedures, as well as step-by-step narration and chapter summaries of critical information for each section of the megacode, according to 2005 ACLS guidelines. The expectation was that the video would, ultimately, result in more effective, safe, and consistent care. Use of the video for training also was expected to positively impact staff attitudes and confidence in assisting or participating in resuscitations.
An additional goal of this project was to enhance the skills and knowledge of all team members as an interdisciplinary team. Historically, training for code blue resuscitation occurs on an individual basis, whereas this new approach placed greater emphasis on the effectiveness of teamwork in responding to a cardiac arrest through best practice. In light of the advent of family presence during resuscitations in many ICUs, enhanced knowledge of drugs and procedures that are consistently used in megacode situations provides improved confidence for ICU nurses and other staff who may experience increased anxiety in the presence of a family witness (Halm, 2005; MacLean et al., 2003).
Description of the event
The megacode simulation workshop began with a plenary lecture reviewing key elements of response to a code blue that enhance the chances of survival and also a review of the importance of each team member's role in a resuscitation attempt. Following this presentation, attendees witnessed a surprise cardiopulmonary arrest situation, involving actors and staff from throughout the hospital. The education theatre was set up with state-of-the-art equipment resembling a mock ICU suite, where participants were able to observe firsthand how a resuscitation code is managed. To improve viewing options, participants had both a live view of the event and the ability to view it on a large-screen TV monitor located in the education theatre. The event script, contrived by a critical care nurse and physician, allowed attendees to observe an unexpected (but planned) collapse of an individual and the ensuing response by the code blue team. Attendees were able to get a glimpse of the intensity and energy of a code blue, as the collapsed individual was subsequently transported via stretcher to a simulated ICU setting and treated by critical care nurses, an ICU physician, respiratory therapists, and support staff undertaking CPR. During the brief transport, the real person was unobtrusively switched with a doll simulator (SimMan[R], Laerdal Medical, New York).
Throughout the episode, ACLS principles were followed and a critical care physician narrated exactly what was occurring. The narrator described the various cardiac rhythms experienced by the collapsed individual, results of blood gas values, medications that were administered and the need for any other treatments, along with an explanation of the reasoning for each.
A unique aspect of the simulation was the inclusion of a family member (actor) who attended the resuscitation and the interaction between the family member and the team. The family member entered the scenario part way through the resuscitation after the team mutually agreed that it was permissible for the family member to be present. The family member was accompanied by a family facilitator--a support person who provided explanations and emotional support to the family member throughout the scenario. The inclusion of this family witness and the use of a family facilitator were based on recent family presence during resuscitation literature (Halm, 2005; MacLean et al., 2003), translating the importance of providing families with this option.
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The ending of the mock resuscitation involved the resuscitation team's planning for and transferring of the "patient" to a cardiac specialty unit. This was facilitated by a local emergency medical service.
Following the mock resuscitation, participants spent time at practical, "hands-on" review stations using resuscitation equipment or techniques. The review stations, facilitated by certified ACLS educators, included (1) establishing airways, (2) automated electrical defibrillators (AEDs), (3) compression techniques, (4) code blue documentation (charting), (5) medications, and (6) "mending it all together".
The day following this event, the mock ICU suite was made available to the public during a health fair sponsored by the facility. Members of the public were shown the equipment used in critical care environments, given explanations of its use, and were able to ask questions of health professionals.
Feedback
Feedback from participants, both written and verbal, was very positive (Table 1). Participants completed evaluation forms at the end of each portion of the event (Figure 1). Approximately 90% of participants believed that attending the workshop improved their knowledge of megacodes and 84% would attend another similar event (n = 39). Of those who gave an evaluation of the interactive training sessions (n = 37), 95% stated that the hands-on practice time was useful. Almost all (97%) who evaluated the megacode simulation believed that the presentation was audience-friendly.
Megacode training video
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The events of the megacode simulation workshop were professionally filmed and edited to create a 20-minute training video--Code blue: Live and interactive. This video serves as an educational tool to train nurses and health care professionals on the 2005 ACLS guidelines for cardiopulmonary resuscitation. The script, written by an experienced ICU nurse educator, a physician, and a physiotherapist, incorporates the narration of the simulation and 2005 ACLS algorithms. Within this video, splices from the original simulation scene are accompanied by narrated dialogue and text highlights of the guidelines. The video was designed to be user-friendly and was divided into the following segments: (a) introduction, (b) rapid response, (c) critical care, (d) defibrillation, (e) intubation, (f) medications, (g) atrial fibrillation, (h) sinus bradycardia, (i) central line, (j) pacing, (k) pneumothorax, and (l) continuing care.
This video has been made available on request to nurses and other health care professionals both within and outside of the critical care environment at health care institutions in Canada and the U.S. It has also been presented at several venues and has been made available for purchase online. The potential educational benefit of this unique educational tool has, thus, been widespread.
Impact on critical care nursing
Approximately 50 nurses at both novice and expert levels, along with several other health care providers (respiratory therapists, spiritual care, social work, managers, nurse educators, program facilitators, and nursing and spiritual care students) have already benefited from this live enactment of a cardiac arrest code. Participants were employed in critical care departments, as well as in rural hospitals where similar critical events are less common, but equally important. These nurses reported an increase in their megacode knowledge after witnessing the simulation and participating in hands-on training.
The topic of a cardiac arrest and the running of a "code blue" resuscitation are extremely relevant to critical care nursing. Although written ACLS guidelines are available, keeping critical care nurses current on this topic and using techniques that enhance adult learning are imperative. The simulation workshop on the running of a resuscitation code with participation by nurses and other health care workers is extremely useful for professional development and enhances knowledge transfer. The production of a video with a focus on up-to-date ACLS guidelines that can be used across North America to assist in training or retraining of nurses or other health care professionals in critical care is a novel educational medium. This project has addressed a gap in the educational process related to cardiopulmonary resuscitations.
For critical care nurses, this topic is of particular importance, as they participate in codes on a regular basis. Both junior and senior critical care nurses may repeatedly watch the video to hone their clinical knowledge of current ACLS guidelines, which includes family-witnessed resuscitation. Nurse educators in ICUs or in critical care education programs can use the video as a teaching tool when the topic of cardiac arrest sessions is being discussed. This enhanced education of critical care nurses relating to cardiopulmonary codes via the video is paramount if the running of a code is to be smooth and successful. In addition, for geographic areas that do not have easy access to experts such as nursing educators to provide education in ACLS, this review will serve as a valuable tool for training. It is also of high value to nurses who work in remote areas where critical cardiac events are less common.
Conclusion
Most resuscitation occurs in the critical care areas of a facility (ER and ICU). Rapid response time and teamwork are critical to the best outcome for the affected patients and their families. We believe that best practice education, megacode simulation, and team training is an ideal way to enhance the ability of team members to work quickly and effectively together. The perceptions and feedback received indicate that this workshop was an effective means of accelerating knowledge translation from the literature to the bedside. This event is hoped to have contributed to improved patient care and outcomes for patients through the dissemination of knowledge regarding best practice for cardiac resuscitation.
References
American Heart Association. (2005). Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 112(24, Suppl.), 58-66.
Halm, M.A. (2005). Family presence during resuscitation: A critical review of the literature. American Journal of Critical Care, 14, 494-511.
MacLean, S.L., Guzzetta, C.E., White, C, Fontaine, D., Eichhorn, D.J., Meyers, T.A., & Desy, P. (2003). Family presence during cardiopulmonary resuscitation and invasive procedures--Practices of critical care and emergency nurses. Journal ofEmergency Nursing, 29, 208-221.
About the authors
Lynda Loucks, BMR PT, MSc (Rehab), Researcher, Concordia Hip and Knee Institute, University of Manitoba, Winnipeg, MB.
Address for correspondence: Lynda Loucks, BMR PT, MSc (Rehab), Researcher, Suite 310- 1155 Concordia Ave., Concordia Hip and Knee Institute, Winnipeg, MB R2K 2M9. Phone (204) 926-1240; Fax (204) 940-2263; E-mail lloucks@cjrg.ca
Jessica Leskowski, BSc, Research Assistant, Clinical Institute ofApplied Research and Education (CIARE), Victoria General Hospital, Winnipeg, MB.
Wendy Fallis, RN, PhD, Founding Director, Clinical Institute ofApplied Research and Education (CIARE), Victoria General Hospital, Winnipeg, MB. Adjunct Professor, Faculty ofNursing, University ofManitoba, Winnipeg, MB.
This work was supported in part by the 2008 Spacelabs Innovative Project Award, provided through the Canadian Association ofCritical Care Nurses (CACCN).
Table 1: Comments by participants
of the megacode simulation workshop
* "Wonderful learning opportunities"
* "I really learned a lot"
* "Very practical"
* "Excellent teamwork"
* "Megacode extremely interesting"
*"Very useful"
* "Many participants have never seen [an actual code
run] and thought it was great"
* "Good review of knowledge"
* "Well done"
* "Very valuable code simulation event"
Figure 1: Results of participant evaluation of the
megacode simulation workshop
Plenary (n = 39) Megacode Interactive
Simulation Training
(n = 39) (n = 37)
Relevant to my 87 100 100
practice setting
Based on best 90 100 95
practice/recent
research
Would attend 77 92
similar presentation/
training session
Improved my 87 92
megacode knowledge
Speakers/actors 85 100 100
knowledgeable/helpful
during training
Speaker/simulation 64 97
kept me engagedSource Citation
Loucks, Lynda, Jessica Leskowski, and Wendy Fallis. "Megacode simulation workshop and education video--a megatonne of care and code blue: live and interactive." Dynamics 21.3 (2010): 22+. Academic OneFile. Web. 6 Aug. 2010.
Document URL
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