- Email: [email protected]
Using Simulation to Implement an OR Cardiac Arrest Crisis Checklist
Using Simulation to Implement an OR Cardiac Arrest Crisis Checklist DARLEEN DAGEY, MSN, RN, CNOR
ABSTRACT Crisis checklists are cognitive aids used to coordinate care during critical events. Simulation training is a method to validate process improvement initiatives such as checklist implementation. In response to concerns staff members expressed regarding their comfort level when responding to infrequent occurrences such as cardiac arrest and other OR emergencies, the OR Comprehensive Unit-based Safety Program team at our facility decided to institute the use of crisis checklists in the OR during critical events. We provided 90-minute education sessions, simulation opportunities, and debriefings to help staff members become more comfortable using these checklists. Based on program evaluations, 80% of staff members who participated in the training expressed an increased comfort level when caring for a patient in cardiac arrest. AORN J 105 (January 2017) 67-72. ª AORN, Inc, 2017. http://dx.doi.org/10.1016/j.aorn.2016.11.002 Key words: checklists, cardiac arrest, OR emergencies, crisis, simulation.
S
ibley Memorial Hospital, a 318-bed community hospital in Washington, DC, houses 14 ORs, and 10,595 procedures per year are performed here. Because OR emergencies (eg, cardiac arrests) are infrequent and staff members expressed concern about their ability to respond appropriately, our OR Comprehensive Unit-based Safety Program (CUSP) team evaluated instituting crisis checklists. Comprehensive unit-based safety programs “make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together.”1 Our CUSP team includes RN and surgical technologist unit champions, physician champions (ie, surgeons, anesthesiologists), a facilitator, an executive member, an OR manager, and the director of perioperative services. This group saw an opportunity to improve patient safety and surgical care by helping staff members acquire the skills and confidence to respond effectively to cardiac arrests in the OR. Crisis checklists and similar emergency manuals for critical events have proven successful for safety in the
aviation industry and are now being used in health care facilities across the United States.2-4 Simulations also have been shown to be effective at easing discomfort and raising skill levels of staff members faced with new skill acquisition.3,5 Our CUSP team identified a resource in the Johns Hopkins Medicine affiliates group to assist with simulation training. Beginning in October 2014, the OR CUSP team collaborated with the Johns Hopkins Medicine Simulation Center in Baltimore, Maryland, to provide an opportunity for staff members to practice responding to a cardiac arrest and to test the validity of the proposed crisis checklist. The training received overwhelming support from the executive team and physician leaders, and funding for the project was provided by the Sibley Foundation, which supports nursing education. The CUSP team introduced the concept of crisis checklists to perioperative nursing and anesthesia professionals before their participation in the 90-minute OR cardiac arrest simulations.
http://dx.doi.org/10.1016/j.aorn.2016.11.002 ª AORN, Inc, 2017
www.aornjournal.org
AORN Journal j 67
Dagey
January 2017, Vol. 105, No. 1
Figure 1. The checklist for responding to a cardiac arrest with ventricular fibrillation/ventricular tachycardia in the perioperative area. The team provided a debriefing after each session and asked participants to identify at least one new piece of information learned. All participants were asked to complete a program evaluation.
CHECKLIST BENEFITS The concept of using a checklist was not new to staff members. Checklists are commonly used during surgical verifications or time outs and to identify all necessary preoperative criteria (eg, laboratory tests and results, consents). Using a checklist during an emergency was a new idea for nursing and anesthesia staff members, however. The purpose of the checklist created by the CUSP team is to provide the appropriate steps, medication dosages and 68 j AORN Journal
treatments, and role assignments during emergencies. During high-stress, emotionally charged situations, cognitive information is less likely to be processed effectively.6,7 A checklist provides instructions and considerations to help ensure that all vital steps are completed.2 The CUSP team believes that successful implementation of crisis checklists will help maintain a strong patient safety culture at Sibley.
IMPLEMENTING A CHECKLIST Several steps were taken to ensure effective implementation of the crisis checklist. The CUSP team began by looking at other hospitals that had successfully implemented crisis checklists or emergency manuals. The team also conducted a literature review of surgical crisis checklists and simulation-based training
www.aornjournal.org
January 2017, Vol. 105, No. 1
Simulation to Implement Crisis Checklists
Figure 1. (continued).
and found that failure to adhere to lifesaving care processes was less common during simulations in which checklists were available than when they were not available.8 GoldhaberFiebert et al3 noted that simulation staff member training sessions increase familiarity and clinical use of crisis checklists. A separate crisis checklist workgroup consisting of frontline perioperative nurses, nurse managers, nurse educators, and an anesthesia professional worked to develop specific checklists for various emergencies or critical events that might occur in the OR. Members of this workgroup were also either members of what is known as the Code Blue Committee, which reviews all hospital cardiac arrests and approves practice changes related to arrest protocols, or possessed additional expertise in advanced cardiac life support. The Code Blue Committee met outside the regular CUSP meeting times to compare tools from different institutions. They decided to use the templates from Project Check,9 a project funded by the Agency for Healthcare Research and Quality to provide the public with lifesaving medical checklists, to design crisis checklists using instructions specific to Sibley’s environment and culture. The crisis checklist workgroup collaborated with the CUSP team to determine best practices to use during a cardiac arrest. After creating the checklist (Figure 1), they presented it to the Code Blue Committee, whose members approved it for use. The CUSP team introduced the crisis checklist to OR staff
www.aornjournal.org
members during a monthly education session in June 2015. The anesthesia professional in the workgroup and the chair of the Code Blue Committee provided education to the anesthesia group. The crisis checklist workgroup met multiple times to evaluate the checklist and ensure that it was complete. The team performed small-scale simulations outside the OR environment, using tabletop exercises in meeting areas to avoid disrupting hospital operations. Team members assumed the roles of the surgical team and practiced responding to a cardiac arrest, using the checklist. The crisis checklist workgroup and CUSP team met after the simulations to review participant evaluations of the program and to discuss the observers’ findings. The decision regarding who would be responsible for reading the checklist prompted extensive discussion in the workgroup. Taking into consideration the historical hierarchy of roles in health care, members of the workgroup questioned whether the nurse or surgical technologist would be intimidated reading the checklist to a physician. The anesthesia professional is normally the code leader in the perioperative setting, so the workgroup concluded that he or she would designate a checklist reader during an emergency. The reader would likely be the anesthesia technologist or the hospitalist on the cardiac arrest response team. The group assumed that the hospitalist would be a good candidate to read the checklist because of his or her clinical expertise and ability to offer insight into AORN Journal j 69
Dagey
underlying causes; however, any member of the surgical or response team could be a checklist reader candidate. The workgroup had the cardiac arrest checklists laminated and placed in a hanging file folder adjacent to the anesthesia cart in the ORs for anesthesia accessibility. When an arrest occurs, the anesthesia professional will assign the checklist reader role and physically hand the checklist to the designated reader. After the emergency event, the checklist remains in the OR as a tool for use during future emergencies. The Code Blue Committee reviews all cardiac arrest codes; such reviews which include whether the crisis checklist was used appropriately.
Resource Needs The team partnered with the Johns Hopkins Baltimore simulation team for the simulation experience on August 27, 2015. Under the partnership agreement with the Baltimore simulation team, a three-person team consisting of the simulation coordinator, technologist, and instructor provided a high-fidelity mannequin and the technology to simulate a cardiac arrest in the OR. The OR supplied the defibrillator, emergency cart, and accessories, including tubing, fluids, and medications. The team coordinated simulation staffing for both OR and anesthesia professionals in advance to ensure adequate participation (ie, enough staff members to manage the OR with additional staff members to participate in the simulations). The director of perioperative services approved any overtime incurred by nursing staff members as a result of participating in this educational activity. The OR educator also coordinated with the physician assistant manager to secure physician assistant representation as part of the surgical team. The anesthesiologist on the CUSP team was responsible for assigning personnel to participate in the interdisciplinary training the day of the simulation. Surgeon representation was missing during the initial sessions. The surgical staff members were not originally invited to participate, because they would not be compensated for their time. Staff members played the role of the surgeon during the simulation sessions to allow for more staff participation. The CUSP team requested that the chief of surgery ask for a physician volunteer to participate in subsequent training sessions. Physician leaders agreed to volunteer their time because they felt that the training was an important safety initiative.
Simulation Preparation Before this educational activity, the majority of OR personnel had limited experience participating in simulation-style 70 j AORN Journal
January 2017, Vol. 105, No. 1
learning activities, with the exception of the annual fire drills and basic life support courses. As a result, team members thought they might feel uncomfortable performing in front of others. During huddles and staff meetings in the weeks leading up to the simulations, the OR educator described how simulations would be incorporated into regular education to set expectations for participation and to create excitement among staff members. It was important for the instructors to create a safe environment during the simulations. The morning of the simulations, the OR educator reminded the OR manager and schedule coordinator of the afternoon exercises to ensure that the OR designated for the simulations remained closed. If arrests are announced using an overhead paging system, educators should consider informing personnel in surrounding departments and surgical waiting areas of the training to mitigate unnecessary anxiety of visitors and family members waiting for their loved ones in surgery when conducting OR simulations. In addition, posting signs such as “training in progress” alerts visitors and family members. It was necessary for our educator to prepare the learning environment by bringing additional clean supplies (eg, drapes, gowns, Mayo stand covers, instruments) into the OR where the simulations would take place to recreate a surgery in progress, and remove any unnecessary equipment from the OR to accommodate participants and observers. The educator also prepared role cards (identifying the role each participant would play) in advance to give to participants to facilitate assignments. Figure 2 shows staff members participating in the simulation.
Equipment Requirements The high-fidelity simulator mannequin was critical to the realism of the exercise. Procedures such as starting IV lines, intubation, and defibrillation could be performed on this mannequin, which also included a monitor that displayed electrocardiogram rhythms, pulse oximetry readings, and heart rate. This technology allowed the team to receive real-time feedback on the quality of chest compressions during cardiopulmonary resuscitation (CPR) and to practice their skills in a safe learning environment. The defibrillator and emergency cart were also necessary for the training. The educator coordinated with the sterile processing department, which stocks and supplies the hospital’s emergency carts, to make sure there was an extra cart ready for the simulations. The OR leadership team considered using a training cart for the simulations to reduce costs related to supplies, but after consulting with the pharmacy supervisor, they decided that a training cart would not be used. It would
www.aornjournal.org
January 2017, Vol. 105, No. 1
Simulation to Implement Crisis Checklists
Figure 2. Participants in the simulation setting. be brought into a real OR environment, so the team did not want to risk mixing training medications into regular OR stock. Any medications used during the exercise would be charged to the OR.
deficits and to assist with the training as needed. After running through the scenario, participants underwent a debriefing about the experience and what worked well or did not.
OUTCOMES Learning Environment The simulations took place in an OR that was not in use at the time. To accommodate multiple unplanned staff member absences and add-on surgical procedures, the OR manager selected participants the day of the simulation based on staffing availability and the OR schedule. The perioperative nurse educator collaborated with the simulation-training experts to plan the scenario, in which a relatively healthy 45-year-old male with abdominal pain arrives in the OR for a laparotomy. Shortly after incision, the simulated patient goes into ventricular tachycardia.
After completing the simulation, all participants were able to identify one piece of new information they had learned. The educator also asked them to complete an evaluation. In an effort to make simulations a part of the accepted OR culture, the educator asked simulation participants to share their positive experiences with other staff members who were unable to participate.
Before beginning the simulation, the educator assigned roles and introduced everyone. The simulation instructor asked participants to perform their activities as if responding to a real arrest, using available resources and following hospital policy. The instructor could sense apprehension from some participants and assured them that it was a safe learning environment in which to practice their response to a cardiac arrest in the OR.
Before the simulations, a full hospital arrest team included both an intensive care and telemetry RN to respond to cardiac arrests in the OR. The workgroup decided to make changes to the crisis checklist as a result of the simulations, reducing the total number of OR arrest responders by eliminating the telemetry nurse and reassigning roles. The Code Blue Committee is considering adding a CPR coach10 to the team, most likely an intensive care unit nurse. The CPR coach would be responsible for responding to monitors and providing the team with feedback on the depth and frequency of compressions needed to maintain maximum blood circulation during CPR.
Two 90-minute sessions using the same scenario took place the day of the simulations. To expose as many team members to the training as possible, different team members participated in each session. Additional observers, including educators and managers, also were present to evaluate knowledge
The simulation identified knowledge deficits related to proficiently connecting the defibrillator pad cable to the defibrillator. In the first simulation, the RN circulator fumbled with the defibrillator pad cable attachment. Perioperative leaders discussed leaving the defibrillator pads connected to the
www.aornjournal.org
AORN Journal j 71
Dagey
January 2017, Vol. 105, No. 1
CONCLUSION Crisis checklists can assist teams to work more effectively during critical events in the OR. The checklists help remind personnel of the appropriate response during emergencies when clinicians’ stress levels are high. Simulation-based training also can increase clinicians’ cultural acceptance of, skill acquisition for, and compliance with new processes and are valuable in familiarizing staff members with best practices.
References Figure 3. Results of the simulation debriefing. machine even when the defibrillator was not in use as a measure to save time during a cardiac arrest response, but ultimately decided against this because the gel on the pads may dry out and lose efficacy. The educator provided staff members with instruction on the placement and use of the defibrillator equipment and asked participants to provide a return demonstration of connecting the defibrillator pads to the defibrillator machine. The biggest challenge encountered was adequate staffing on the day of the simulations. Participation was lower than planned as a result of unexpected staff member absences and add-ons to the surgery schedule. To include more staff members in the simulation training, the CUSP team is exploring creative scheduling options, such as a full-day weekend class.
EVALUATION The crisis checklist workgroup and CUSP team met after the simulations to review participant feedback and to discuss the observers’ findings. Despite obstacles (eg, delays to the planned start time, limited participation), the simulations were considered a success. Based on program evaluations, 80% of the staff members who participated expressed an increased comfort level when caring for a patient in cardiac arrest (Figure 3). The CUSP team plans to schedule subsequent sessions to accommodate the remaining staff members who did not take part in the initial sessions. Our next steps will focus on implementation of additional checklists for potential emergencies such as hemorrhage, failed airway, and anaphylaxis.
72 j AORN Journal
1. CUSP toolkit. Agency for Healthcare Research and Quality. http:// www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/ index.html. Accessed August 25, 2016. 2. Cole E, Crichton N. The culture of a trauma team in relation to human factors. J Clin Nurs. 2006;15(10):1257-1266. 3. Goldhaber-Fiebert SN, Lei V, Nandagopal K, Bereknyei S. Emergency manual implementation: can brief simulation-based OR staff trainings increase familiarity and planned clinical use? Jt Comm J Qual Patient Saf. 2015;41(5):212-220. 4. Stanford Anesthesia Cognitive Aid Group. Emergency manual: cognitive aids for perioperative critical events. Stanford Medicine. http://emergencymanual.stanford.edu. Accessed August 11, 2016. 5. Byrd D, Mullen L, Renfro D, Harris TA. Implementing a perioperative RN training program for recent graduates. AORN J. 2015; 102(3):236-240. 6. Kindermann NK, Werner NS. The impact of cardiac perception on emotion experience and cognitive performance under mental stress. J Behav Med. 2014;37(6):1145-1154. 7. Arriaga AF, Bader AM, Wong JM, et al. Simulation-based trail of surgical-crisis checklists. N Engl J Med. 2013;368(3):246-253. 8. Harvey A, Nathens AB, Bandiera G, Leblanc VR. Threat and challenge: cognitive appraisal and stress responses in simulated trauma resuscitations. Med Educ. 2010;44(6):587-594. 9. OR crisis checklists. Project Check. http://www.projectcheck.org/ crisis.html. Accessed September 10, 2016. 10. Infinger AE, Vandeventer S, Studnek JR. Introduction of performance coaching during cardiopulmonary resuscitation improves compression depth and time to defibrillation in out-of-hospital cardiac arrest. Resuscitation. 2014;85(12):1752-1758.
Darleen Dagey, MSN, RN, CNOR, is a clinical nurse educator specialist at Sibley Memorial Hospital, Washington, DC. Mrs Dagey has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
www.aornjournal.org
ABSTRACT Crisis checklists are cognitive aids used to coordinate care during critical events. Simulation training is a method to validate process improvement initiatives such as checklist implementation. In response to concerns staff members expressed regarding their comfort level when responding to infrequent occurrences such as cardiac arrest and other OR emergencies, the OR Comprehensive Unit-based Safety Program team at our facility decided to institute the use of crisis checklists in the OR during critical events. We provided 90-minute education sessions, simulation opportunities, and debriefings to help staff members become more comfortable using these checklists. Based on program evaluations, 80% of staff members who participated in the training expressed an increased comfort level when caring for a patient in cardiac arrest. AORN J 105 (January 2017) 67-72. ª AORN, Inc, 2017. http://dx.doi.org/10.1016/j.aorn.2016.11.002 Key words: checklists, cardiac arrest, OR emergencies, crisis, simulation.
S
ibley Memorial Hospital, a 318-bed community hospital in Washington, DC, houses 14 ORs, and 10,595 procedures per year are performed here. Because OR emergencies (eg, cardiac arrests) are infrequent and staff members expressed concern about their ability to respond appropriately, our OR Comprehensive Unit-based Safety Program (CUSP) team evaluated instituting crisis checklists. Comprehensive unit-based safety programs “make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together.”1 Our CUSP team includes RN and surgical technologist unit champions, physician champions (ie, surgeons, anesthesiologists), a facilitator, an executive member, an OR manager, and the director of perioperative services. This group saw an opportunity to improve patient safety and surgical care by helping staff members acquire the skills and confidence to respond effectively to cardiac arrests in the OR. Crisis checklists and similar emergency manuals for critical events have proven successful for safety in the
aviation industry and are now being used in health care facilities across the United States.2-4 Simulations also have been shown to be effective at easing discomfort and raising skill levels of staff members faced with new skill acquisition.3,5 Our CUSP team identified a resource in the Johns Hopkins Medicine affiliates group to assist with simulation training. Beginning in October 2014, the OR CUSP team collaborated with the Johns Hopkins Medicine Simulation Center in Baltimore, Maryland, to provide an opportunity for staff members to practice responding to a cardiac arrest and to test the validity of the proposed crisis checklist. The training received overwhelming support from the executive team and physician leaders, and funding for the project was provided by the Sibley Foundation, which supports nursing education. The CUSP team introduced the concept of crisis checklists to perioperative nursing and anesthesia professionals before their participation in the 90-minute OR cardiac arrest simulations.
http://dx.doi.org/10.1016/j.aorn.2016.11.002 ª AORN, Inc, 2017
www.aornjournal.org
AORN Journal j 67
Dagey
January 2017, Vol. 105, No. 1
Figure 1. The checklist for responding to a cardiac arrest with ventricular fibrillation/ventricular tachycardia in the perioperative area. The team provided a debriefing after each session and asked participants to identify at least one new piece of information learned. All participants were asked to complete a program evaluation.
CHECKLIST BENEFITS The concept of using a checklist was not new to staff members. Checklists are commonly used during surgical verifications or time outs and to identify all necessary preoperative criteria (eg, laboratory tests and results, consents). Using a checklist during an emergency was a new idea for nursing and anesthesia staff members, however. The purpose of the checklist created by the CUSP team is to provide the appropriate steps, medication dosages and 68 j AORN Journal
treatments, and role assignments during emergencies. During high-stress, emotionally charged situations, cognitive information is less likely to be processed effectively.6,7 A checklist provides instructions and considerations to help ensure that all vital steps are completed.2 The CUSP team believes that successful implementation of crisis checklists will help maintain a strong patient safety culture at Sibley.
IMPLEMENTING A CHECKLIST Several steps were taken to ensure effective implementation of the crisis checklist. The CUSP team began by looking at other hospitals that had successfully implemented crisis checklists or emergency manuals. The team also conducted a literature review of surgical crisis checklists and simulation-based training
www.aornjournal.org
January 2017, Vol. 105, No. 1
Simulation to Implement Crisis Checklists
Figure 1. (continued).
and found that failure to adhere to lifesaving care processes was less common during simulations in which checklists were available than when they were not available.8 GoldhaberFiebert et al3 noted that simulation staff member training sessions increase familiarity and clinical use of crisis checklists. A separate crisis checklist workgroup consisting of frontline perioperative nurses, nurse managers, nurse educators, and an anesthesia professional worked to develop specific checklists for various emergencies or critical events that might occur in the OR. Members of this workgroup were also either members of what is known as the Code Blue Committee, which reviews all hospital cardiac arrests and approves practice changes related to arrest protocols, or possessed additional expertise in advanced cardiac life support. The Code Blue Committee met outside the regular CUSP meeting times to compare tools from different institutions. They decided to use the templates from Project Check,9 a project funded by the Agency for Healthcare Research and Quality to provide the public with lifesaving medical checklists, to design crisis checklists using instructions specific to Sibley’s environment and culture. The crisis checklist workgroup collaborated with the CUSP team to determine best practices to use during a cardiac arrest. After creating the checklist (Figure 1), they presented it to the Code Blue Committee, whose members approved it for use. The CUSP team introduced the crisis checklist to OR staff
www.aornjournal.org
members during a monthly education session in June 2015. The anesthesia professional in the workgroup and the chair of the Code Blue Committee provided education to the anesthesia group. The crisis checklist workgroup met multiple times to evaluate the checklist and ensure that it was complete. The team performed small-scale simulations outside the OR environment, using tabletop exercises in meeting areas to avoid disrupting hospital operations. Team members assumed the roles of the surgical team and practiced responding to a cardiac arrest, using the checklist. The crisis checklist workgroup and CUSP team met after the simulations to review participant evaluations of the program and to discuss the observers’ findings. The decision regarding who would be responsible for reading the checklist prompted extensive discussion in the workgroup. Taking into consideration the historical hierarchy of roles in health care, members of the workgroup questioned whether the nurse or surgical technologist would be intimidated reading the checklist to a physician. The anesthesia professional is normally the code leader in the perioperative setting, so the workgroup concluded that he or she would designate a checklist reader during an emergency. The reader would likely be the anesthesia technologist or the hospitalist on the cardiac arrest response team. The group assumed that the hospitalist would be a good candidate to read the checklist because of his or her clinical expertise and ability to offer insight into AORN Journal j 69
Dagey
underlying causes; however, any member of the surgical or response team could be a checklist reader candidate. The workgroup had the cardiac arrest checklists laminated and placed in a hanging file folder adjacent to the anesthesia cart in the ORs for anesthesia accessibility. When an arrest occurs, the anesthesia professional will assign the checklist reader role and physically hand the checklist to the designated reader. After the emergency event, the checklist remains in the OR as a tool for use during future emergencies. The Code Blue Committee reviews all cardiac arrest codes; such reviews which include whether the crisis checklist was used appropriately.
Resource Needs The team partnered with the Johns Hopkins Baltimore simulation team for the simulation experience on August 27, 2015. Under the partnership agreement with the Baltimore simulation team, a three-person team consisting of the simulation coordinator, technologist, and instructor provided a high-fidelity mannequin and the technology to simulate a cardiac arrest in the OR. The OR supplied the defibrillator, emergency cart, and accessories, including tubing, fluids, and medications. The team coordinated simulation staffing for both OR and anesthesia professionals in advance to ensure adequate participation (ie, enough staff members to manage the OR with additional staff members to participate in the simulations). The director of perioperative services approved any overtime incurred by nursing staff members as a result of participating in this educational activity. The OR educator also coordinated with the physician assistant manager to secure physician assistant representation as part of the surgical team. The anesthesiologist on the CUSP team was responsible for assigning personnel to participate in the interdisciplinary training the day of the simulation. Surgeon representation was missing during the initial sessions. The surgical staff members were not originally invited to participate, because they would not be compensated for their time. Staff members played the role of the surgeon during the simulation sessions to allow for more staff participation. The CUSP team requested that the chief of surgery ask for a physician volunteer to participate in subsequent training sessions. Physician leaders agreed to volunteer their time because they felt that the training was an important safety initiative.
Simulation Preparation Before this educational activity, the majority of OR personnel had limited experience participating in simulation-style 70 j AORN Journal
January 2017, Vol. 105, No. 1
learning activities, with the exception of the annual fire drills and basic life support courses. As a result, team members thought they might feel uncomfortable performing in front of others. During huddles and staff meetings in the weeks leading up to the simulations, the OR educator described how simulations would be incorporated into regular education to set expectations for participation and to create excitement among staff members. It was important for the instructors to create a safe environment during the simulations. The morning of the simulations, the OR educator reminded the OR manager and schedule coordinator of the afternoon exercises to ensure that the OR designated for the simulations remained closed. If arrests are announced using an overhead paging system, educators should consider informing personnel in surrounding departments and surgical waiting areas of the training to mitigate unnecessary anxiety of visitors and family members waiting for their loved ones in surgery when conducting OR simulations. In addition, posting signs such as “training in progress” alerts visitors and family members. It was necessary for our educator to prepare the learning environment by bringing additional clean supplies (eg, drapes, gowns, Mayo stand covers, instruments) into the OR where the simulations would take place to recreate a surgery in progress, and remove any unnecessary equipment from the OR to accommodate participants and observers. The educator also prepared role cards (identifying the role each participant would play) in advance to give to participants to facilitate assignments. Figure 2 shows staff members participating in the simulation.
Equipment Requirements The high-fidelity simulator mannequin was critical to the realism of the exercise. Procedures such as starting IV lines, intubation, and defibrillation could be performed on this mannequin, which also included a monitor that displayed electrocardiogram rhythms, pulse oximetry readings, and heart rate. This technology allowed the team to receive real-time feedback on the quality of chest compressions during cardiopulmonary resuscitation (CPR) and to practice their skills in a safe learning environment. The defibrillator and emergency cart were also necessary for the training. The educator coordinated with the sterile processing department, which stocks and supplies the hospital’s emergency carts, to make sure there was an extra cart ready for the simulations. The OR leadership team considered using a training cart for the simulations to reduce costs related to supplies, but after consulting with the pharmacy supervisor, they decided that a training cart would not be used. It would
www.aornjournal.org
January 2017, Vol. 105, No. 1
Simulation to Implement Crisis Checklists
Figure 2. Participants in the simulation setting. be brought into a real OR environment, so the team did not want to risk mixing training medications into regular OR stock. Any medications used during the exercise would be charged to the OR.
deficits and to assist with the training as needed. After running through the scenario, participants underwent a debriefing about the experience and what worked well or did not.
OUTCOMES Learning Environment The simulations took place in an OR that was not in use at the time. To accommodate multiple unplanned staff member absences and add-on surgical procedures, the OR manager selected participants the day of the simulation based on staffing availability and the OR schedule. The perioperative nurse educator collaborated with the simulation-training experts to plan the scenario, in which a relatively healthy 45-year-old male with abdominal pain arrives in the OR for a laparotomy. Shortly after incision, the simulated patient goes into ventricular tachycardia.
After completing the simulation, all participants were able to identify one piece of new information they had learned. The educator also asked them to complete an evaluation. In an effort to make simulations a part of the accepted OR culture, the educator asked simulation participants to share their positive experiences with other staff members who were unable to participate.
Before beginning the simulation, the educator assigned roles and introduced everyone. The simulation instructor asked participants to perform their activities as if responding to a real arrest, using available resources and following hospital policy. The instructor could sense apprehension from some participants and assured them that it was a safe learning environment in which to practice their response to a cardiac arrest in the OR.
Before the simulations, a full hospital arrest team included both an intensive care and telemetry RN to respond to cardiac arrests in the OR. The workgroup decided to make changes to the crisis checklist as a result of the simulations, reducing the total number of OR arrest responders by eliminating the telemetry nurse and reassigning roles. The Code Blue Committee is considering adding a CPR coach10 to the team, most likely an intensive care unit nurse. The CPR coach would be responsible for responding to monitors and providing the team with feedback on the depth and frequency of compressions needed to maintain maximum blood circulation during CPR.
Two 90-minute sessions using the same scenario took place the day of the simulations. To expose as many team members to the training as possible, different team members participated in each session. Additional observers, including educators and managers, also were present to evaluate knowledge
The simulation identified knowledge deficits related to proficiently connecting the defibrillator pad cable to the defibrillator. In the first simulation, the RN circulator fumbled with the defibrillator pad cable attachment. Perioperative leaders discussed leaving the defibrillator pads connected to the
www.aornjournal.org
AORN Journal j 71
Dagey
January 2017, Vol. 105, No. 1
CONCLUSION Crisis checklists can assist teams to work more effectively during critical events in the OR. The checklists help remind personnel of the appropriate response during emergencies when clinicians’ stress levels are high. Simulation-based training also can increase clinicians’ cultural acceptance of, skill acquisition for, and compliance with new processes and are valuable in familiarizing staff members with best practices.
References Figure 3. Results of the simulation debriefing. machine even when the defibrillator was not in use as a measure to save time during a cardiac arrest response, but ultimately decided against this because the gel on the pads may dry out and lose efficacy. The educator provided staff members with instruction on the placement and use of the defibrillator equipment and asked participants to provide a return demonstration of connecting the defibrillator pads to the defibrillator machine. The biggest challenge encountered was adequate staffing on the day of the simulations. Participation was lower than planned as a result of unexpected staff member absences and add-ons to the surgery schedule. To include more staff members in the simulation training, the CUSP team is exploring creative scheduling options, such as a full-day weekend class.
EVALUATION The crisis checklist workgroup and CUSP team met after the simulations to review participant feedback and to discuss the observers’ findings. Despite obstacles (eg, delays to the planned start time, limited participation), the simulations were considered a success. Based on program evaluations, 80% of the staff members who participated expressed an increased comfort level when caring for a patient in cardiac arrest (Figure 3). The CUSP team plans to schedule subsequent sessions to accommodate the remaining staff members who did not take part in the initial sessions. Our next steps will focus on implementation of additional checklists for potential emergencies such as hemorrhage, failed airway, and anaphylaxis.
72 j AORN Journal
1. CUSP toolkit. Agency for Healthcare Research and Quality. http:// www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/ index.html. Accessed August 25, 2016. 2. Cole E, Crichton N. The culture of a trauma team in relation to human factors. J Clin Nurs. 2006;15(10):1257-1266. 3. Goldhaber-Fiebert SN, Lei V, Nandagopal K, Bereknyei S. Emergency manual implementation: can brief simulation-based OR staff trainings increase familiarity and planned clinical use? Jt Comm J Qual Patient Saf. 2015;41(5):212-220. 4. Stanford Anesthesia Cognitive Aid Group. Emergency manual: cognitive aids for perioperative critical events. Stanford Medicine. http://emergencymanual.stanford.edu. Accessed August 11, 2016. 5. Byrd D, Mullen L, Renfro D, Harris TA. Implementing a perioperative RN training program for recent graduates. AORN J. 2015; 102(3):236-240. 6. Kindermann NK, Werner NS. The impact of cardiac perception on emotion experience and cognitive performance under mental stress. J Behav Med. 2014;37(6):1145-1154. 7. Arriaga AF, Bader AM, Wong JM, et al. Simulation-based trail of surgical-crisis checklists. N Engl J Med. 2013;368(3):246-253. 8. Harvey A, Nathens AB, Bandiera G, Leblanc VR. Threat and challenge: cognitive appraisal and stress responses in simulated trauma resuscitations. Med Educ. 2010;44(6):587-594. 9. OR crisis checklists. Project Check. http://www.projectcheck.org/ crisis.html. Accessed September 10, 2016. 10. Infinger AE, Vandeventer S, Studnek JR. Introduction of performance coaching during cardiopulmonary resuscitation improves compression depth and time to defibrillation in out-of-hospital cardiac arrest. Resuscitation. 2014;85(12):1752-1758.
Darleen Dagey, MSN, RN, CNOR, is a clinical nurse educator specialist at Sibley Memorial Hospital, Washington, DC. Mrs Dagey has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
www.aornjournal.org