Acquisition and Retention of Resuscitation Knowledge and Skills
Introduction
Approximately 209 000 in-hospital adult cardiopulmonary arrests occur each year in the United States.[1] In children, reported incidence is 1.8 cardiopulmonary resuscitation (CPR) events per 100 admissions to the pediatric intensive care unit.[1] Most cardiopulmonary arrests occur in a critical care unit, the operating room, or the emergency department. Based on the American Heart Association's "Get With the Guidelines" data, survival to discharge is estimated at 28% for neonates, 38% for children, and 26% for adults.[1] These statistics suggest that 2 to 3 out of 10 cardiac arrest victims survive and, thus, survival rates remain extremely low. Survival outcomes are directly related to a shorter time between cardiopulmonary arrest and first shock and initiation of high-quality CPR[2–4] consisting of compressions with 2- to 2.4-in (5-6 cm) depth for adults and 1.5-in (4 cm) depth for children, and ventilations with appropriate volume between 500 and 600 mL for adults and to the point of chest rise in children.[5–8] Poor-quality CPR skills have been identified as a preventable harm.[9] Studies have documented that CPR skills are suboptimal, inconsistent, and at best retained 3 to 6 months, degrading over time. Skill degradation may correlate with low frequency of use and/or practice.[10–14]
Robust resuscitation studies and accumulated outcome data have accelerated at a remarkable pace in the past decade, providing paradigm-changing evidence of what most effectively saves lives. Changes in resuscitation have focused on simplifying CPR protocols to enhance skill retention, with an emphasis on increasing the number and depth of chest compressions to deliver oxygen to the heart and brain.[10]These changes have led to realignment of course constructs and modalities to better meet skills requirements needed to perform optimal CPR. New approaches to resuscitation training have been examined; examples include blended learning via HeartCode; mannequins with real-time automated voice feedback; and short practice sessions with realistic, in situ, low-fidelity or high-fidelity simulation. Thus, the PICO(T) (problem/patient/population, intervention/indicator, comparison, outcome, and time element/type of study) question of interest for this clinical evidence review is, "What effect do novel approaches to resuscitation training such as simulation and low-dose, high-frequency (LDHF) practice have on knowledge/skill acquisition and retention?"
Method
The strategy included searching CINAHL and MEDLINE. Key words included resuscitation, basic life support, simulation, low-fidelity simulation, high-fidelity simulation, skill retention, and nurses. The search was limited to original research in the past 10 years.
Results
Table 1 outlines findings of 11 studies.[7,10,15–23] Studies varied by format and frequency of training: (1) low-fidelity versus high-fidelity simulation; (2) instructor-led versus LDHF high-fidelity simulation practice, automated feedback, instructor-led plus automated feedback, or Heart-Code with LDHF practice and voice advisory mannequin feedback; (3) automated feedback versus debriefing; and (4) review versus LDHF high-fidelity simulation practice and debriefing. Resuscitation knowledge and skills were measured at baseline and 1 month,[20] 3 months,[10,20] 6 months,[15,20] 9 months, and 12 months[21] after training.
LDHF practice using simulation or blended learning (HeartCode) increased knowledge/skill acquisition[10,15,21,23] and retention[10,20,21,23]over traditional courses. Compared with low-fidelity simulation, high-fidelity simulation led to greater knowledge/skill acquisition and retention in basic life support,[23] pediatric advanced life support,[15] and advanced cardiac life support.[18] An instructor effect for greater skill retention (compared with automated feedback) was noted, especially with complex skills such as bag-valve-mask ventilation.[22]
Recommendations for Practice
Most evidence for LDHF practice and simulation training represents level B evidence (Table 2). As typical first responders to cardiac arrests, nurses need optimal resuscitation skills. In From Novice-to Expert, Benner[25]noted that competent decision-making is a result of knowledge/skill and experience. Acquisition and retention of resuscitation skills were significantly better with novel training approaches compared with traditional basic life support, pediatric advanced life support, and advanced cardiac life support courses. Practice helped nurses acquire, improve, and retain skills over time. Compared with traditional training, high-fidelity simulation had superior outcomes as it allowed clinicians to practice and apply knowledge skills in a contextual situation and a safe learning environment. Thus, frequent simulation practice may prevent skill degradation and foster competency.
The construct of "preventable harm" has shaped health care reform for more than a decade. As a constant champion of evidence-based interventions since the early 1970s, the American Heart Association improved and sustained cardiac arrest survival outcomes with incremental advances in resuscitation training methods that relied on low-frequency, high-volume face-to-face classes. These standards have now been juxtaposed against new proven educational methods that emphasize adult mastery learning with self-guided didactic review and LDHF skill practice. Technological developments in training equipment have contributed to the revolutionary changes occurring in resuscitation education. These advancements are a classic example of "disruptive innovation"[26] upsetting the status quo of resuscitation training. Admittedly this training strategy is initially disruptive, but once adopted, it can advance the Quadruple Aim[27] (Table 3) over time through educational efficiency.[9] This strategy offers simplicity, convenience, and accessibility to a clinician's daily work life, and it is cost-effective without the additional training expenses of traditional classes—along with the promise to save more lives.[26]
This novel resuscitation education paradigm incorporates the following principles:
Training standards should be reexamined—regardless of role/expertise[15,28]—as 2-year intervals have not been shown to be sufficient for knowledge/skill retention. "Spaced learning" with more frequent sessions every few months improves learning outcomes.[9,28]
Contextualized learning using simulators with advanced physical features and scenarios based on recent code data/issues/lessons learned, and root cause analyses of "failures to save" provide clinical realism that improves understanding and engagement of providers.[9,15,23,28]
Mastery learning emphasizes deliberate LDHF practice of key skills until mastery occurs. This type of learning minimizes skill decay, improves equipment familiarity, and boosts teamwork and confidence about performance in real resuscitation events, which are rare and stressful.[9,10,15,18,20,23]
In situ simulation in the clinical setting provides a safe team-based learning experience in which clinicians can practice skills without harm to patients.[9,28] Mock codes, especially when unannounced, reveal gaps in procedural processes and help staff identify ways to mitigate future failures to save. Integrating postevent feedback and debriefing using a structured checklist of quality metrics promotes a reflective discussion about individual and team performance[5,8,9,28,29] that facilitates transfer of learning to real-life resuscitation events.
Benchmarking performance with external databases/registries such as Get With the Guidelines can guide continuous improvement.[8,28]Acquiring technology that captures quality data on actual events can provide organizations with real-time performance feedback to advance resuscitation improvement efforts further.[8]
In reflecting on how the evolution of resuscitation training challenges the status quo, Dr Cole Edmondson[26]—an early adopter of Resuscitation for the Quality Improvement (RQI)—advocated:
"As healthcare professionals, we must reexamine what has always been and use evidence-based practices to achieve the best possible patient outcomes."
Survival from cardiac arrest: a breakthrough may well be on the horizon!
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