Finishing the standard introductory slides, I’m met by an even mix of stoic, flat-affect and nervous fidgeting. Evidence of the blended demographic: night-shifters coming straight to class after a long shift; clinicians who haven’t fully titrated caffeine to the desired effect; and a few students from various allied healthcare training programs that shift nervously in their seats, probably unsure of what to expect in their first-ever Advanced Cardiac Life Support (ACLS) certification course.
“Okay, so who’s excited to take ACLS?”
The expressions are unchanged.
“…who’s indifferent about ACLS?”
A few smiles, and I have even prompted a hand in to go into the air.
“Alright, who didn’t vote?”
With that, I've garnered a little more crowd support and even a chuckle from the back of the room.
As a paramedic who’s taken countless continuing medical education (CME) courses, I have experienced first-hand some of the barriers to high-yield, low-stress training and I’ve been on the receiving end of presentations that were facilitated by someone who carried the preverbal “chip on the shoulder”--the class syllabus seemingly only allowing time to undermine the learner’s confidence. On the opposite end of the spectrum is the learner who doesn’t immediately recognize the value to be gained from today’s opportunity to refine their skills. Worse still is anyone that argues that their longevity of certification or affiliation with a busy department leaves them little to no room for improvement. Nobody wins in these classes. Not the instructor, not the student, and definitely not patients.
How then do we find a common ground where clinicians receive high impact training and education that can literally change the way they practice medicine? Training that has an impact on patient-important outcomes in our communities and in our facilities when a person in our care deteriorates into cardiac arrest?
Why We Train
Each year, over 359,000 out-of-hospital cardiac arrests occur in the United States. (AMERICAN HEART ASSOCIATION, 2016). For years, the American Heart Association has reaffirmed that high-quality CPR and early defibrillation whenever necessary have the highest impact on survival to hospital discharge following a cardiac arrest. The mechanical skills utilized during an intra-arrest resuscitation are perishable. Studies cite that even the most experienced healthcare providers suffer a degradation of their CPR skills in the days, weeks, and months following a CPR renewal course. (Mary Fran Hazinski) Ongoing training and repetition of performance utilizing objective data on a student's performance is one of the best ways to leave a student prepared to perform the skills in a real-life situation.
A perfectly run code is a thing of beauty; but this ‘creature’, although sometimes observed in captivity (on the carpets or tables in training centers), is unfortunately seldom seen in the wild. This is not good. Some patients are deprived of the benefits embodied in resuscitation protocols; some rescuers are deprived of the greatest motivation and reinforcement to improve performance – a successful code – and some resuscitation study conclusions may be weakened by the confounding impact of suboptimal cardiopulmonary resuscitation performance.
Mindset: Be Excellent
The Resuscitation Academy, in King County, Washington is well-known for their education tracks geared towards improving the survival of out-of-hospital cardiac arrest, and the region boasts survival rates of 62% for witnessed ventricular fibrillation. One of the first things you’ll hear is the mantra, “measure, improve, measure, improve…” It urges even the most experienced physician, nurse, or paramedic to be better. It should be recognized that there are several barriers to a team’s success: personal bias of a team member, degradation of psychomotor skill, poor communication, etc. Those who come to class with a mindset that their full-participation ensures them the opportunity to measure proficiency and establish a benchmark score, and their participation in practice and their receptiveness to corrective feedback will ensure they leave the training environment more proficient, more confident, and better prepared to participate in the care of a patient in need.
“Under pressure, you don’t rise to the occasion, you sink to the level of your training. That’s why we train so hard.” – Anonymous
The Resuscitation Academy outlines 10 steps for Improving Survival from Sudden Cardiac Arrest. Among them, “Implement high-performance CPR w/ ongoing training and Quality Improvement”, and “Work towards a culture of excellence”. A CPR, ACLS, or PALS in-service is the perfect environment to further those two initiatives. Successful training evolutions are dependent on a partnership between educators and learners. There needs to be a mutual buy-in that today's activities in the classroom carry with them high expectations of maximum effort and high performance. Real-time simulation of intra-arrest management. The performance of psychomotor skills in real-time, without verbalization that the participant will "do it right in a real code". Performance in the classroom will define the standard of care at the bedside.
Perhaps one of the most effective ways you can alleviate the stress associated with the certification and testing process is to allow yourself adequate time with the course material and arrive to class with a good understanding of basic ECG rhythm interpretation, pharmacology, and a familiarity with the course algorithms and flowcharts. It should be noted that the 2015 guidelines update introduced mandatory student participation in the ACLS or PALS student pre-test. Students must achieve a minimum score of 70% following the self-directed review and quiz, administered online. Many standardized CME courses dedicate time to a review of the didactic information, but the reality is that all of the course content cannot be discussed in class while still allowing time for clinical correlation through scenario-based skills evolutions. Time in the classroom is mainly spent connecting the dots, and participants who arrive at the course with the cellophane still surrounding their textbook always express increased levels of anxiety as the course progresses.
Do it Right; Do it in Real Time
It can be a challenge to modify clinician behavior when the learner is steadfast that their performance--which deviates from the standard of care--has been, and will continue to be acceptable. By engaging in corrective-feedback leveraging technology utilized at Cascade Training Centers, such as the tablet-based simulation software or the high-fidelity Ambu Smartman training manikins that are capable of providing real-time feedback on the accuracy of a student’s CPR compression rate, depth, and recoil or the efficacy of their ventilation rates and tidal volume, students are able to receive real-time objective data in response to their performance. For example, poor compressions, verified to be too slow, and too shallow by the real-time CPR feedback results in a corresponding decrease in the measurable capnometry, forcing the student to think critically and verify compression quality, assure ventilations are not excessive, and run through a list of treatable causes of cardiac arrest. Gone are the days that instructors are interjecting feedback like, “Your compressions are too slow,” during skills evolutions. Instead, we simulate the physiologic response the provider is likely to observe in real-life when similar conditions exist.
Measure, Improve, Measure, Improve
Educators should set a performance target for their students and even the most experienced clinicians should be open to attempts to meet and exceed these goals. An example of a lesson aim would be "Every student will be able to perform 2 minutes of high-quality chest compressions with at least 90% accuracy." Students are afforded the opportunity to develop the good psychomotor memory that guides their performance towards the American Heart Association's recommendations of appropriate chest compression rate, depth, and recoil.
Ongoing recertification and frequent trainings are the best ways to develop the confidence to react to what is in real-life, an anxiety-provoking event. Clinicians who refine their skills, and seek to constantly improve are likely to be the most beneficial to their patients when the patient’s life is on the line.