Effects of Simulation-Based Education on Interprofessional Teamwork Skills in Cardiac Arrest ScenariosNGR 6813:EVIDENCE-BASED NURSING PRACTICE

UNIVERSITY OF CENTRAL FLORIDA

MARY BAERTLEIN

Research Question:

Do interprofessional healthcare providers who participate in simulation-based resuscitation education demonstrate an increase in teamwork skills?

Significance and Background: Why IP education?

IOM (2000) - “To err is human: Building a safer health system” $17 billion – estimated annual cost of medical errors IOM (2003) - “Health professions education: A bridge to quality” IP collaboration becomes healthcare priority 2013 – IPE endorsed by NLN, Joint Commission, AHRQ

(Institute of Medicine, 2000; Institute of Medicine, 2003; Garbee et al., 2013a; Neumar et al., 2015)

Significance and Background: Why focus on resuscitation scenarios?

Breakdown of IP teamwork during cardiac arrest resuscitation:o Adverse effect on ROSCo Detrimental patient outcomes / safety practiceso Negative impact on patient survival to discharge

Degradation of resuscitation knowledge and skills within 6 months 2015 AHA - course curriculum updated - team concepts / simulation

(Brock et al., 2013; Figueroa et al., 2013; Neumar et al., 2015 Yang et al., 2012 Zhu & Zhang, 2016)

Significance and Background: Why use simulation-based education? SBTT – identified as effective educational methodology

o Crisis-Resource Management (CRM)o Team Strategies and Tools to Enhance Performance and Patient Safety

(TeamSTEPPS)o Emergency Team Coordination Course (ETCC)

Challenge - prepare IP healthcare providers to effectively respond to high-risk clinical events

(Andel et al., 2012; Dillon, Noble, & Kaplan, 2009; Garbee et al., 2013a; Garbee et al., 2013b; Shapiro, 2004)

MethodsSearch Terms:Databases:

CINAHLMEDLINECochrane LibraryERICPsycINFOAcademic Search PremierGoogle Scholar

▪ Interprofessional

▪ Teamwork

▪ Simulation-based education

▪ Cardiac arrest

▪ Mock code

▪ Survival

MethodsInclusion Criteria: Exclusion Criteria:

Focus on teamwork IP healthcare participants Cardiac arrest events In-hospital setting Simulation-based training Published in English

Computer-based simulation only Evaluation of participant confidence

Methods

Study Design Level I

Level II

Level III

Quality A

Quality B

Quality C

Randomized Control Crossover (n = 180) 2 1 1Quasi-experimental (n = 160) 3 3Cohort Study (n = 37) 1 1Prospective – Blinded Assessors (n = 342) 2 1 1Pilot Study (n = 112) 1 1Descriptive Study (n = 72) 1 1

Total Sample Size = 903 (202 Physicians; 297 RNs; 9 Nurse Anesth.; 51 RT; 8 PT; 36 non-category; 300 non-specified)

Search retrieved 170 articles: 8 articles retained + 2 hand search = 10 articles

(Dearholt, Dang, Sigma Theta Tau International, & Institute for Johns Hopkins Nursing, 2012)

JHNEBP Evidence Rating Scales

Findings: TeamworkSummary - 9 out of 10 Studies Demonstrated Improvement in Teamwork Skills:

Paired t-test: 8 Studies (p < 0.001 to p < 0.05) Participant mean Team Based Behavior (TBB) 4.74 to 5.62 (p < 0.05) Observer results (5 studies) - increased from 3.56 to 4.75 (p < .05)

Retention: (1) none; (1) 2 weeks; (2) 3 months; (3) 6 months; (1) year

(Figueroa et al., 2013; Frengley et al., 2011; Garbee et al., 2013a; Garbee et al., 2013b; Gilfoyleet al., 2017; Mahramus et al., 2016; Shapiro et al., 2004; Wong, Gang, Szyld, & Mahoney, 2016)

Cohen’s d / Pearson’s r test: 1 study – large effect size (d = 0.84 and r = 0.39)

Retention: None(Sawyer et al., 2013)

Findings: CommunicationSummary - 7 Studies Demonstrated Improvement in Communication Skills:

Paired t-test: 6 Studies (p ≤ 0.004 to p < 0.05) Participant mean increased from 2.5 to 3.8 (p < 0.05)

Retention: (2) 3 Months; (1) 1 Year

(Figueroa et al., 2013; Frengley et al., 2011; Garbee et al., 2013a; Garbee et al., 2013b; Gilfoyleet al., 2017; Wong, Gang, Szyld, & Mahoney, 2016)

Cohen’s d / Pearson’s r test: 3.0 vs 4.4 (95% CI; p < 0.001)

Retention: None

(Sawyer et al., 2013)

Findings: Situational AwarenessSummary - 3 Studies Demonstrated Improvement in Situational Awareness:

Paired t-test: 3 studies (p < 0.001 to p < 0.05) Mean observer scores increased 86.77 to 90.75 Mean percentage score increased from 0.55 to 0.75

Retention: (1) none; (2) 6 months

(Garbee et al., 2013a; Garbee et al., 2013b; Gilfoyle et al., 2017)

Gaps and Limitations:

Lack of a standardized medical simulation evaluation tool Inability to blind study participants Variation related to retention timeframe measures Convenience sample – voluntary participation Attrition of study participants - retention Technical / ethical issues - video recording / debriefing in clinical setting

Recommendations:Implications for Practice: Level II / Quality B

Development of a quality improvement strategy Implement standardized IP SBTT for in-hospital cardiac arrest scenarios Mock Codes to occur at least every 3 - 6 months (less than 1 year) Duration of practice - (1) hour including pre- and post-debrief Improve patient outcomes (i.e. ROSC, morbidity and mortality, LOS, reduce

readmission rates)

Recommendations:Implications for Future Research: Level II / Quality B Develop a standardized / validated medical simulation evaluation tool Teamwork / communication / situational awareness Standardize retention timeframe measures Larger studies needed to assess impact on quality measures Does IP SBTT improve ROSC, LOS, readmission rates, costs? Pilot studies

o Measure teamwork and performance outcomes of similar unitso Consider using blinded assessors

Conclusion:Evidence supports IP simulation-based resuscitation education: Simulation-based education is a valid methodology to improve skills

o Teamwork o Communication o Situational awareness

Ongoing IP healthcare provider resuscitation team education to improve retention of knowledge and skills

Additional research o Need to develop a validated medical simulation evaluation toolo Larger studies needed to assess IP SBTT on patient quality measures and

healthcare costs

ReferencesAndel, C., Davidow, S. L., Hollander, M., & Moreno, D. A. (2012). The economics of health care quality and

medical errors. Journal of Health Care Finance, 39(1), 1-37. Retrieved from http://wolterskluwerlb.com/health/resource-center/articles/2012/10/economics-health-care-quality-and-medical-errors

Brock, D., Abu-Rish, E., Chia-Ru, C., Hammer, D., Wilson, S., Vorvick, L., ... Zieler, B. (2013). Interprofessional education in team communication: Working together to improve patient safety. BMJ Quality and Safety, 22(5), 414-423.

Dearholt, S., Dang, D., Sigma Theta Tau International, & Institute for Johns Hopkins Nursing (2012). Johns Hopkins nursing evidence-based practice: Models and guidelines (2nd ed.). Retrieved from http://guides.ucf.edu/database/EBSCOeBooks

Dillon, P. M., Noble, K. A., & Kaplan, L. (2009). Simulation as a means to foster collaborative interdisciplinary education. Nursing Education Perspectives, 30(2), 87-90.

Figueroa, M. I., Sepanski, R., Goldberg, S. P., & Shah, S. (2013). Improving teamwork, confidence, and collaboration among members of a pediatric cardiovascular intensive care unit multidisciplinary team using simulation-based team training. Pediatric Cardiology, 34(3), 612-619. http://dx.doi.org/10.1007/s00246-012-0506-2

ReferencesFrengley, R. W., Weller, J. M., Torrie, J., Dzendrowskyj, P., Yee, B., Paul, A. M., ... Henderson, K. M. (2011). The

effect of a simulation-based training intervention on the performance of established critical care teams. Critical Care Medicine, 39(12), 2605-2611. http://dx.doi.org/10.1097/CCM.0b013e3182282a98

Garbee, D. D., Paige, J., Barrier, K., Kozmenko, V., Kozmenko, L., Zamjahn, J., ... Cefalu, J. (2013a). Interprofessional teamwork among students in simulated codes: A quasi-experimental study. Nursing Education Perspectives, 34(5), 339-344.

Garbee, D. D., Paige, J. T., Bonanno, L. S., Rusnak, V. V., Barrier, K. M., Kozmenko, L. S., ... Nelson, T. K. (2013). Effectiveness of teamwork and communication education using an interprofessional high-fidelity human patient simulation critical care code. Journal of Nursing Education and Practice, 3(3), 1-12.

Gilfoyle, E., Koot, D. A., Annear, J. C., Bhanji, F., Cheng, A., Duff, J. P., ... Gottesmann, R. D. (2017). Improved clinical performance and teamwork of pediatric interprofessional resuscitation teams with a simulation-based education intervention. Pediatric Critical Care Medicine, 18(2), e62-e69.

Institute of Medicine (2000). To err is human: Building a safer health system. L. T. Kohn, J. M. Corrigan, & M. S. Donaldson (Eds.). Washington, DC: National Academy Press.

ReferencesInstitute of Medicine (2003). Health professions education: A bridge to quality. A. C. Greiner & E. Knebel (Eds.).

Washington, DC: National Academy Press.

Mahramus, T. L., Penoyer, D. A., Waterval, E. M., Sole, M. L., & Bowe, E. M. (2016). Two hours of teamwork training improves teamwork in simulated cardiopulmonary arrest events. Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, 330(5), 284-291.

Neumar, R. W., Eigel, B., Callaway, C. W., Estes, N. A., Jollis, J. G., Kleinman, M. E., ... Sendelbach, S. (2015). American Heart Association response to the 2015 Institute of Medicine report on strategies to improve cardiac arrest survival. Circulation, 132(11), 1049-1070. http://dx.doi.org/10.1161/CIR.0000000000000233

Renna, T. D., Crooks, S., Pigford, A., Clarkin, C., Fraser, A. B., Bunting, A. C., ... Boet, S. (2016). Cognitive Aids for Role Definition (CARD) to improve interprofessional team crisis resource management: An exploratory study. Journal of Interprofessional Care, 30(5), 582-590. http://dx.doi.org/10.1080/13561820.2016.1179271

Sawyer, T., Laubach, V. A., Hudak, J., Yamamura, K., & Pocrnich, A. (2013). Improvements in teamwork during neonatal resuscitation after interprofessional TeamSTEPPS training. Neonatal Network, 32(1), 26-33.

References

Shapiro, M. J., Morey, J. C., Small, S. D., Langford, V., Kaylor, C. J., Jagminas, L., ... Jay, G. D. (2004). Simulation based teamwork training for emergency department staff: Does it improve clinical team performance when added to an existing didactic teamwork curriculum. Quality & Safety in Health Care, 417-421.

Wong, A. H., Gang, M., Szyld, D., & Mahoney, H. (2016). Making an “Attitude Adjustment”: Using a simulation-enhanced interprofessional education strategy to improve attitudes toward teamwork and communication. Journal of the Society for Simulation in Healthcare, 11(2), 117-125. http://dx.doi.org/10.1097/SIH.0000000000000133

Zhu, A., & Zhang, J. (2016). Meta-analysis of outcomes of the 2005 and 2010 cardiopulmonary resuscitation guidelines for adults with in-hospital cardiac arrest. American Journal of Emergency Medicine, 34(6), 1133-1139.

Any Questions?

AUGUST 4, 2017