Simulation has long been used to practice individual skills in medicine. The healthcare simulation center is considered a “safe place” where such practice can occur in a controlled environment without placing patients at risk.
Beyond individual skills, there is a growing interest for the use of simulation in team training — particularly interdisciplinary team training, which helps bring participants out of their silos and improves communication skills. Good communication leads to reduced errors and efficient teamwork as well. Efficient teamwork is crucial to saving lives, particularly in settings where a patient’s life is measured in minutes. Such critical situations are often rare events; simulation provides the opportunity to repeat such events in a practice setting until mastery by multiple providers is achieved. These scenarios then can be repeated at specified intervals as refresher practice to prevent degradation of skills over time.
One example of a rare, high risk situation is the setting of cardiac arrest in a post-operative cardiac surgery patient. When this occurs, the patient can only be saved by rapid, highly skilled intervention, quite often when a cardiac surgeon is not immediately available. In the past, the protocols most often used in typical cardiac arrest situations (Advanced Cardiac Life Support — ACLS) were applied to these patients, but these interventions are often ineffective and sometimes dangerous after open-heart surgery.
"Every experience is an experience, and even though it’s not a real patient, it reminds everyone of the basic procedures and what needs to be done to optimize the outcome when it is a real patient whose life is measured in minutes"
Following years of focused research, new protocols for cardiac arrest after cardiac surgery were developed in the United Kingdom in 2003 and were adopted as a standard of care in Europe in 2010. The set of protocols, known as Cardiac Surgery Advanced Life Support (CALS in the U.K.) and Cardiac Surgical Unit Advance Life Support (CSU-ALS, NA) in North America, addresses postoperative decompensation and cardiogenic shock, emergency pacing, re-opening of the chest incision, open cardiac massage, and internal defibrillation. Training includes simulation for both individual skills and team performance, and is presented to clinicians in a 1-2 day course. Availability of the CSU-ALS course has gradually been increasing in the U.S. since 2012 and in 2017 was ratified by the Society of Thoracic Surgeons as standard of care.
The Surgical ICU at St. Joseph Mercy Ann Arbor hospital has been offering training in CSU-ALS protocols internally on a monthly basis since 2014. All SICU staff and cardiac surgery Advanced Practice Providers (APPs — Physician Assistants and Nurse Practitioners) are required to rotate through the course. This results in a biannual exposure for the SICU nurses and a quarterly practice opportunity for the APPs, who serve 24/7 as first responders to post op cardiac surgery patients.
In 2015, members of the Michigan Society of Thoracic and Cardiovascular Surgery (MSTCVS) proposed that all Michigan cardiovascular surgery programs travel to St. Joe’s in Ann Arbor to receive instruction on implementing protocols at their own institutions. As the St. Joe’s simulation program became more involved and officially trained by the CSU-ALS, NA organization, the program was recognized as an Accredited Center, awarding official certification to St. Joe’s SICU staff who participated in the monthly sessions.
In 2018, we were recognized at the national meeting of the Society of Thoracic Surgeons by then-president Dr. Richard Prager. In his address, he suggested that all cardiac surgery programs implement training for their postoperative care units. Later that year, St. Joe’s was designated as a Center of Excellence for achieving CSU-ALS certification in greater than 90 percent of cardiac surgery providers and ICU staff. This designation officially qualified our training sessions to teams from other hospitals. These external courses are offered on a quarterly basis and have had participants from multiple institutions throughout Michigan and the upper Midwest.
While it is intuitive that “practice makes perfect” for individuals learning new skills, we have definitely seen it enhance team function. It also yields improved respect between disciplines, which impacts the efficiency of all care provided. One nurse put it very much in perspective when she stated: “The monthly training surrounding cardiac surgery has had a spillover effect on all the care we provide. During emergencies of any kind, we now automatically identify individual roles very rapidly, which reduces chaos and improves efficiency in all of our resuscitations.”
Every experience is an experience, and even though it’s not a real patient, it reminds everyone of the basic procedures and what needs to be done to optimize the outcome when it is a real patient whose life is measured in minutes.