These data clearly show that ACLS skills acquired by 38 Northwestern University internal medicine residents following an educational intervention using simulation technology and deliberate practice did not decay significantly over a 14-month time span. This finding is in sharp contrast with earlier research that shows ACLS skills are not retained without sustained practice and retesting.5–9,22–24,31 At the 2001 Utstein Conference on CPR Education, recommendations were made to simplify CPR education to improve provider skill and the quality of resuscitation efforts.32 Simulation technology was advocated as a useful method to provide small-group facilitated teaching, and a call was made for research into improved resuscitation performance with a suggested follow-up of six months. Our program has been in existence for three years and has been successfully utilized in three residency classes with a fourth currently in progress (n = 159).19–21 Thus, we report an educational intervention in ACLS skills using deliberate practice and small group teaching that maintains a high level of performance over fourteen months, is feasible for internal medicine residents and is rated highly by learners.
Several factors may be responsible for our results including the very high level of ACLS skill acquisition achieved by the residents in the previous randomized trial,19 resident motivation to maintain high performance, and resident familiarity with the simulation-based testing environment that was used for all performance evaluations. Our program includes features of other successful initiatives including the use of simulated events,33 reliable assessment measures,34 and the multiple teaching and practice sessions.35 We do not believe that the single day ACLS provider course in May 2004 or additional clinical experience rather than the simulation training accounts for the high achievement at the time of residency graduation. Baseline data from graduating residents without simulator training shows much weaker results (on average, 17% poorer performance across the six simulations) despite three years of patient care experiences and successful completion of two ACLS courses.36 Future research will study possible sources of variation in resident performance data as well as the generalizability of our results to trainees in other programs.
Data for one of the six scenarios (bradycardia) showed a modest skills decay over the 14-month study period. We believe that this is most likely due to the small number of items as well as the difficulty of the case, requiring the use of multiple medications and pieces of equipment. However, the decay was mitigated in our overall results given the stability of the other five scenarios.
This study has several limitations. It was conducted in one residency program at a single academic medical center. The sample size (n = 38) was relatively small but similar in size to other studies of skill acquisition and retention in basic life support skills.37,38 A computer-enhanced simulation mannequin was used for ACLS skill acquisition, short-run outcome evaluation, and long-run skill retention assessments. These limitations do not, however, diminish the pronounced and lasting impact that the simulation-based ACLS educational program produced among the internal medicine residents.
This study demonstrated that ACLS skills acquired by internal medicine residents in a simulation-based educational program used as an adjunct to traditional ACLS provider courses are robust to deterioration over a 14-month time span. The skills were retained without further simulation training or other educational interventions. The project was implemented successfully in a complex residency schedule and features reliable assessment of ACLS competence. New ACLS guidelines published in December 200539 have streamlined several algorithms and emphasized high quality CPR skills as the basis for high quality ACLS. In an accompanying editorial, Hazini and colleagues call for the “…training of lay rescuers and health care providers in simple, high quality CPR skills that can be easily taught, remembered and implemented to save lives.”40 After our three-year experience with medical simulation in teaching and assessing ACLS skills, we believe programs such as ours can be a useful adjunct to traditional didactic courses to develop and maintain high quality resuscitation skills for prolonged periods of time.
This research was supported in part by the Excellence in Academic Medicine Act under the State of Illinois Department of Public Aid administered through Northwestern Memorial Hospital. We thank the Northwestern University internal medicine residents for their dedication to patient care and education. We acknowledge Charles Watts, MD and J. Larry Jameson, MD, PhD for their support and encouragement of this work.
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