Simulation-based medical education is an established teaching method.1 Simulation fidelity is defined as the extent to which the simulation reflects “reality.” The degree of fidelity incorporated in healthcare education simulation training and evaluation events optimally matches the minimum fidelity required to achieve identified educational objectives. Low-fidelity simulation is frequently used for discrete objectives, such as psychomotor skills training. High-fidelity capability is characteristically required for complex multifaceted educational objectives, such as those identified for team training of resuscitation and operating room teams.
High-fidelity simulation techniques are used to conduct training and evaluation of students focused on rare and high-risk morbidity and mortality disease states. High-acuity disease management skills that are not frequently practiced will erode over time. Airway management skills2 and advanced cardiac life support (ACLS) resuscitation skills3–6 are both documented to deteriorate in the absence of frequent clinical experience or refresher training. Simulation-based training uses high-fidelity manikins (HFMs) routinely for training in these clinical areas and has been demonstrated to improve retention of skills and clinical performance.7
Cardiac resuscitation training includes delivery of electrical defibrillation and/or cardioversion therapy for malignant cardiac arrhythmias. Use of defibrillation equipment with the capacity to deliver electrical energy during simulation promotes trainee device familiarization, enhances fidelity, and encourages realistic interaction with the manikin. Thus, “Live defibrillation” is an integral component in many cardiac resuscitation training scenarios.
Defibrillation, although a lifesaving therapy, is not without risk. Harm to medical practitioners from defibrillation/cardioversion is reported. Gibbs et al8 found eight accidental injuries or shocks to emergency medical technicians (EMTs) or mobile intensive care technician from a defibrillator shock in King's county over a 10-year span; the most serious case was hospitalized for 3 days and required lidocaine for frequent premature ventricular contractions. The other seven experienced shocks or pain, which resolved quickly. These incidents were reportedly caused by inadvertent practitioner unsafe contact with the patient, the stretcher, or the defibrillation equipment. Gibbs estimates the incidence of accidental shock as approximately 1 in 1000 defibrillations for EMTs and 1 in 1700 for mobile intensive care technicians. He also reported 13 cases throughout the United States of accidental shock injuries from defibrillations that were reported to the Food and Drug Administration; three were hospitalized for observation, and none suffered long-term sequelae. Two of these injuries were suffered while testing equipment, and one was during a training exercise. He speculates this number likely represents a large underestimation due to lack of reporting.
Accidental defibrillation through the cranium of a 9-year-old boy was reported by Cooper.9 The patient suffered transient seizures, altered mental status and memory loss but appeared fully recovered the next day.
Iserson10 reported an accidental cranial defibrillation during an ACLS class. The victim, who was the instructor and was reported as being familiar with the equipment, discharged the paddles after raising them to either side of his head. He suffered minor burns and symptoms similar to electroconvulsive shock therapy. His symptoms and injury may have been minimized, as part of the discharge was observed to have been conducted by his eyeglasses.
Montauk11 reported the case of previously healthy 23-year-old man who died during a routine defibrillator check. He placed the paddles over his chest and self-administered a shock causing a lethal cardiac arrhythmia. It is the only reported case of a fatal self-inflicted defibrillator shock.
These reports illustrate the inherent risk of live defibrillator electricity. Because the objective of simulation is to mimic the high-fidelity clinical environment, should safety training standards for simulation be any different than the safety standards of the clinical environment?
There is no published information regarding attitudes or practices regarding defibrillation safety in designated “simulation centers.” We conducted a pilot study to describe practices and attitudes regarding defibrillation safety during simulation-based training in healthcare simulation training centers. A survey was designed to assess self-reported existing simulation centers' policies and practices for assessing whether trainees can use defibrillation equipment safely.
A convenience sample of persons attending the 7th annual International Meeting on Simulation in Healthcare (IMSH: January 2007, Orlando, Florida) was provided a closed-ended 23-item survey instrument. The instrument was designed by the authors and was not pretested. Survey domains included responder and simulation center demographics, simulation center live defibrillation safety training policies, and attitudes toward defibrillation practices in simulation training environments. The study was conducted after institutional review board protocol approval.
Attendees at the IMSH were provided access to survey instruments at a booth in the conference display area, at a general announcement board in the registration foyer, and on tables during lunch. Investigators also solicited participation and distributed surveys in public areas. The total number of surveys distributed and the number of attendees who declined to participate were not recorded, although the overwhelming majority of those approached agreed to participate.
Distribution of responses among the categorical questionnaire items was analyzed using a Pearson χ2. Significant statistical comparisons are at the standard 0.05 significance level. Statistical analyses were performed using SPSS 16.0 (SPSS, 2007).
Fifty-seven individuals returned surveys, representing 39 simulation centers, 29 of which were in the United States. Responder demographics are illustrated in Table 1. Some respondents did not answer all survey domains; thus, the total for some domains is less than the number of respondents.
Simulation center size was reported as small (1–2 HFM), n = 15 (38%); medium (3–5 HFM), n = 16 (41%); or large (6 or more HFM) n = 8 (21%); (Table 2). There were 11 centers (28%) established before 2004 and 11 (28%) established in 2004 or later; for 17 centers (44%), there was no response regarding the year of establishment. Centers were affiliated with 28 medical schools, 10 nursing schools, 19 university hospitals, and 18 others (some simulation centers had multiple affiliations). Live defibrillation was used in 35 of the 39 centers (90%). A live defibrillation safety training policy was in effect at 14 of 39 centers (36%). Reported responsibility for defibrillation safety and training rested with the simulation center (n = 6); with course directors (n = 4); and with others (n = 4).
Formal training before the use of live defibrillation in the simulation training environment was considered necessary by 48 of 55 responders (87%) (two nonresponders, Table 3). Of the 48 respondents who identified a need for formal training, 39 (81%) indicated that training should be conducted by the simulation center staff, 13 (27%) answered it should be done by course directors, and three (6%) stated by “others” (some surveys had multiple answers). Forty-eight of 54 responders (89%, with three nonresponders) strongly agreed or agreed with the statement, “I feel using live defibrillation plays an important role in simulation-based education.”
There was a statistically significant difference between age of center and presence of a training policy; 10% (1/10) of older centers had no policy versus 64% (7/11) of younger centers with a policy (P = 0.011, there was no response for one center in the older group; Table 4).
There were no statistical differences between response distribution regarding size of center and presence of a training policy or between age, gender, or professional status and attitudes regarding need for a training policy.
Modeling best practice is one element of optimal simulation- based training. One primary purpose of healthcare simulation-based education and training is to promote patient safety. However, before promoting patient safety, the safety of the training environment must be secured. Despite our findings that the majority (89%) of responders considered live defibrillation an important element of simulation-based education and that 87% felt there was a need for formal defibrillator training before using live defibrillation, just over a third of the centers in this survey had a formal training policy in effect. These results reveal an incongruity between beliefs and practice.
As we have discussed, the risk of personal injury and death with live defibrillation devices due to improper techniques is described in both the clinical care and the training settings.8–11 That some of these mishaps have occurred during routine training should not be lost on simulation center safety policymakers. As these reports illustrate the inherent risk of defibrillation, training before the use of live defibrillation should be considered, to ensure user safety and reinforce principles of safety in healthcare.
The Zoll operator manual12 states “Emergency defibrillation should be attempted only by appropriately trained, skilled personnel who are familiar with equipment operation. Training appropriateness, such as ACLS or Basic Life Support (BLS) certification, should be determined by the prescribing physician.” It continues, “These operating instructions... are not intended as a substitute for a formal training course. Operators should obtain formal training from an appropriate authority prior to using the device for patient care.”
The implication is clear; training should be obtained before using defibrillation in a clinical environment. Is this for operator, or patient, or ancillary team member safety? Is it safe to allow live defibrillation in a simulation environment before adequate training?
There are 115 simulation centers listed on the Society of Simulation in Healthcare directory. The American Heart Association reports that nearly 1,000,000 healthcare workers were certified in ACLS last fiscal year (Jacobi KK. Personal communication. American Heart Association training dashboard; 2008). Additional healthcare facilities and training centers using simulation-based training techniques are distributed throughout the United States in professional healthcare training institutions (nursing, medicine, EMT/paramedic, etc.), technical schools, military training activities, emergency medical response organizations, and others. Defibrillation is likely a component of scenarios used in these simulation and training centers. However, because the frequency of defibrillation use is in these settings is not known, the magnitude of potential risk of training with live defibrillation is difficult to ascertain.
Recently, Lloyd et al,13 suggested that there is little to no risk of accidental shock from inadvertent provider contact with patients or contiguous surfaces with proper use of defibrillation pads. Their conclusion assumes immaculate adherence to proper application of pads. This report suggests continuing chest compression during defibrillation, but as yet, that recommendation is not widely accepted or practiced.
Our results indicate that newer centers are more likely to have a defibrillator training policy in effect, when compared with older centers. This suggests that more recently established centers have increased safety awareness. However, safety climate was not assessed in this study. In addition, because some respondents did not answer the question “Year Simulation Center Operation Began,” data on only 21 of the 39 centers was available for this analysis and may limit conclusions regarding age of center and the existence of a defibrillation safety policy.
The simulation environment should reflect the clinical environment with as much fidelity as required to accomplish necessary training objectives. The risks of poor defibrillation technique to operators, other team members, and the patient (manikin) are clearly described. We feel that simulation center management best practice should assure adequate defibrillator safety training for all students, faculty, staff, and other users before actual defibrillator use during simulation-based education and training. Center-based defibrillator operation and safety training for all trainees before education and training programs using defibrillation is one method to accomplish this goal.
Individuals who are trained in simulation centers may have had prior defibrillator operation and safety training (ACLS), mitigating risk of injury during simulation-based training. The method simulation centers use to assess adequate defibrillator training was not queried or otherwise defined in this study.
A more robust survey of all simulation centers listed on the Society of Simulation in Healthcare directory may be warranted to more precisely define universal practices and attitudes. Comparison between groups of simulation students who do and do not receive defibrillator safety training before practice may illuminate the true risk for potential harm to students who use defibrillation during simulation-based training.
This survey was of a convenience sample of respondents attending the 7th annual IMSH. Small sample size, compounded by incomplete survey responses, may not reflect attitudes and practices in all simulation centers and thus limits generalization of our findings. The small sample size also precludes potentially important subgroup analyses. Results are subject to recall bias, because some respondents may have provided estimates of the simulation center's size and age. Respondents may not be fully cognizant of their center's policies, especially if they do not conduct simulation scenarios that incorporate defibrillation. Respondents may not be representative of a majority of healthcare workers in simulation who were not in attendance at the meeting or were unable or unwilling to answer the survey.
Our survey reports incongruity between attitudes and practices, regarding the use of defibrillator safety training in simulation. Although live defibrillation was used in 90% of the simulation centers responding, only 36% of the centers reported use of a standard organizational defibrillator safety policy. Most respondents considered live defibrillation an important element of simulation-based education and indicated that users should receive formal training before using live defibrillation. Simulation center administrators may want to consider implementing a safety policy, assuring user demonstration of minimum competency before use of live defibrillation during simulation training. It remains to be determined whether safety training before using live defibrillation increases user safety.
1.Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach
2.Kuduvalli PM, Jervis A, Tighe SQ, Robin NM. Unanticipated difficult airway management in anaesthetised patients: a prospective study of the effect of mannequin training on management strategies and skill retention. Anaesthesia
3.O'Steen DS, Kee CC, Minick MP. The retention of advanced cardiac life support knowledge among registered nurses. J Nurs Staff Devel
4.Brennan RT, Braslow A. Skill mastery in public CPR classess. Am J Emerg Med
5.Moser DK, Dracup K, Guzy PM, Taylor SE, Breu C. Cardiopulmonary resuscitation
skills retention in family members of cardiac patients. Am J Emer Med
6.Smith KK, Gilcrest D, Pierce K. Evaluation of staff's retention of ACLS and BLS skills. Resuscitation
7.Wayne DB, Siddall VJ, Butter J, et al. A longitudinal study of internal medicine residents' retention of advanced cardiac life support skills. Acad Med
8.Gibbs W, Eisenberg M, Damon S. Dangers of defibrillation: injuries to emergency personnel during patient resuscitation. Am J Emer Med
9.Cooper L. Accidental defibrillation of the cranium. J Emerg Nurs
10.Iserson K. Accidental “cranial” defibrillation. J Am Coll Emerg Phys
11.Montauk L. Lethal defibrillator mishap. Ann Emerg Med
12.Zoll M Series®. Operators Guide
. Chelmsford: Zoll Medical Corporation; 2007.
13.Lloyd M, Heeke B, Walter P, Langberg J. Hands-On Defibrillation: an Analysis of Electrical Current Flow Through Rescuers in Direct Contact With Patients During Biphasic External Defibrillation. Circulation